Study Highlights Relationship Between Alcohol, Suicide, and Firearms

Alcohol intoxication is associated with an increased risk of suicide death by firearms compared with other methods, especially among males and among young and middle-aged females, a study in the American Journal of Preventive Medicine suggests.

“Understanding the nuances of the relationship between alcohol and firearm-involved suicides—the method of suicide that makes up the greatest proportion of suicides in the U.S.—allows for a better understanding of how a prevention initiative targeting alcohol (e.g., alcohol taxation), for example, would impact suicide in the U.S.,” wrote Shannon Lange, Ph.D., M.P.H., of the Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, in Toronto and colleagues.

The researchers examined data from the National Violent Death Reporting System for 34,972 females and 113,851 males who died by suicide from 2003 to 2020. The researchers divided the individuals according to age at time of death: young, aged 18 to 34 years; middle-aged, aged 36 to 64 years; and older, aged 65 years or older. The individuals’ blood alcohol content at the time of death was determined via toxicology testing. The researchers defined alcohol intoxication as having a blood alcohol content of at least 0.08 g/dL, which corresponds to approximately four drinks for females and five drinks for males within two hours.

Overall, males were more likely to be intoxicated at the time of death than females, and people in the young and middle-aged groups were more likely to be intoxicated at the time of death than those in the older group. Males were more likely to use a firearm than females, and older males had the highest proportion of death by suicide using a firearm.

Young and middle-aged females who were intoxicated at the time of death had a 31% and 34% greater risk of using a firearm compared with their non-intoxicated peers, respectively. Young, middle-aged, and older intoxicated males had a 28%, 17%, and 4% increased risk of using a firearm compared with their non-intoxicated peers, respectively.

“In light of the current findings, there is a clear need for prevention efforts to address the alcohol-firearm-suicide relationship,” Langue and colleagues wrote. They added that such efforts could include the following:

• Laws that prohibit firearm possession for individuals with alcohol use disorder or who are being treated for alcohol-related reasons.
• Screening and brief interventions for alcohol use of all individuals who present in the health care system with suicidal thoughts or for a suicide attempt and connecting these individuals with resources for treatment for substance use.
• The enactment of safe firearm storage policies and mandatory waiting periods following a firearm purchase.
• Minimum unit pricing on alcohol.

“Given that a firearm is the most lethal means of suicide, alcohol control policies targeting excessive alcohol consumption may stem the tide of firearm suicides in the U.S.,” the authors wrote.

For related information, see the Psychiatric Services article “Preventing Suicide Through Better Firearm Safety Policy in the United States.”

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Moms Encounter Barriers, Discrimination to Accessing MH Care for Traumatized Youth

Callers posing as mothers of adolescents with trauma symptoms who tried scheduling outpatient appointments at safety-net mental health centers were successful during only 17% of calls, a study published yesterday in Psychiatric Services found. Further, the authors identified a bias against non-White callers.

“Despite the benefits of early intervention, fewer than half of youths with a psychiatric disorder receive such intervention,” wrote Danielle Adams, Ph.D., M.S.W., of Washington University in St. Louis and colleagues. “Furthermore, research indicates that discrimination may occur during scheduling, creating additional barriers for families of color. Given the United States’ youth mental health crisis, which has worsened during the pandemic, substantial work is needed to identify and reduce the treatment barriers families face when seeking care.”

Adams and colleagues used a “mystery shopper” method to call publicly listed community mental health centers and federally qualified health centers in Cook County, Ill. The centers were called in two waves during the COVID-19 pandemic, once in the spring (from mid-May to mid-June 2021) and again in the summer (from mid-June to mid-July 2021). Voice actresses who self-identified as White, Latina, or Black posed as mothers seeking therapy for their adolescent children (14 to 18 years old) who had recently witnessed a traumatic event and were experiencing symptoms of posttraumatic stress disorder. Each center was called twice, with the callers claiming to have either Medicaid or private insurance. Completed contacts were defined as those contacts that resulted in a scheduler returning the call to schedule an appointment or to explain why an appointment could not be scheduled.

The callers reached out to 229 centers 451 times. The callers were unable to reach anyone at 32 health centers (14%) during the two sampling waves. Regardless of the insurance type or race/ethnicity of the caller, an appointment was offered in fewer than 1 out of 5 calls. The average wait time for an appointment was 12 days, regardless of the caller’s insurance type. Further, Medicaid-insured callers had to wait an average of 13.6 days for an appointment, whereas privately insured callers had to wait 9.5 days, though the authors noted that this difference was not statistically significant. An appointment was offered to 28% of the Medicaid callers who were able to connect with a scheduler and 24% of private insurance callers.

The number of completed contacts varied by the callers’ race or ethnicity. For White callers, 89% of calls resulted in a completed contact, compared with only 58% for Black callers and 53% for Latina callers.

“These results add to the growing literature indicating that discrimination may occur at mental health care scheduling, with schedulers having a bias toward being more likely to call back and schedule individuals with a White-sounding name and voice,” the authors wrote. “It is vital that safety-net health centers have an antidiscrimination policy in place and regularly audit whether employees are offering equitable services to everyone.”

For related information, see the Psychiatric Services article “Racial-Ethnic Disparities in Outpatient Mental Health Care in the United States.”

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Cannabis Use Disorder Rising Among Veterans, Study Finds

The prevalence of U.S. veterans diagnosed with cannabis use disorder more than doubled between 2005 and 2019, with the greatest increases reported among those with bipolar disorder and psychotic spectrum disorders, according to a report published today in The American Journal of Psychiatry.

People with psychiatric disorders are known to be at an increased risk for substance use, but few studies have compared cannabis use disorder in people with and without other psychiatric disorders, wrote Ofir Livne, M.D., M.P.H., of the New York State Psychiatric Institute and colleagues.

For the current study, the researchers analyzed electronic health records from the Veterans Health Administration collected from 2005 to 2014 and 2016 to 2019. They compared trends in the prevalence of cannabis use disorder diagnoses among those with depressive, anxiety, posttraumatic stress, bipolar, or psychotic spectrum disorders with those without any of these disorders. The primary outcome was a cannabis use disorder diagnosis made by a provider during at least one outpatient or inpatient encounter within a calendar year.

