Higher Daily Step Counts Associated With Fewer Depression Symptoms Among Adults

Another reason to lace up your sneakers: higher daily step counts are associated with fewer depressive symptoms in cross-sectional and longitudinal studies of the general adult population, according to a meta-analysis issued yesterday by JAMA Network Open.

“The results of meta-analytic studies have consistently indicated that higher levels of [physical activity] provide protection against the emergence of depression,” wrote Bruno Bizzozero-Peroni, Ph.D., M.P.H., at the Universidad de Castilla-La Mancha in Cuenca, Spain, and colleagues. “Light-intensity activities, such as walking, may constitute an adequate form of [physical activity] for reducing the risk of depression.”

The researchers compiled data on all published observational studies that objectively measured daily step counts and also examined depression outcomes. They found 27 cross-sectional studies and six longitudinal studies involving 96,173 adults across five continents.

Compared with a more sedentary lifestyle, walking 5,000 or more steps a day was associated with fewer depressive symptoms among the cross-sectional studies, with slightly higher benefits seen at 7,500 and 10,000 daily steps.

Further, among cross-sectional studies that measured depression as a categorical outcome, achieving 7,500 or more steps a day was associated with a 42% lower prevalence of depression compared with walking less than 7,500 steps a day. These findings were corroborated by the cohort studies, which found that adults who increased their activity by 1,000 steps a day had a 9% lower risk of developing depression, while those who accumulated 7,000 or more steps a day had a 31% lower risk.

The researchers noted that it cannot yet be established whether there is a ceiling above which there would be no additional benefit from increasing steps. Furthermore, the study did not discriminate between various types of physical activity or examine the role of other potential physical activity–related benefits, such as social well-being. The researchers noted that the optimal number of steps to prevent depression may vary according to sex, age, and individual risk of mental disorders.

“Our results showed significant associations between higher numbers of daily steps and fewer depressive symptoms as well as lower prevalence and risk of depression in the general adult population,” the researchers wrote. “The objective measurement of daily steps may represent an inclusive and comprehensive approach to public health that has the potential to prevent depression.”

For related information, see the Psychiatric News article “Exercise Is Neuroplastic Medicine.”

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Majority of Patients Want to Know if AI Is Used in Their Health Care

Are you using artificial intelligence (AI) in the care you offer patients? Chances are they want to know that. A study in JAMA Network Open suggests that more than half of patients wish to be notified when AI is used in their health care.

Jodyn Platt, Ph.D., M.P.H., of the University of Michigan Medical School, and colleagues conducted a survey of 2,021 adults from June 27 to July 17, 2023. The survey included a video that described how AI is used in health care and scenario-based questions that provided examples. Participants were asked how true it was that “It is important that I am notified about the use of AI in my health care.” Options were “not at all true,” “somewhat true,” “fairly true,” and “very true.”

More than half—62.7%—of participants stated it was “very true” that they want to be notified, whereas only 4.8% of participants did not find notification important. Females expressed greater desire for notification than males, and White respondents expressed greater desire for notification than Black or Hispanic respondents.

The authors noted that the average level of desire to be notified about AI was higher than found in a previous survey using the same scale that asked about notification when using patients’ health information or biospecimens.

“[O]ur findings suggest that notification about AI will be necessary for ethical AI and should be a priority for organizations and policymakers,” Platt and colleagues wrote. “With this signal about the public’s preference for notification, the question for health systems and policymakers is not whether to notify patients but when and how. As health systems begin to establish governance for AI tools, multiple approaches to notification will be needed.”

For related information, see the Psychiatric News article “AI in Psychiatry: What APA Members Need to Know.”

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Community Stabilization Programs May Reduce Psychiatric Boarding Among Youth

Youth who experience a mental health crisis and participate in a community stabilization program are significantly less likely to return to an emergency department (ED) or inpatient psychiatric unit, according to a study issued yesterday in Psychiatric Services.

Rebecca Marshall, M.D., M.P.H., of the Oregon Health & Science University, and colleagues used data from the Oregon Health Authority’s Crisis and Transition Services (CATS) program. Youth qualified for CATS if they were at risk for boarding in the ED due to safety concerns, severe depression or anxiety, or other mental health concerns that impaired their functioning. CATS provided 24/7 crisis response, crisis safety planning, short-term clinical interventions, and connections to longer-term services. Services lasted for 45 days after enrollment.

The researchers included 533 youth ages 11 to 17 years (69% female) who participated in CATS from 2018 to 2020. Using All Payer All Claims data, each participant was matched with two controls (n=1,066) of the same sex and similar age who had the same reason for an ED or inpatient care visit. One control group included those discharged from an inpatient hospital or psychiatric unit, while the other included those discharged from the ED. Youth in the control groups received either behavioral health treatment that did not include CATS or no treatment at all.

CATS participants were significantly less likely than those who did not participate to return to the ED or require inpatient hospitalization in the year after their initial mental health crisis. While the risk of returning to the ED for a suicide attempt was similar for CATS participants and nonparticipants, the risk of receiving hospitalization for a suicide attempt was significantly lower for those enrolled in CATS.

“This finding suggests that, although CATS may not reduce suicide attempts overall, youths in this program were able to return home rather than be hospitalized in an [inpatient] unit, thereby decreasing the burden placed on EDs to board youths and allowing youths to stay in the community,” the researchers wrote.