Overall, the prevalence of diagnoses for cannabis use disorder among veterans increased from 0.85% in 2005 to 1.92% in 2019. Among patients with any psychiatric disorder, the prevalence increased from 2.48% in 2005 to 4.68% in 2019. The increase in cannabis use disorder diagnoses among those without psychiatric diagnoses was much lower from 0.35% in 2005 to 0.57% in 2019.

In both time periods examined, diagnoses of cannabis use disorder were the most prevalent in patients with bipolar disorder and/or psychotic spectrum disorder, the authors reported.

“U.S. adults have become increasingly likely to perceive cannabis use as harmless and useful for treating conditions such as stress, anxiety, and depression,” Livne and colleagues wrote. “Consequently, greater public health and clinical efforts are needed to systematically monitor risky cannabis use and cannabis use disorder and to develop preventive and harm reduction strategies in these cannabis-using populations.”

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

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APA Poll Finds U.S. Adults Worried About Costs Associated With Holidays

Nearly one-third of U.S. adults anticipate that this holiday season will be more stressful than last year, with costs associated with holiday gifts and meals possibly contributing to this stress. This was one of several findings of APA’s latest Healthy Minds Poll.

The poll—which was fielded from November 9 through 11—asked 2,210 adults living in the United States to rank their anxiety about current events (for example, international conflict and inflation) as well as holiday activities/obligations. APA has polled about holiday mental health for the past three years.

Of the holiday stressors respondents were asked to assess, 51% expressed at least some worry about their ability to afford holiday gifts, and 23% reported being very worried about affording gifts. Similarly, 40% reported worry about finding and securing gifts, and 39% expressed worry about affording holiday meals.

“Economic burdens have run high in our polling for the past few years as a source of concern, and that makes sense given the challenges we’ve all shared,” said APA President Petros Levounis, M.D., M.A., in a news release. “Connecting with supportive family and friends is more meaningful to our mental health than the commercial aspects of the season. The kindness with which you treat yourself and those you love during the holiday season is the very best gift you can give.”

U.S. adults appear to recognize the importance of connection during the holidays. When asked about what they are most looking forward to this holiday season, 44% ranked seeing friends and family at the top of their list.

“Tis the season to keep our mental and physical health in mind as we enjoy the festivities,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “It’s tempting to want to do everything, to travel to see everyone, to shop for that very special gift, and to compare ourselves to that very perfect staged family picture we see on social media. But in January, when the holidays come to an end, what will be most important is that you are feeling well, and that will come when you take the occasional breath and have some perspective.”

As has been the case for much of 2023, anxiety about inflation, a recession, and gun violence dominated the top worries listed by U.S. adults. In contrast, worries about the COVID-19 pandemic remained consistently low in comparison with other current events.

For related information, see the Psychiatric News Alert “Practicing Kindness Has Positive Impact on Mental Health, APA Poll Finds.”

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This #GivingTuesday: Act Now to Create a Mentally Healthy Nation

With #GivingTuesday just a few days away, the APA Foundation encourages you to act today to advance a mentally healthy nation by texting APAF2023 to #44321. Your donations will help support a psychiatry student’s research on connecting underserved populations to care, digitize the history of psychiatry, and more.

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Tailored Text Messages May Help Reduce Risky Alcohol Use

Daily text messages offering encouragement and advice may help some individuals significantly reduce their alcohol consumption, reports a study published today in Addiction. Compared with individuals who received a text asking about their weekly drinking behaviors, those who received tailored text messages reported significantly fewer drinks and drinking days per week after 6 months.

Frederick Muench, Ph.D., of the Partnership to End Addiction in New York and colleagues recruited women who drank at least nine drinks per week and men who drank at least 11 drinks per week and were seeking to lower their alcohol intake. A total of 723 adults (average age of 40) were randomly assigned one of three text groups for 6 months:

• Drink tracking: Participants received a weekly assessment sent by text that inquired about their drinking over the previous 7 days. They were also asked if they had met their week’s goal.
• Tailored static messaging: Participants received weekly assessment texts as well as daily text messages; about half were tailored to the participant (for example, they included the individual’s name or provided advice geared toward the individual’s ability to resist cravings).
• Tailored adaptive messaging: Participants received weekly assessment texts as well as daily tailored messages that were adjusted each week depending on the extent to which they achieved their weekly goals. Participants in this group were also provided a list of key words (for example, “heavy” and “drinking”) that they could text to receive additional text support.

The researchers assessed multiple drinking variables, including the total number of weekly drinks, drinking days per week, drinks per drinking day, and heavy drinking days (four or more drinks) per month at 1, 3, 6, and 12 months.

After 6 months, participants receiving adaptive messaging showed significantly greater reductions in most drinking behaviors compared with the drink tracking group; however, there was no difference between those who did and did not receive tailored messages with regard to heavy drinking days per month.

Overall, participants receiving adaptive messaging reduced their total weekly drinks from 28.7 to 12.5, drinks per drinking day from 5.3 to 3.1, and drinking days per week from 5.5 to 3.8.

Participants in the adaptive messaging and static messaging groups demonstrated similar improvements at six months, outside of a slightly greater decrease in drinks per drinking day for those in the adaptive messaging group.

“Overall, [the] results highlight the opportunity to significantly reduce risky drinking with long-term automated messaging interventions that are scalable” and require little effort from those motivated to reduce alcohol use, Muench and colleagues concluded.

To read more about this topic, see the Psychiatric News article “Can Ketamine Curb Excess Drinking?”

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Overdose Deaths During Pregnancy, Postpartum Period Rose From 2018 to 2021

From 2018 to 2021, drug overdose deaths rose significantly among pregnant and postpartum girls and women aged 10 to 44, according to a report published today in JAMA Psychiatry. Among pregnant and postpartum women aged 35 to 44 years, drug overdose deaths more than tripled—from 4.9 deaths per 100,000 mothers aged 35 to 44 with a live birth in the 2018 period to 15.8 per 100,000 in the 2021 period.

The study revealed that most of these overdose deaths occurred outside health care settings, indicating the need for strengthening community outreach and maternal medical support.

“The stigma and punitive policies that burden pregnant women with substance use disorder increase overdose risk by making it harder to access lifesaving treatment and resources,” National Institute on Drug Abuse (NIDA) Director Nora Volkow, M.D., who was senior author of the study, said in a news release. “Reducing barriers and the stigma that surrounds addiction can open the door for pregnant individuals to seek and receive evidence-based treatment and social support to sustain their health as well as their child’s health.”

For the study Volkow, Beth Han, M.D., Ph.D., M.P.H., and others at NIDA analyzed data from the National Center for Health Statistics, including cause of death files and semiannual numbers of mothers aged 10 to 44 years with a live birth. Pregnancy-associated mortality ratios were defined as deaths during pregnancy or within one year of delivery per 100,000 mothers with a live birth during each period. The researchers focused the analysis on three groups:

• 1,457 individuals who died from overdose during pregnancy or the postpartum period.
• 4,796 individuals who died from obstetric causes.
• 11,205 individuals who died from overdose who were not pregnant in the past 12 months.

Compared with individuals who died from obstetric causes, those who died from drug overdose tended to be younger (age 10 to 34), unmarried, and more likely to die outside of health care settings.

Comparisons of health care resources at the county level revealed that “70% to 75% [of] pregnant and nonpregnant overdose decedents resided in counties with the number of physicians practicing emergency medicine per 100,000 population ranking over the 65th percentile among U.S. counties, suggesting that in many instances, emergency services may have been available but not accessed,” the researchers noted. Additionally, “51% to 53% resided in counties with two or more general hospitals with obstetric care ranking at the 95th percentile among U.S. counties, and 58% to 67% resided in counties with numbers of practicing psychiatrists per 100,000 county residents ranking over the 75th percentile among U.S. counties.”

“These results reflect the persistent national overdose crisis and demonstrate that pregnancy is an urgent time for interventions that can reduce the risk of overdose,” said Emily Einstein, Ph.D., NIDA Science Policy Branch Chief and study co-author. “Effective treatments and medical services exist—unfettered access is needed to help mothers and children survive.”

For related information, see the Psychiatric News article “Suicide, Overdose Are Significant Contributors to Pregnancy-Related Maternal Deaths.”

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Prenatal Exposure to Alcohol Not Linked to Accelerated Brain Aging, Study Shows

Exposure to alcohol in the womb is known to increase the risk of abnormal brain development and a range of cognitive and behavioral problems known as fetal alcohol spectrum disorders (FASD) in offspring. A study appearing in JAMA Network Open that compared the brains of a group of middle-aged people with and without FASD suggests that those with FASD are no more likely to experience accelerated brain aging in their 40s than those without FASD. 

While the study participants with FASD continued to exhibit alcohol-induced structural deficits in the brain and had observable behavioral symptoms as they did as young adults, “our findings do not suggest that FASD is a progressive disorder by middle age but one for which continued habilitative efforts are warranted,” wrote Adolf Pfefferbaum, M.D., of Stanford University School of Medicine and colleagues.

Pfefferbaum and colleagues recruited adults who had participated in a University of Washington FASD study as young adults. As part of the original study, participants received a thorough clinical assessment for FASD as well as an MRI brain scan. For the current study, Pfefferbaum and colleagues repeated MRI scans in 66 middle-aged adults representing three groups:

• 22 adults (average age, 41 years) with fetal alcohol syndrome—defined as the presence of central nervous system dysfunction, growth deficits, and sentinel facial features of prenatal alcohol exposure.
• 18 adults (average age, 43 years) with fetal alcohol effects—defined as the presence of some, but not all characteristics of fetal alcohol syndrome.
• 26 adults (average age, 42 years) who had no history of prenatal alcohol exposure—the control group.

The follow-up MRI scans were taken about 20 years after the first ones. The researchers found the same pattern of brain volume differences between the three groups as they had previously identified: Average total intracranial brain volume as well as the volume of specific regions such as the cerebellum were much larger in the control group than the group with fetal alcohol syndrome; the brain volumes of those with fetal alcohol effects were lower than the control group but larger than the group with fetal alcohol syndrome.

All three groups showed normal changes in brain volume over time; that is, there was no evidence of any accelerated brain aging or reversal of brain volume deficits in the group with fetal alcohol syndrome and fetal alcohol effects compared with the control group.

Pfefferbaum and colleagues emphasized the importance of continuing to track the brain health of adults with FASD as they age. “There is a critical need to extend the longitudinal assessment of this cohort into older ages when clearer signs of accelerated aging might manifest morphologically to track whether the FASD population is at heightened risk for premature or exacerbated dementia or other disorders of aging,” they wrote.

To read more about this topic, see the Psychiatric News article “Patients With Prenatal Alcohol Exposure Frequently Misdiagnosed, Face Multiple Challenges.”

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APA Remembers the Mental Health Legacy of Rosalynn Carter

APA released a statement today commemorating the life and legacy of Former First Lady Rosalynn Carter, who passed away on Sunday at the age of 96. Throughout her public service career, Mrs. Carter worked tirelessly to improve the quality of life for people with mental illness and substance use disorders. (In the photo at left, she speaks at a special luncheon at APA’s 1985 Annual Meeting.)

“Few, if any, other Americans have been able to accomplish what she did for the cause of mental health,” APA’s statement reads. “She used her bully pulpit to bring the conversation about mental health out from the darkness and advocate for a more comprehensive system of care.”

Years before her husband, Jimmy Carter, was elected president of the United States, Mrs. Carter began seeking ways to support people living with mental illness and their families (see Rosalynn Carter's Leadership in Mental Health). As the first lady of Georgia, she served on her husband’s commission to improve the state’s mental health services. While in the White House, she served on the Presidential Commission on Mental Health, eventually helping to bring about the passage of the Mental Health Systems Act of 1980, which provided grants for community health centers.