“This study suggests that community-based crisis intervention programs with an array of services and that focus on bridging youths to longer-term services may represent a safe and effective alternative to ED boarding for some youths with high-acuity behavioral health needs,” the researchers concluded.

For related information, see the Psychiatric News article “Oregon Pilot Program Would Expand MH Crisis Services for Youth.”

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CBT Plus Lisdexamfetamine Dramatically Reduces Binge-Eating Episodes, AJP Study Finds

Combining cognitive behavioral therapy (CBT) with lisdexamfetamine (LDX) reduced binge-eating frequency in adults with binge-eating disorder by more than 95%—significantly greater than either treatment alone, according to a clinical study published yesterday in the American Journal of Psychiatry. However, CBT or LDX alone still resulted in robust binge-eating reduction.

“The superiority of the combined … approach might reflect, in part, complementary and synergistic effect of the two treatments,” wrote Carlos M. Grilo, Ph.D., of Yale University School of Medicine, and colleagues. “CBT and LDX likely operate via distinct mechanisms (the former via reducing unhealthy restraint and unstructured eating and addressing the core body-image disturbance and the later via eating regulation and reward effects and reduced impulsivity) and one can speculate that some of the LDX effects on improving executive functioning might enhance ability to derive greater benefit from CBT.”

Grilo and colleagues enrolled 141 adults ages 18 to 64 (83.7% women) with binge-eating disorder and comorbid obesity. The participants were equally divided into one of three treatment arms for 12 weeks: CBT only, LDX only (target dose of 50 to 70 mg/day), or CBT+LDX. The CBT involved 12 weekly 60-minute sessions and focused on helping individuals identify maladaptive eating thoughts and behaviors and work toward normalized eating patterns.

After 12 weeks, participants who received CBT+LDX reported a 96.1% decrease in the frequency of binge-eating episodes in the past 28 days; further, 70.2% of participants achieved remission (zero binge-eating episodes in the past 28 days). Patients in the CBT and LDX groups also reported significant binge-eating declines, although only 44.7% and 40.4%, respectively, achieved remission.

In terms of weight loss, those receiving CBT+LDX or LDX lost an average of 4.8% and 5.5% of their baseline body weight, respectively, while those receiving only CBT lost 0.5% of their baseline weight.

For related information, see the American Journal of Psychiatry study “Naltrexone-Bupropion and Behavior Therapy, Alone and Combined, for Binge-Eating Disorder: Randomized Double-Blind Placebo-Controlled Trial.”

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New Schizophrenia Drug Shows Marked Effect on Cognitive Deficits

Individuals with schizophrenia and cognitive deficits who were treated with the combination of xanomeline and trospium chloride showed clinically significant improvements in cognition compared with those receiving placebo, according to a report today in the American Journal of Psychiatry. The results, pooled from two Phase 3 clinical trials, replicate cognitive benefits seen in smaller studies.

Xanomeline/trospium chloride was approved for use by the U.S. Food and Drug Administration (with the brand name Cobenfy) in September 2024 for the treatment of schizophrenia in adults. Cognitive deficits are a stubborn feature in many cases of schizophrenia that significantly affect long-term trajectory and daily functioning.

“Collectively, the xanomeline/trospium clinical studies reflect the first time a monotherapy for the treatment of schizophrenia has shown a replicable cognitive benefit,” wrote lead author William Horan, Ph.D., executive director of clinical development at Bristol Myers, and colleagues. This study was sponsored by Karuna Therapeutics, a Bristol Myers Squibb company.

Across the two trials, 357 patients with acute schizophrenia were randomly assigned to receive oral xanomeline/trospium or placebo twice daily for five weeks. Most participants assigned to xanomeline/trospium were taking the maximum dosage of 125 mg/30 mg twice daily at week 5, with the remainder taking an intermediate dosage of 100 mg/20 mg.

Participants completed a computerized assessment of four key cognitive domains (executive function, visual memory, sustained attention, and verbal recall and recognition) at baseline, week 3, and week 5. Overall, 137 participants had significant cognitive deficits at baseline.

Among patients with cognitive impairment, those receiving xanomeline/trospium showed a significantly larger improvement in their cognitive scores from baseline to week 5 than the placebo group, with a calculated effect size of 0.54 (indicating a moderate level of improvement). The largest difference in performance between the xanomeline/trospium and placebo groups observed at week 5 was for verbal recall and recognition.

The effect remained significant after accounting for changes in positive and negative symptoms—suggesting that the effect on cognition is independent of improvement in psychotic symptoms. As with previous studies, there was no evidence of cognitive benefit for xanomeline/trospium when analyzing the full sample of 357 participants.

Cobenfy is the first drug approved for schizophrenia that does not act on dopamine (D2) receptors in the brain; rather it targets muscarinic acetylcholine receptors in areas of the brain more central to the cognitive and behavioral symptoms of schizophrenia.

For related information, see the Psychiatric News article “Questions and Excitement About New Schizophrenia Drug.”

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New Guideline Advises Metformin to Prevent Antipsychotic-Induced Weight Gain

Clinicians should prescribe metformin when initiating an antipsychotic in order to prevent weight gain in many cases, according to a new evidence-based guideline issued by Schizophrenia Bulletin yesterday.