The former first lady continued to advocate for mental health long after departing the White House in early 1981 (see Mental Health Program). From 1985 through 2016, Mrs. Carter held the Rosalynn Carter Symposium on Mental Health Policy at The Carter Center, which brought together representatives of mental health organizations nationwide to focus and coordinate their efforts on key issues. In 1996, Mrs. Carter launched the Rosalynn Carter Fellowships for Mental Health Journalism, which aims to equip journalists around the world with the tools needed to accurately and effectively report on behavioral health issues. Additionally, Mrs. Carter recognized the importance of insurance companies covering treatments for mental illnesses at the same levels as other types of medical illnesses.

“To me, it is unconscionable in our country and morally unacceptable to treat 20 percent of our population (1 in every 5 people in our country will experience a mental illness this year) as though they were not worthy of care,” Mrs. Carter wrote in a letter supporting the passage of the Mental Health Parity and Addiction Equity Act of 2008. “We preach human rights and civil rights, and yet we let people suffer because of an illness they didn’t ask for and for which there is sound treatment. Then we pay the price for this folly in homelessness, lives lost, families torn apart, loss of productivity, and the costs of treatment in our prisons and jails. … I have always believed that if insurance covered mental illnesses, it would be all right to have them. This may be why the stigma has remained so pervasive—because these illnesses are treated differently from other health conditions.”

The APA statement concludes, “An Honorary Fellow of the APA, Mrs. Carter was a friend to those whom society might otherwise have forgotten. … She will be deeply missed, and her legacy will live on for all those who are touched by mental illness and substance use disorders.”

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Virtual Civil Commitment Hearings May Result in Inaccurate Safety Decisions

During the height of the COVID-19 pandemic, many courts began conducting involuntary civil commitment hearings virtually with patients in the hospital. (Such hearings are used to determine if a person presents a threat to his/herself and/or others and needs court-ordered inpatient care.) As some courts continue to conduct virtual hearings in the pandemic’s aftermath, the authors of a Viewpoint in Psychiatric Services argue that such hearings may challenge the court’s ability to make fair and accurate commitment determinations.

“Every patient has the right to a formal hearing in which a hearing official considers all evidence and testimony and may order release from care unless specified criteria have been met,” wrote Stephanie Hare, Ph.D., of the University of Maryland School of Medicine and colleagues. “Although prior publications have discussed the ethics of virtual [civil commitment] hearings, we argue that this literature presents a one-sided view and highlights the convenience of virtual hearings for legal officials and counselors. What is needed is a thorough ethical analysis of the benefits versus costs (or risks or challenges) of virtual [civil commitment] hearings.”

Hare and colleagues outlined numerous ways in which virtual civil commitment hearings may compromise the ability of the court to make accurate safety determinations, including the following:

• Court officials may miss important information when patients are muted: In some instances, patients may be muted during virtual hearings, perhaps to prevent disruptions. But muting patients, “may prevent them from providing vital information that can help to explain their perspective or behavior,” the authors wrote. It may also, “prevent the hearing officials from witnessing statements or behaviors that either affirm or refute safety risk.”
• Court officials lose opportunities to observe patients’ symptoms when cameras are angled away: Patients’ cameras may be angled away from them to prevent disruptions. For example, if a patient has repeated, paranoid outbursts that interrupt the hearing, onsite staff may mute the patient and angle the camera away from him or her for convenience. This could limit officials’ direct observation of the patient’s symptoms, leading the officials to miss signs that the patient needs continued inpatient care.
• Patients may grow frustrated due to the digital divide: The virtual format may make it difficult for patients to perceive court officials’ social or nonverbal cues, resulting in stress or frustration on the part of the patient. “This behavior could be interpreted by officials at the hearing as cause for safety concerns, when in fact the behavior may have simply been triggered by additional obstacles or stressors being placed before the patient,” the authors wrote. This could lead to overutilization of commitment decisions.
• Patients may have a harder time communicating with their legal counselors: Less experience with digital technologies among patients may make it challenging for them to communicate with their legal counselors during prehearing meetings, as well as with officials during the hearing. This could further interfere with accurate commitment assessments.

The authors acknowledged that their views were based on their own experiences, and that different courts and hospitals could have different needs. “[W]e advise gathering feedback from various stakeholders in the [civil commitment] process about their experiences, including feedback from involuntarily admitted patients about their experiences with virtual technologies,” they wrote. “This feedback will not only provide fresh perspectives on key challenges but also help to ensure that the highest standards of fairness, accuracy, and integrity are maintained in the [civil commitment] process.”

For related information, see the Psychiatric Services report “Taking an Evidence-Based Approach to Involuntary Psychiatric Hospitalization.”

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Prenatal Anxiety, Depression Associated With MH Symptoms in Children, Independent of Genetic Risk

Anxiety and depression among pregnant mothers was associated with a greater risk of internalizing and externalizing symptoms among their children even after controlling for the child’s genetic risk for mental disorders, according to a study published this week in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Our findings suggest that genetics alone do not fully account for the association between prenatal depression and child mental health,” wrote Lawrence Chen, B.Sc., and Kieran O’Donnell, Ph.D., of the Douglas Research Centre at McGill University in Canada, and colleagues.

Chen, O’Donnell, and colleagues used data from the Avon Longitudinal Study of Parents and Children, which included women who were pregnant between April 1, 1991, and December 31, 1992, and their children.

Maternal depressive symptoms were assessed when mothers were 32 weeks pregnant using the Edinburgh Postnatal Depression Scale (EPDS), while anxiety symptoms were assessed using the Crown Cusp Experiential Index (CCEI). The children’s internalizing, externalizing, and total emotional/behavioral symptoms were assessed using the Strengths and Difficulties Questionnaire (SDQ). Mothers completed the questionnaire when their children were four, seven, eight, nine, 11, 13, and 16 years of age. The authors analyzed the children’s polygenic risk score for depression, attention-deficit/hyperactivity disorder, and schizophrenia, all of which have been previously associated with exposure to prenatal adversity.

Among 5,546 mothers and children, the authors found that prenatal maternal depression and anxiety was associated with the child’s internalizing, externalizing, and total emotional symptoms across all ages tested. Children’s total SDQ scores increased by approximately 0.1 points per 1 point increase in the mother’s EPDS score.

Women with elevated prenatal maternal depression (defined as an EPDS score of 13 or greater) or anxiety (defined as a CCEI score of nine or greater) were also more likely to have children with clinically significant mental health symptoms (SDQ score of 14 or greater) at both four and 16 years. This increased risk was independent of such factors as postpartum depression; the risk was also independent of the child’s polygenic risk score.

Sensitivity analyses revealed a significant association between prenatal depression and the child’s mental health, which the authors attributed to the shared genetic risk among the mothers and their children. Shared genetic risk factors accounted for 43% and 46% of the association between prenatal maternal depression and externalizing symptoms among the children at four and 16 years of age, respectively.

“[T]he study results emphasize the need for large-scale interventions to examine the clinical benefits of prenatal interventions on both maternal and child mental health,” the authors concluded.

For related information, see the Psychiatric News article “Treating Family Members Can Break Depression Cycle, Says Expert.”

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Patients With Parkinson’s May Be at High Risk of Suicidal Thinking, Behavior

Individuals with Parkinson’s disease may be at significantly higher risk for suicidal thinking and behavior than people without the disease, according to a meta-analysis published this week in JAMA Neurology.

“Patients with [Parkinson’s disease] possess multiple risk factors for suicidality, such as advanced age, living with a chronic condition, as well as limitations in physical mobility and functional ability,” wrote Aaron Shengting Mai, M.S., of the National University of Singapore; Yinxia Chao, M.D., Ph.D., of the National Neuroscience Institute in Singapore; and colleagues. Efforts at early detection and management of suicidality in patients with Parkinson’s can help to reduce patients’ risk of death and improve their quality of life, they continued.

The researchers analyzed data from 28 studies comprising 505,950 patients with Parkinson’s to determine the prevalence of suicidal ideation and behavior in this population. The researchers also compared the risk of suicidal ideation and behavior between patients with Parkinson’s and those without the disease. Of the 28 studies, 15 studies were cross-sectional studies, eight were retrospective cohort studies, and three were case-control studies. 

The meta-analysis revealed that 22.2% and 1.25% of people with Parkinson’s disease experienced suicidal ideation and behavior, respectively. Compared with people without the disease, those with Parkinson’s disease were twice as likely to have engaged in suicidal behavior.

“Patients with [Parkinson’s disease] often experience great psychiatric comorbidity, of which the most prominent is depression,” the researchers wrote. “Depressive mood disorders are the greatest risk factors for both suicidal ideation and suicidal behavior and are present in almost half of patients with [Parkinson’s disease].”

People with Parkinson’s disease often face other hurdles as well, including sleep disorders and feelings of hopelessness. “Efforts directed at identifying and addressing these risk factors, such as improving the quality and quantity of sleep through medications, could be helpful for these patients,” they added.

For related information, see the Psychiatric News article “Phone CBT Effective for Patients With Parkinson’s Disease.”

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New Survey Data Highlight the Scope of Nation’s Behavioral Health Crisis

Substance use disorder continues to haunt tens of millions of adults and youth living in the United States, according to the results of the 2022 National Survey on Drug Use and Health (NSDUH). Yet, most of those surveyed did not seek treatment for substance use nor did they think they should.

These were among the many findings released yesterday by the Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual survey to capture a snapshot of the mental health needs of people living in the United States.

Using both in-person and web surveys, the NSDUH asks U.S. civilians aged 12 or older to reflect on their use of tobacco, alcohol, and illicit drugs; substance use disorders; mental health conditions; suicidal thoughts and behaviors; and substance use and mental health treatment. The final respondent sample of 71,369 individuals for 2022 was weighted to be representative of the U.S. civilian, noninstitutionalized population aged 12 and older.

Analysis from the 2022 survey revealed that 48.7 million people aged 12 or older (17.3% of the population) reported substance use that met DSM-5 criteria for substance use disorder (SUD) in the past year—up from 46.3 million people in 2021 (see Highlights for the 2021 National Survey on Drug Use and Health).

Among the 1.8 million adolescents aged 12 to 17 in 2022 who had an SUD in the past year and did not receive substance use treatment in the past year, 1.7 million people did not seek treatment or think they should get it, the report found. Similarly, among the 39.7 million adults aged 18 or older in 2022 who had an SUD in the past year and did not receive substance use treatment, 36.8 million people did not seek treatment or think they should get it.

Other findings from the 2022 report included the following:

• Almost 1 in 4 adults aged 18 or older had mental illness in the past year; 1 in 12 adults reported co-occurring mental illness and SUD.
• About 1 in 5 adolescents aged 12 to 17 had a major depressive episode in the past year; 1 in 5 of adolescents with an MDE had a co-occurring SUD.  
• Over 1 in 8 adolescents aged 12 to 17 had serious thoughts of suicide, and about 1 in 15 made suicide plans in the past year.
• Over 1 in 20 adults 18 or older had serious thoughts of suicide, and about 1 in 60 made suicide plans.

“To tackle the behavioral health crisis in this nation, we need to fully understand the issues surrounding mental health and substance use, and the impact they have on people and communities,” said HHS Deputy Secretary Andrea Palm in a news release. “The 2022 National Survey on Drug Use and Health allows us to follow an evidence-based path forward as we provide support for those struggling with substance use and work to build healthier futures.”

For related information, see APA’s Top 10 Things Everyone Should Know About Addiction.

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Impacts of Childhood Adversity on Mental Health May Be Delayed for Some Youth, Study Suggests

Children who do not develop mental health problems early in life despite exposure to multiple adversities may experience such challenges in early adulthood, suggests a report in The American Journal of Psychiatry.

“Although resilient individuals may escape their childhood relatively unscathed, the stress of maintaining psychological health despite adversity may catch up with them later in development,” wrote William E. Copeland, Ph.D., of the University of Vermont and colleagues.