“A 2022 Cochrane review of pharmacological interventions for the prevention of AIWG (antipsychotic-induced weight gain) found that metformin was the only pharmacological agent that may be effective for preventing weight gain when started with an antipsychotic,” wrote Aoife Carolan, M.Pharm., at Saint John of God Hospital and the Royal College of Surgeons in Dublin, and colleagues. “Despite this, metformin for the prevention of AIWG is not routinely offered in psychiatric practice.”

Carolan and colleagues developed the guideline utilizing the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to ensure a high standard was followed. This included undertaking a comprehensive review of the literature and having the guideline findings reviewed by an independent panel of experts.

The guideline offered three core recommendations:

• Initiate metformin when prescribing a high-risk weight-inducing antipsychotic, such as olanzapine or clozapine.
• Initiate metformin with a medium-risk antipsychotic (quetiapine, paliperidone or risperidone) in patients with one or more cardiometabolic risk factors; in people ages 10 to 25 years; or for those with a BMI between 25 and 30.
• Initiate metformin with any antipsychotic if >3% increase in baseline body weight is observed during the first year of treatment.

In terms of dose, the new guideline recommends escalating from 500 mg daily to 500 mg twice daily over two weeks, followed by biweekly increases of 500 mg as tolerated up to 1 g twice daily at week 6. Metformin should be discontinued if risks for lactic acidosis are present, or the condition is suspected; if body mass index falls below 20; or if the antipsychotic medicine is discontinued. Metformin should be avoided where there is harmful use of alcohol.

Though the guideline focused on metformin, it also recommended that, if available, GLP-1 agonists should be considered for patients with a BMI above 30, certain cardiometabolic diseases, or obstructive sleep apnea.

For related information, see the Psychiatric News article “Metformin May Reduce Weight Gain in Youth Taking Antipsychotics.”

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Study Calculates Huge Mental Health Cost of Leaded Gasoline

Exposure to lead via car exhaust in the first five years of life may be responsible for an estimated 151 million excess mental disorders in the United States, according to a study in the Journal of Child Psychology and Psychiatry.

Michael J. McFarland, Ph.D., and colleagues at the University of Florida used data from the National Health and Nutrition Examination Surveys (NHANES) and historic data on leaded-gasoline consumption to estimate early life blood-lead levels from 1940 to 2015. McFarland and colleagues then calculated general psychopathology points (or p-factor points), gained by the U.S. population based on the level of early-life exposure. P-factor points roughly equate mental illness risk in that every three points gained by an individual above a certain threshold will result in one new psychiatric diagnosis. In addition to general psychopathology, the researchers calculated points for three behavioral subdomains known to be adversely affected by lead exposure: internalizing symptoms, attention-deficit/hyperactivity disorder (ADHD) symptoms, and the personality traits of neuroticism and conscientiousness.

Assuming that published lead-psychopathology associations are causal and not purely correlational, the researchers found that by 2015 the U.S. population had gained 602 million general psychopathology points as a result of childhood lead exposure. This equates to around 1.9 points per person, and potentially 151 million excess mental disorders. By 2015, the U.S. population had also:

• Gained 202 million internalizing symptom-points
• Gained 135 million ADHD symptom-points
• Gained 45 million neuroticism points
• Lost 63 million conscientiousness points

The association between lead exposure and mental illness was most pronounced in individuals born between 1966 and 1986, most of whom belong to Generation X and were children during the peak use of leaded gasoline.

“Large swaths of the population likely experienced elevated lead-linked mental illness symptomatology and altered personality, with significant implications for national well-being, innovation, economic productivity, need for and use of psychiatric services, and the prevalence of physical comorbidities, all of which bear individual investigation and estimation,” the researchers wrote. “The contribution of legacy lead exposures to population health and disease may be much larger than previously assumed.”

For related information, see the Psychiatric News article “Mental Health Impact of Air Pollution in the Southeast Asian Subcontinent.”

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Having a Geographically Diverse Social Network May Boost Mental Health

Individuals who have a diverse social network that spans multiple communities are less likely to use antidepressants, according to a spatial analysis published today in Science Advances.

A rich amount of research has shown that “bonding” social capital—having strong social support within a community—can reduce stress, anxiety, and depression, noted Balázs Lengyel, Ph.D., of the Corvinus University of Budapest, and colleagues. “Fewer investigators have argued for or explored the importance of diverse networks that can mobilize ‘bridging’ social capital, despite their pivotal role in providing, say, economic opportunities that subsequently influence health outcomes,” they wrote.

Lengyel and colleagues used data from the Hungarian National Healthcare Service Centre to assess antidepressant purchases from 2011 to 2015 for all Hungarians living in small towns (5,000 to 20,000 population). They linked that data to individuals’ social networks in 2011 using the International Who Is Who social media site, where people could create an online phone and address book of their friends. A total of 277,344 individuals had both antidepressant and social network information available.

The analysis found that both higher local cohesion—having a strong, connected group of friends within a town—and higher spatial diversity—having friends in diverse communities across the country—were associated with fewer days of antidepressant use over five years. However, the association was significantly greater for spatial diversity than local cohesion. The benefits of spatial diversity were also greater for younger individuals than older ones.

“Bridging social capital is extremely important for members of geographically isolated communities, where the lack of outside connections can make bonding social capital and cohesive social networks possibly even harmful for mental health by placing too much control on the individual, or by isolating the individual in an unhealthy social environment,” Lengyel and colleagues wrote.