Copeland and colleagues examined data from The Great Smoky Mountains Study, a longitudinal study that tracked the outcomes of three cohorts of children (aged 9, 11, and 13 years), recruited from 11 counties in Western North Carolina. Annual assessments were conducted with the children and caregivers each year until the children reached 16; the young adults were assessed alone at ages 19, 21, 25, and 30. Up until 16, the youth answered questions about childhood adversities, which the researchers categorized into the following five domains:

• low socioeconomic status
• unstable family structure
• family dysfunction
• maltreatment
• peer victimization

The researchers estimated cumulative childhood exposure to adversity by counting the number of categories of adversity experienced.

Copeland and colleagues analyzed the reports of 1,266 participants, who answered questions about psychiatric disorders and functioning at ages 25 and/or 30. Of this group, 941 (74%) experienced psychiatric illnesses or subthreshold psychiatric symptoms by the age of 16. Of the 325 (26%) who did not meet criteria for a psychiatric diagnosis or subthreshold disorder by the age of 16, 63 of them had been exposed to multiple adversities in childhood. (The authors characterized these youth as “resilient”).

The researchers found that compared with children with limited exposure to adversity and no childhood disorders (low-risk/no disorders group), resilient children had nearly 3 times the risk of developing anxiety and 4.5 times the risk of developing depression in adulthood. In addition, the resilient group had worse physical and financial health compared with individuals in the low-risk/no disorders group. However, the resilient group had better functioning compared with the group of participants with childhood psychiatric problems in the domains of health and social functioning.

“Thus, the well-being of adults who had been characterized as resilient children was better than that of the adults with childhood psychiatric problems but sometimes worse than that of adults exposed to less childhood adversity,” the authors wrote. “[T]he development of some level of mental health problems is the normative response to significant adversity. Individual resilience followed by persistent mental health is rare and may not be a reasonable goal. Public health efforts should prioritize reducing risk and treating individuals who are ill.”

To read more on this topic, see the Psychiatric News article “Intervention, Resilience May Counter Poverty’s Impact on Brain Development.”

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PTSD Symptoms in Women May Increase Cardiovascular, Neurocognitive Disease Risk

High levels of posttraumatic stress disorder (PTSD) among women was associated with greater risk of carotid artery disease, according to a study in JAMA Network Open. Further, among women who tested positive for the Alzheimer’s risk gene APOEε4, greater PTSD symptoms were associated with greater brain small vessel disease and poorer cognitive performance.

“Women have double the risk of PTSD relative to men,” wrote Rebecca Thurston, Ph.D., of the University of Pittsburgh and colleagues. “PTSD is associated with a 50% to 60% increased risk of incident [cardiovascular disease] and elevated stroke and dementia risk. While evolving literature links PTSD to women’s cardiovascular and neurocognitive health, key questions remain.”

Thurston and colleagues analyzed data collected as part of the MsBrain study, which investigated menopause and brain health and included women aged 45 to 67. The data were drawn from the following measures:

• Genetic tests to determine if the participants had the APOEε4 gene.
• Carotid ultrasonographic examinations to measure the participants’ carotid intima media thickness, which is an indicator of carotid artery disease.
• MRI scans to measure the participants’ white matter hyperintensity or volume, which reflect small vessel disease and are linked to later dementia, cognitive decline, and mortality.
• Cognition tests to evaluate the participants’ attention and working memory, perceptual speed, memory, learning, letter fluency, semantic fluency, spatial ability, and global cognitive function.
• Assessments of the participants’ PTSD symptoms with the PTSD Checklist-Civilian Version, with higher scores indicating higher PTSD symptoms.

A total of 274 women were included in the study. Women with greater PTSD symptoms had higher carotid intima media thickness. Although the relationship between PTSD symptoms and carotid intima media thickness did not vary according to APOEε4 status, the researchers found the associations of PTSD symptoms with neurocognitive outcomes varied significantly by the participant’s APOEε4 status. Among the 64 participants who carried the APOEε4 gene, higher PTSD symptoms were associated with greater white mater hyperintensity or volume. Additionally, higher PTSD symptoms in APOEε4 gene carriers were associated with poor cognitive performance in multiple areas, including attention and working memory, semantic fluency, processing speed, and perceptual speed.

“These findings point to the adverse outcomes associated with PTSD symptoms for cardiovascular and neurocognitive health at midlife, particularly for women who are APOEε4 carriers,” the authors wrote. “PTSD is a major women’s health issue, affecting 10% of women in their lifetime. Our findings point to an at-risk population that may warrant early intervention and prevention efforts to reduce cardiovascular and neurocognitive risk at midlife and beyond.”

For related information, see the article “Cerebral Small Vessel Disease Progression and the Risk of Dementia: A 14-Year Follow-Up Study” in The American Journal of Psychiatry.

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Practicing Kindness Has Positive Impact on Mental Health, APA Poll Finds

In a world where much feels outside of our control, U.S. adults largely recognize the positive feelings that stem from practicing small acts of kindness.

This was one of the major takeaways from APA’s most recent Healthy Minds Poll, which asked 2,210 adults living in the United States about the ways in which they practice kindness, most often see others practicing acts of kindness, and more. According to the survey, 89% said that showing others kindness made them feel better, and 90% said receiving an act of kindness made them feel better.

Those polled were also asked to reflect on their feelings of anxiety over current events. (The survey took place October 16 to 19—less than two weeks after the attack by Hamas on Israel.) Two-thirds of respondents (67%) reported feeling anxious about international conflict—up 12% from last month’s poll.

“When we are feeling stressed or sad, doing something for others, no matter how small, boosts our mood,” said APA President Petros Levounis, M.D., M.A., in a news release. “Whether it is an innate response that rewards altruistic behavior or a mental reframing that puts positivity in the world, doing something for someone else makes us feel better.”