“Whether our findings hold in large cities where local networks can provide more diversity is a question to be answered,” the researchers continued. “Social media can also spoil mental health; thus, we need a better understanding how the role of online and offline communication networks changes over time.”

For related information, see the Psychiatric News article “Faith Communities Are Potent Resource for Creating Connection and ‘Mattering’.”

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Meta-Analysis Finds Trauma-Focused CBT Most Effective Psychological Treatment for Pediatric PTSD

Compared with other psychological treatments, trauma-focused cognitive behavioral therapies (TF-CBTs) are associated with the greatest reduction in pediatric posttraumatic stress disorder (PTSD) symptoms, according to a study issued yesterday in JAMA Psychiatry.

Thole Hoppen, Ph.D., of the University of Munster, Germany, and colleagues conducted a systematic review and meta-analysis of how psychological interventions for pediatric PTSD performed compared with either a passive (e.g., wait-list) or active (e.g., psychoeducation) control. They looked at four interventions: TF-CBTs (any CBT-based intervention with a trauma focus, such as prolonged exposure or cognitive process therapy), eye-movement desensitization and reprocessing (EMDR, which uses eye movements or other external stimuli to speed up the trauma healing process), non-trauma-focused interventions, and multidisciplinary treatments (treatments that combine techniques).

The researchers identified 70 randomized clinical trials that had at least 10 participants in both the intervention and control groups. The trials’ 5,528 participants were 19 years old or younger (average age of 12) with full or subthreshold PTSD. Most (74%) of the trials examined TF-CBTs.

All the psychological interventions were associated with significantly larger reductions in pediatric PTSD than passive controls, but TF-CBTs had the highest reductions both immediately posttreatment and long term (six or more months after treatment). After TF-CBTs, the order of most effective interventions was EMDR, multidisciplinary treatments, and non-trauma-focused interventions. EMDR was associated with significant reductions in PTSD immediately posttreatment and up to five months later, but the authors noted that data on long-term improvements was lacking. TF-CBTs were also the most effective treatment when compared with active controls, when restricting analyses to high-quality trials, and when only including trials that involved parents.

“The findings suggest TF-CBTs should be the first-line treatment recommendation for pediatric PTSD,” the authors wrote. They added that “disseminating these results may help reduce common treatment barriers by counteracting common misconceptions, such as the notion that TF-CBTs are harmful rather than helpful.”

The authors continued: “[W]hile data for other treatment approaches are emerging with some promising findings, more data (including long-term data) are needed to draw firmer conclusions.”

For related information, see the Psychiatric News article “Trauma-Focused CBT, Racial Socialization Build Resilience in Black Youth.”

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Donepezil Found Effective for Improving Memory After Traumatic Brain Injury

Donepezil, an acetylcholinesterase inhibitor, appears to be an effective treatment for severe, persistent verbal memory impairment after traumatic brain injury, according to a report in the Journal of Neuropsychiatry and Clinical Neurosciences.

Although the sample size was small, improvements in other cognitive domains such as processing speed were also observed in patients who responded to donepezil.

“Verbal memory impairments are common and persistent problems among persons with moderate to severe traumatic brain injury, interfere with everyday function, and are among the most important barriers to functional independence and productivity,” wrote lead author David Arciniegas, M.D., of the University of Colorado School of Medicine, and colleagues.

Arciniegas and colleagues randomized 75 patients with mild, moderate, or severe traumatic brain injury to receive donepezil 5 mg daily for two weeks followed by donepezil 10 mg daily for eight weeks or placebo for 10 weeks. After the 10-week treatment period, treatment was discontinued, and patients were observed for an additional four weeks. All patients were at least six months out from their injury.

Verbal learning as assessed by the Hopkins Verbal Learning Test–Revised was the primary outcome measure in this study. Secondary outcomes included co-occurring cognitive and noncognitive neuropsychiatric problems, and functional status.

Donepezil significantly improved verbal learning when compared with placebo. Overall, 42% of patients taking donepezil responded to treatment (defined as at least a 0.5-standard-deviation improvement in the Hopkins test total score), compared with 18% of those taking placebo. Among patients who responded to donepezil, improvements were also observed in other aspects of memory recognition and retention, attention, and executive function. The researchers observed no differences in improvement of everyday memory function (such as conversational memory) between the donepezil and placebo groups.

“Studies evaluating augmentation of evidence-based cognitive rehabilitation with donepezil, or other acetylcholinesterase inhibitors, are needed to better define the potential usefulness of such medications in the rehabilitation and long-term care of persons with persistent verbal memory impairments after [traumatic brain injury],” the authors concluded.

For more information, see the Psychiatric News article “Understanding the Breadth and Depth of the Subspecialty: TBI and Neuropsychiatry.”

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Contingency Management App Improved OUD Treatment Outcomes

Augmenting medications for opioid use disorder (MOUD) with smartphone app–based contingency management resulted in improved treatment outcomes in a group of underinsured patients, according to a study issued yesterday in JAMA Network Open.

Traditionally delivered in clinics, contingency management (CM) provides financial incentives for accomplishing treatment goals, typically an opioid-negative finding on urine drug screens, wrote Elise N. Marino, Ph.D., from the University of Texas Health Science Center at San Antonio, and colleagues. “Although many individuals benefit from adding CM to MOUD, a long-standing limitation of this treatment is the requirement to attend multiple in-person appointments per week.”