In the past three months, 93% of respondents did something kind, including 69% who had greeted a stranger, 68% who reported holding a door open for someone, and 65% who had given someone a compliment. Other ways that respondents reported practicing kindness included the following:

• 39% had checked in on someone who seemed down or depressed.
• 33% had donated goods to a charitable cause.
• 24% had donated money to a charitable cause.
• 19% had given up their seat for someone.
• 17% had paid for someone else’s tab.
• 11% had volunteered or participated in a charity event.

Those surveyed also reported on how they have felt in the past when others showed them an act of kindness. Some of the most common feelings included happiness (56%), gratitude (51%), and hope (29%).

“The next time you are in line to pay for food, tell the cashier to take care of the next person’s bill—say ‘I am paying it forward for the person behind me’ and leave. Then, consider what you have just done to make that person’s day and the smile it will bring them,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Especially now as we enter the holiday season, and especially as we encounter so many disturbing horrific events in the news, little gestures become meaningful in bolstering us in the day-to-day.”

The poll also asked respondents to reflect on what they are most grateful about as another holiday season begins. Most answered their family (70%), their partner (33%), their home (32%), and their physical health (31%).

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Psychiatrists, Patients See Important Gains in 2024 Medicare Physician Fee Schedule

APA advocacy scored important victories for psychiatrists and patients in the 2024 Medicare Physician Fee Schedule, released by the Centers for Medicare and Medicaid Services (CMS) last week. These include policies regarding physician reimbursement, outpatient telepsychiatry, MIPS (Merit-Based Incentive Payment System) reporting, and virtual supervision of trainees. The new policies will go into effect January 1, 2024.

Importantly, CMS accepted APA’s recommendation to increase the relative value units (RVUs) for psychotherapy codes used alongside a code for an evaluation and management (E/M) services by approximately 19.1%, phased in over four years. For 2024, this will result in an increase in payment for psychotherapy visits of between $3 and $6.

Additionally, CMS approved a new E/M add-on code (G2211), which can be used in addition to codes for outpatient E/M services to recognize the resource costs associated with care of patients with chronic or complex conditions.

The 2024 fee schedule also includes good news for psychiatrist in the following areas:

• CMS extended through 2024 the current temporary policy to reimburse outpatient telepsychiatry in the patient’s home (code POS 02) at the same rate as in-person care. (The patient’s home can include temporary lodgings or other community-based settings.)
• Medicare practitioners may continue to report their practice location instead of home address when providing telehealth services from their homes.
• Payment for telehealth services delivered by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) without a prior in-person visit will be extended through 2024.
• Through 2024, resident physicians can continue to be virtually supervised when they are delivering telehealth—an important APA advocacy priority. However, in-person care delivered by residents must still be supervised in person, and resident training sites should be prepared to provide in-person supervision beginning in January. (An exception to this is if the resident and patient are in rural areas; in which case virtual supervision is permitted.) This issue will continue to be an APA priority for the 2025 Medicare fee schedule.
• CMS will maintain the MIPS reporting threshold for neutral payment adjustments at 75% for an additional year, alleviating the pressure to increase MIPS reporting.
• CMS payment for audio-only periodic assessments in opioid treatment programs is extended through 2024.
• Services in intensive outpatient programs (IOP) will be covered when delivered by hospital outpatient departments, community mental health centers, RHCs, and FQHCs.

To learn more about what this news might mean for psychiatrists, register to attend APA’s 30-minute live discussion of 2024 Medicare Physician Fee Schedule & Telehealth Policy Updates next Thursday, November 16, starting at noon.

For more information, also see the 2024 Physician Fee Schedule fact sheet and look for additional coverage in the December issue of Psychiatric News.

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Clinical Trial Supports Use of Brexpiprazole for Alzheimer's Agitation, Study Suggests

The Food and Drug Administration’s decision to approve brexpiprazole (Rexulti) for the treatment of agitation related to Alzheimer’s disease in May was met with a mixed response. While some viewed the drug approval as a positive step for treating a common behavioral symptom of dementia, others questioned whether the benefits of the medication were worth the risk. Today, JAMA Neurology published the results of a key phase 3 clinical trial used in the FDA’s decision.

The trial of adults aged 55 to 90 with a diagnosis of probable Alzheimer’s disease who were experiencing agitation found that those who took brexpiprazole daily experienced a modestly greater drop in agitation behaviors over a 12-week period than those who took placebo. The study was funded by Otsuka Pharmaceutical and H. Lundbeck, co-developers of the drug.

“Treatment of agitation is essential to increase the comfort, quality of life, and safety of patients with Alzheimer dementia; to ease the burden on their caregivers; and to allow patients to live at home longer,” wrote Daniel Lee, M.D., of Otsuka and colleagues.

Lee and colleagues enrolled 345 adults with Alzheimer’s from clinical sites across Europe and the United States. The participants all had agitation symptoms that necessitated medication for at least two weeks prior to baseline screening. The participants also had to be living in a care facility or community-based setting and have a caregiver with enough contact to be able to describe the participant’s symptoms and behavior.

The participants were randomly assigned to 12 weeks of placebo (n=117), 2 mg brexpiprazole (n=75), or 3 mg brexpiprazole (n=153), taken orally once daily. The primary outcome was the participants’ change in Cohen-Mansfield Agitation Inventory (CMAI) scores after 12 weeks; the CMAI assesses the frequency of 29 physical and verbal agitation behaviors (such behaviors include kicking, pacing, and cursing), each on a 1 (never occurs) to 7 (occurs a few times an hour) scale. The CMAIs were filled out by clinicians following interviews with the participants’ caregivers.

The participants’ baseline CMAI scores were around 80. After 12 weeks, average CMAI scores dropped by 22.6 points in the combined brexpiprazole groups and 17.3 points in the placebo group, which was a statistically significant difference. Fifty-seven percent of participants taking brexpiprazole showed a meaningful change in agitation, defined as at least a 20-point CMAI reduction, compared with 37% of the placebo group.