The researchers used data from 3,759 uninsured or underinsured adults with opioid use disorder who were receiving publicly funded opioid treatment—including MOUD—from physicians’ offices or specialized clinics in Texas from November 2020 through November 2023. Participants were also given the option to receive a smartphone app–delivered CM program for one year. The app provided online individual and group support facilitated by peers; daily goal setting related to both substance use and recovery/self-care; encouragement; progress-tracking; and the ability to earn up to $800 in retail gift cards as an incentive.

In all, 622 participants (16.5%) opted to take part in the app-based CM. The researchers compared treatment outcomes of 300 participants who used the CM app with 300 participants who were similar in terms of age, sex, race, and ethnicity and chose to receive only MOUD.

Participants who chose the CM app reported significantly fewer days of opioid use at the end of treatment (8 days) compared with those who chose to receive MOUD only (12 days). Overall, 62% of the CM app group remained in treatment for the full year, compared with just 39% of the MOUD-only group. App participants were also significantly more likely to stay in treatment longer (290 days), compared with 236 days among MOUD-only participants.

“As a virtual treatment, app-based CM has fewer infrastructure barriers to implementation and should provide opportunities for rapid dissemination to patients,” Marino and colleagues wrote. “[H]owever, less than one-fifth of our entire sample chose to use it. Obtaining, owning, and navigating app-enabled devices may be barriers for some patients, and these apps require consistent use, which may become burdensome or unappealing over time, leading to low use. It is also possible that clinicians themselves may benefit from additional education and training to support adoption.”

For related information, see the Psychiatric News article “Experts Discuss Options for Treating Stimulant Use Disorder.”

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Behavioral Activation Therapy May Improve MH in Older People Who Have Been Abused

Psychotherapy based on the principles of behavioral activation may help reduce depressive symptoms and thoughts of suicide in people who have experienced elder abuse, according to a study published today in the American Journal of Geriatric Psychiatry.

Isabel Rollandi, Ph.D., of the Weill Cornell Institute of Geriatric Psychiatry, and colleagues examined data from 158 participants ages 60 or older who had experienced elder abuse. All participants had depressive symptoms as shown by a score of at least 10 on the nine-item Patient Health Questionnaire (PHQ-9) but did not have significant cognitive impairment. The researchers also collected data on the participants’ demographics, abuse history, and thoughts of suicide (PHQ-9 item 9) at baseline. The most prevalent abuse was emotional/psychological abuse, reported by 78.5% of participants, followed by verbal abuse, reported by 67.1%.

All participants completed 10 weeks of PROTECT therapy either in person or on the phone. PROTECT therapy consists of 45-minute sessions as follows:

• One to three sessions that include discussions and psychoeducation about stress and depression, and to formulate the participants’ treatment goals related to the abuse, such as taking steps to promote safety or improving self-care.
• Four to eight sessions to develop action plans to increase engagement in specific pleasurable and socially rewarding activities and meet the goals set.
• Two sessions to discuss how the participant was faring in accomplishing goals and to work on strategies to maintain gains after completing the therapy.

At the end of treatment, scores on the PHQ-9—which was administered at the start of each session—dropped a mean of 5.58 points among participants who reported thoughts of suicide at baseline and 5.25 points among those without thoughts of suicide at baseline. In addition, the percentage of participants who reported thoughts of suicide decreased from 19% at baseline to 5.7%.

“These findings suggest that a brief intervention for depression delivered in the community can significantly contribute to reducing depressive symptoms in elder abuse victims regardless of depression severity and presence of [thoughts of suicide],” Rollandi and colleagues wrote. “Furthermore, it shows that a depression intervention can reduce suicidal ideation frequency, contributing to decreasing mortality risk in this vulnerable population. These results highlight and reaffirm the imperative to address the mental health needs of elder abuse victims and to deliver effective and scalable psychotherapy treatments that can be integrated in the community.”

For related information, see the Psychiatric News article “Abuse of Older People Increases During Pandemic.”

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Holidays Bring Anxiety for Some but Continue to Be a Source of Merriment for Many

Holidays can be stressful. This year, nearly a third of Americans (28%) say they anticipate more holiday-related stress than last year, according to the latest APA Healthy Minds Monthly Poll. Yet the holidays also remain a season of joy for many: Nearly two-fifths (38%) of adults say the holidays positively impact them.

“Although there are several different holidays we celebrate in December, many of us share the same anxiety and excitement about preparing for them,” said APA President Ramaswamy Viswanathan, M.D., Dr.Med.Sc. “Holiday stress is normal, and as psychiatrists, we understand that the social determinants of mental health can and do influence the experience of the winter holidays.”

This poll, fielded by Morning Consult on behalf of APA, was conducted Nov. 16-17 among 2,201 adults.

When thinking about this holiday season, adults reported they are worried most about missing someone (47%), affording gifts (46%), affording meals (36%), and challenging family dynamics (35%). Smaller percentages of adults worried about loneliness during the holidays (39%) and discussing politics with loved ones (32%). Younger people and parents were more likely to have these worries.

On the positive side, 41% of adults said that being able to see family and friends was the thing they were most looking forward to this upcoming holiday season, followed by 24% of adults who were looking forward to eating good food.

Apart from the holidays, adults continue to be anxious about the economy (75%), gun violence (64%), and hate speech and hate crimes (60%). Many adults also reported feeling anxious about international conflict (57%), climate change (56%), artificial intelligence (52%), and reproductive rights (50%), but those levels have dropped a few percentage points since August 2024. Anxiety around the 2024 election has also dropped significantly now that it is over: 50% said they are anxious now compared with 72% prior to the election.

For related information, see the Psychiatric News article “Dolce-Amaro December.”

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Low-Resource Patients With OUD Engaged With Collaborative Care Intervention

Patients with co-occurring mental illness and opioid use disorders in a low-resource community engaged with a collaborative care treatment program and stuck with it, according to a study in JAMA Network Open today.

“Opioid use disorders (OUDs) remain undertreated, particularly when co-occurring with mental illness,” wrote Katherine E. Watkins, M.D., M.S.H.S., with the RAND Corporation in Santa Monica, California, and colleagues. “The collaborative care model (CoCM), an evidence-based approach for integrating behavioral health treatment in primary care, offers a potential solution, but the extent to which the CoCM can engage high-risk populations with fidelity in community settings is poorly understood.”

Watkins and colleagues tapped into data from a randomized clinical trial in 14 low-resourced primary care clinics in New Mexico involving adults with probable OUD and co-occurring mental illness who were assigned to a six-month CoCM program between 2021 and 2023. About one-quarter of the adults had used fentanyl or heroin in the 30 days prior to enrollment, and three-quarters were prescribed medications for OUD.

The CoCM deployed addiction-certified psychiatric consultants, primary care clinicians, and community health workers as care managers, supported by a caseload tracking tool. Engagement was defined as participating in an intake interview, while fidelity was defined as having at least two care manager encounters, at least two assessments of OUD and mental health symptom severity, and a treatment plan review by a psychiatric consultant.

Of the 369 adults assigned to the CoCM, 297 participants (81%) engaged with it. Of those who engaged, 206 (69%) stuck with the CoCM, with a median of nine care encounters. Rates varied by substance used: Just 54% of individuals with stimulant co-use participated with fidelity, whereas 81% of those who misused only prescription pain medication did so.

Further work is needed to determine whether fidelity to the CoCM is associated with positive patient outcomes, the authors wrote. Limitations included the study’s use of observational data from one arm of a clinical trial in just one state with high OUD rates.

“Our results indicate that the CoCM may offer a solution to the undertreatment of OUD for patients with complex conditions,” researchers wrote. “When community health workers are used, the CoCM may be an efficient approach to address behavioral health professional shortages.”

For related information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

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Wildfire Smoke Linked to Increased Risk of Dementia

Long-term exposure to particulate matter found in wildfire smoke may raise the risk of dementia, according to a study published today in JAMA Neurology. The findings also suggest that wildfire particulate matter increases the risk more than non-wildfire particulate matter.

Holly Elser, M.D., Ph.D., of the University of Pennsylvania, and colleagues examined data from more than 1.2 million members of Kaiser Permanente Southern California. Patients were at least 60 years old and did not have dementia when they were first included in the study.

The researchers estimated the average daily concentrations of total fine particulate matter in each Southern California census tract from 2006 to 2019 using measurements from the Environmental Protection Agency Air Quality System, and then used additional federal and state meteorological data to subtract the contribution of wildfire-generated fine particulate matter from the total. The researchers then calculated three-year rolling periods of particulate exposure (updated every three months) for each patient.

During follow-up, 6.6% of patients received a diagnosis of dementia, with most of the diagnoses being for nonspecific dementia. The researchers found an 18% increase in the odds of dementia for every 1-µg/m³ increase in three-year average wildfire fine particulate matter. For non-wildfire fine particulate matter, the odds of dementia diagnosis increased by just 1% for every 1-µg/m³ increase in three-year average exposure.

In a secondary analysis, the researchers found that the associations between exposure to wildfire fine particulate matter and dementia were stronger among patients younger than 75 when they were included in the study, patients from racially minoritized subgroups, and patients living in high-poverty census tracts compared with low-poverty census tracts.

“These latter findings underscore the importance of research that considers the effects of air pollution on potentially vulnerable population subgroups and aims to identify potential strategies to mitigate inequities in air pollution exposure effects,” Elser and colleagues wrote—though they cautioned that by relying on EHR data they could not fully account for all socioeconomic or behavioral factors that may raise or mitigate the potentially damaging effects of wildfire smoke.

For related information, see the Psychiatric News Alert “Air Pollution Exposure May Be Linked to Late-Onset Depression.”

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Short-Term Menopausal Hormone Therapy Does Not Affect Long-Term Cognition, Study Finds

Short-term menopausal hormone therapy does not appear to have any long-term cognitive effects, either positive or negative, according to a study published yesterday in PLoS One.

The study findings were part of a long-term follow-up of participants in the Kronos Early Estrogen Prevention Study (KEEPS), in which women in early postmenopause and with good cardiovascular health were randomized to four years of oral estrogen, transdermal estradiol, or placebo. At the end of four years, no cognitive benefit or harm was seen in women who received estrogen compared with those who received placebo.

For the follow-up study, Carey Gleason, Ph.D., M.S., of the University of Wisconsin-Madison, and colleagues brought back 275 KEEPS participants after the original study ended—over a range of eight to 14 years. The women completed the same cognitive tests as years before, including an assessment of global cognitive function along with 11 tasks spanning four cognitive domains: verbal learning and memory; auditory attention and working memory; visual attention and executive function; and speeded language and mental flexibility.