Adverse side effects were reported by 40.7% of participants taking brexpiprazole and 31.0% of those taking placebo. Headache was the only side effect with an incidence of greater than 5% in the brexpiprazole group. “At week 12, weight gain of 7% or more from baseline was experienced by 3 of 196 patients (1.5%) in the brexpiprazole, 2 or 3 mg, group and 0 of 104 in the placebo group,” the authors added. Additionally, one patient taking brexpiprazole died of cardiac arrest, but an “autopsy revealed coronary atherosclerosis, and the death was considered unrelated to brexpiprazole,” the authors wrote.

“There are some clear pathways for further research that would build on the evidence provided by this study and inform the optimal use of brexpiprazole in people with AD,” wrote Clive Ballard, M.D., Ph.D., of the University of Exeter Medical School, United Kingdom, in an accompanying editorial. “The first will be to evaluate its efficacy and safety in the frailest patient groups with AD with more severe dementia and more serious comorbidities through studies in nursing home settings. This is particularly important as these individuals are at highest risk of neuropsychiatric symptoms and are most likely to be prescribed antipsychotic drugs.”

To read more on this topic, see the Psychiatric News article “FDA Approves Rexulti for Agitation Associated With Dementia Due to Alzheimer’s Disease.”

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APA Collaborates With Other Medical Associations to Release New Addiction Resource Documents

Yesterday, APA joined three other major medical associations in releasing two resource documents listing the top 10 facts that both the public and every physician should know about addiction.

APA worked with the American Academy of Addiction Psychiatry, the American Academy of Family Physicians, and the American Society of Addiction Medicine to develop the resource documents. The lists are a product of a meeting of medical association leaders that APA President Petros Levounis, M.D., M.A., convened this past summer. The meeting focused on ways that physicians can work together to combat addiction.

“Top Ten Things Everyone Should Know About Addiction” provides basic facts about addiction, such as the importance of talking openly with kids about the risks of substance use to help prevent addiction. It also includes facts about treatment, such as that returning to substance use is a common part of the recovery process and does not mean treatment failed. The list’s top five items include the following:

• Addiction is treatable with medications, therapy, and other supports, including group, individual, and family/friend integrated approaches.
• No one chooses to develop an addiction; addiction is not caused by a moral defect.
• Addiction can affect anyone; some groups of people are more impacted by addiction because of societal marginalization and discrimination.
• Opioid overdose can be reversed by medications such as naloxone and nalmefene.
• We can help prevent and treat addiction by recognizing the signs of addiction and encouraging treatment.

“Top Ten Things Every Physician Should Know About Addiction” emphasizes the judgment that patients often face and encourages physicians to reduce stigma by spreading the message that addiction is a treatable chronic illness. It also dispels myths around substance use, stating that there is no healthy amount of use of an addictive substance, including alcohol. The list’s top five items include the following:

• We already see patients with addiction in our practices. Nonjudgmental screening can identify patients with addiction, and education and referrals can encourage treatment.
• Early identification of substance misuse and intervention saves lives, reduces harm, and promotes well-being for patients and their families.
• There are effective medications and psychotherapy treatments for addiction.
• Treating addiction does not require specialty training or referrals to ancillary clinical services for every patient.
• Addiction is a relapsing-remitting chronic brain disease. Return to use is a common part of the recovery process.

“These resources, with succinct and powerful facts about addiction, are aimed at helping to raise awareness, increase understanding, and combat the stigma associated with addiction and seeking treatment,” the APA news release stated.

For related information, see the Psychiatric News article “Levounis Convenes Medical Leaders to Collaborate on Addiction.”

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Report Finds VA’s Prescribing of Benzodiazepines to Homeless ‘Risky,’ ‘Inappropriate’

Homeless veterans with mental illness who use Veterans Affairs (VA) health services are less likely to receive prescriptions for benzodiazepines than those with mental illness who are not homeless, according to a report published this week in Psychiatric Services. When homeless veterans are prescribed benzodiazepines, however, they appear more likely than their peers to receive prescriptions that put them at risk for substance use disorder, overdose, and death, the study found.

Drug overdose is a leading cause of death among homeless people, and benzodiazepines are often implicated in such overdose deaths, wrote Katherine Koh, M.D., M.Sc., of Massachusetts General Hospital–Harvard Medical School and colleagues.

“Asking patients about whether and how they combine substances and counseling them about these risks should be part of clinical conversations about benzodiazepine prescribing,” Koh and colleagues wrote.

The researchers examined 2018-2019 national data from the VA, specifically focusing on benzodiazepine prescribing among 244,113 homeless veterans with mental illness and 2,763,513 veterans with mental illness who were not homeless. All veterans included in the study had a primary or secondary diagnosis of a mental illness, as determined by ICD-10 codes. Veterans were categorized as being homeless if they had used any VA homelessness program.

The benzodiazepines most frequently prescribed to veterans included lorazepam, clonazepam, alprazolam, and diazepam. The researchers found that 9.4% of veterans who were not homeless were prescribed benzodiazepines at the VA compared with 7.5% of veterans who were homeless—a difference that the authors noted was statistically significant. Other findings included the following:

• Homeless veterans who sought VA care also had a higher rate of concurrent benzodiazepine prescriptions than those who were not homeless (9.4% vs. 7.0%).
• Homeless veterans who sought VA care had a higher rate of concurrent prescriptions for benzodiazepines and opioids than those who were not homeless (36.9% vs. 31.2%), especially oxycodone (12.4% vs. 9.7%) and hydrocodone (13.9% vs. 12.3%) or sedatives (61.9% vs. 45.9%).
• Of those with a benzodiazepine prescription, alcohol use disorder was more prevalent in the group who was homeless relative to the group who was not homeless (24.2% vs. 5.4%), as was drug use disorder (24.3% vs. 3.8%). (Drug use disorder was defined as a substance use disorder other than alcohol use disorder.)

“Structured approaches to the benzodiazepine conversation … may be useful for providers who find themselves in the dilemma of not wanting to prescribe benzodiazepines because of safety issues while striving to maintain a therapeutic alliance,” the authors wrote. This conversation should include nonpharmacologic strategies and interventions to treat conditions, such as anxiety or insomnia.

For related information, see the Psychiatric News article “M.D.s Call for Community Resources Amid Plans to Force Homeless Into Care.”

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