The researchers identified no significant differences in global cognition or any of the four domains between women who had taken either hormone treatment and those who did not—both in the head-to-head performance during follow-up and in the change in cognition from original study to follow-up. A secondary analysis that excluded 40 women who continued to take hormone therapy after KEEPS found similar results.

These findings “may reassure women opting to use hormone therapy in early menopause, to manage menopausal symptoms, that 4 years of therapy started within 3 years of menopause had no long-term deleterious impact on cognition,” Gleason and colleagues wrote. “Our results also indicate that [hormone therapy] does not prevent cognitive decline when initiated around the time of menopause. Therefore, [hormone therapy] should not be recommended as a strategy for improving or preserving cognitive function in recently menopausal women with low cardiovascular risk.”

For related information, see the Psychiatric News Alert “Hormone Therapy May Reduce Relapse Risk for Menopausal Age Women With Schizophrenia.”

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Reaching Age at Which Parent Died by Suicide Increases Suicide Risk Among Offspring

Several studies have shown that individuals with a parent who died by suicide have an increased risk of suicide or self-harm themselves compared with individuals with living parents or a parent who died from other causes. A study issued in Suicide and Life-Threatening Behaviors now finds that this risk may be particularly elevated when the individual reaches the same age at which the parent died by suicide.

“Contemporary models of grief acknowledge that individuals move backwards and forwards between phases or stages of grief rather than in a linear manner,” wrote Yanakan Logeswaran, M.Sc., of the University College of London Division of Psychiatry, and colleagues. “Our findings support the idea of a dynamic process of grief, in so much as the elevated risk of suicidal behavior at [parental] age correspondence might also represent a period of loss orientation and increased distress.”

Logeswaran and colleagues used national data from five Danish registries to identify individuals whose parents died between 1980 and 2016. The data included cause of death as well as hospital records of self-harm or suicide attempt. Individuals were separated into two groups: the 17,806 individuals whose parents died by suicide, and the 452,674 individuals whose parents died due to other causes. The researchers compared the risk of self-harm and suicide during the year before and after individuals reached the age of the deceased parent with the 15 years before and after that period.

Individuals reached the age of their deceased parent a median of 24 years after the loss. The researchers found that individuals whose parents died by suicide had about twice the risk of self-harm or suicide around the time they reached the age of the deceased parent relative to the 15 years before or after. Those whose parents died from other causes did not have an increased risk during this period of age correspondence

“Our findings support the practice of asking suicide-bereaved individuals about age at parental suicide, identifying this as an anticipated period of increased risk and planning increased support,” Logeswaran and colleagues wrote. “This is also an opportunity to reinforce that suicide is not inevitable after the suicide of a parent, with the absolute risk of suicide in offspring of suicide decedents estimated at less than 1%.”

For related information, see the Psychiatric News article “Nature, Nurture Both Contribute to Suicide Risk.”

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FDA Panel Votes 14-1 Against Clozapine REMS

A panel convened by the Food and Drug Administration (FDA) voted overwhelmingly yesterday against key provisions of the Clozapine Risk Evaluation and Mitigation Strategy (REMS) after hearing from clinicians, patients, and caregivers who said access to this effective schizophrenia medication was thwarted by red tape.

The REMS for clozapine is designed to monitor for the relatively rare risk of neutropenia, a potentially deadly reduction in white blood cells.

The panel voted 14-1 against the REMS requirement that prescribers document and pharmacies verify patients’ absolute neutrophil counts (ANC) before dispensing clozapine. The panel also voted 14-1 against the need for educating prescribers and pharmacists on the risk of clozapine-induced severe neutropenia and ANC monitoring.

“I do not believe that the REMS’ approach to documenting and enforcing is serving the health of the patients or the needs of the community,” said panelist Sascha Dublin, M.D., Ph.D., an epidemiologist who studies the health effects of prescription medications for Kaiser Permanente. “I hope we can find better ways to support appropriate monitoring that don’t have a punitive and technocratic approach.”

The FDA is not required to follow the recommendations from this joint meeting of the Drug Safety and Risk Management Advisory Committee and the Psychopharmacologic Drugs Advisory Committee, but it often does.

Kathryn K. Erickson-Ridout, M.D., a member of APA’s Council on Quality Care, testified on behalf of APA. “I have been treating patients with treatment-resistant schizophrenia for 12 years and have seen the life-transforming benefit of this medication—controlling otherwise treatment-resistant psychotic symptoms and providing cognitive clarity.

“The REMS program, while well-intentioned and -designed, does create a barrier to prescribers and patients using clozapine,” said Erickson-Ridout, who is also an inpatient psychiatrist and researcher for Kaiser Permanente. The barriers posed by the REMS can lead to interruptions in access to clozapine, often with disastrous results, she said.

Dozens of patients and their caregivers offered testimonials of rapid decompensation, self-harm, and relapsed psychosis after being denied a refill for their prescribed clozapine—often despite completing required bloodwork—due to missing paperwork or lack of training among pharmacy personnel. Most patients simply could not find a willing clinician, pharmacy, and/or lab to prescribe the drug or complete the required testing.

Tiffany R. Farchione, M.D., director of the FDA’s Division of Psychiatry, testified that 22% to 37% of people with schizophrenia have treatment-resistance illness. Yet only 4% to 5% of patients with schizophrenia receive clozapine, Erickson-Ridout noted in her testimony. She added that surveys have found that since the last change to the Clozapine REMS in November 2021, 66% of prescribers have reported trouble getting the drug for patients.

Read the full story on PN Newswire.

For more information, see the Psychiatric News article “Clozapine Risks Drop Sharply Within Months, May Warrant Less Monitoring.”

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For Coordinated Specialty Care, Fidelity to Program Components Matters

Individuals with first-episode psychosis who received the wide range of services provided in coordinated specialty care (CSC) programs experienced improved symptoms, higher quality of life, and improved functioning, according to a study published today in Psychiatric Services. This was especially true for individuals who were treated in programs that adhered to the core components of CSC.

CSC is a recovery-oriented treatment model for people experiencing first-episode psychosis that provides a range of evidence-based services delivered through a multidisciplinary team. A variety of programs exist, but in 2014, the National Institute of Mental Health (NIMH) outlined the core components of CSC:

• Medication management
• Psychotherapy
• Case management
• Family education and support
• Supported employment
• Supported education.

This study demonstrates that “the six CSC components identified by NIMH may constitute the core essential ingredients that should be made available in all CSC programs, regardless of the specific model, and that fidelity to those components may enhance positive outcomes,” wrote Abram Rosenblatt, Ph.D., of the health care consulting firm Westat, and colleagues.

Rosenblatt and colleagues looked at patient- and clinician-rated measures of psychotic symptom frequency, quality of life, and social and role functioning for 770 individuals receiving CSC services in 36 federally funded programs; patients were assessed at time of entry and every six months for up to 18 months. All programs were also assessed for fidelity to the core components outlined by NIMH. Additional program-level variables assessed during the study included staff turnover rate and time spent on CSC services.

Overall, the average frequency of psychotic symptoms decreased among patients receiving CSC services from baseline to follow-up, while quality of life, social functioning, and role functioning scores all increased. In programs that had higher fidelity to the NIMH model, individuals showed a greater improvement in psychotic symptom frequency and social functioning. After accounting for the other program-level characteristics, the researchers also found that the more time the team leader spent on CSC program services, the greater the patient symptom improvement and social functioning.

Rosenblatt and colleagues said additional research is needed to identify how and whether services specific to existing models yield the most effective CSC programs, including the quality of services offered and received. “…[M]aximizing the value of CSC across a broad range of settings and diverse client populations requires further understanding of and attention to fidelity, implementation, and adaptation,” they wrote.

For related information, see the Psychiatric News article “Look for Hope and You Will Find It: Outlook for First Episode Psychosis Has Never Been Better.”

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DEA, HHS Issue Third Extension of Pandemic Telehealth Prescribing Flexibilities

On Friday the Drug Enforcement Administration (DEA) in concert with the U.S. Department of Health and Human Services (HHS) issued a third extension of COVID-19 telehealth flexibilities for the prescribing of controlled medications, to be effective through December 31, 2025.

These telemedicine flexibilities, originally granted in March 2020 as part of the COVID-19 Public Health Emergency, authorize qualified health professionals to prescribe Schedule II-V controlled medications via telemedicine, including Schedule III-V narcotic-controlled medications approved by the Food and Drug Administration for the treatment of opioid use disorder via audio-only telemedicine encounters.

“This additional time will allow DEA (and also HHS, for rules that must be issued jointly) to promulgate proposed and final regulations that are consistent with public health and safety, and that also effectively mitigate the risk of possible diversion,” the extension states. “Furthermore, this Third Temporary Rule will allow adequate time for providers to come into compliance with any new standards or safeguards eventually adopted in a final set of regulations.”

Early in 2023, the DEA proposed regulations that would curtail some 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 2023, urging that the DEA balance common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment. In October 2023, the DEA and HHS issued a second temporary extension that continued the telehealth flexibilities until December 31, 2024.

For related information, see the Psychiatric News article “DEA, HHS Extend Telemedicine Flexibilities Through 2024.”

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Pandemic-Fueled Rise in Drinking Persisted Into 2022

Alcohol consumption among adults increased during the early part of the COVID pandemic, and this increase was sustained two years later, according to an analysis published in Annals of Internal Medicine.

“Potential causes of this sustained increase include normalization of and adaptation to increased drinking due to stress from the pandemic and disrupted access to medical services,” wrote Divya Ayyala-Somayajula, M.D., of Thomas Jefferson University in Philadelphia, and colleagues.

The researchers examined data from the 2018, 2020, and 2022 editions of the nationally representative National Health Interview Survey (NHIS), which included responses on drinking behaviors from 24,965 adults 18 or over in 2018, 30,829 in 2020, and 26,806 in 2022.

Between 2018 and 2020, the number of adults who reported any drinking in the past year increased by 2.69% (from 66.34% to 69.03%), with increases seen in both men and women and across racial groups. Likewise, the rate of past-year heavy drinking—defined as 5+ drinks in one day or 15+ drinks per week for males, and 4+ drinks in one day or 8+ drinks per week for females—rose from 5.1% to 6.13% between 2018 and 2020.

In 2022, the rate of any drinking among adults remained elevated overall (69.3%) and across race and gender groups. The overall rate of heavy drinking in 2022 also remained elevated (6.29%), but the researchers noted that among Asian American and American Indian adults, the rate of heavy drinking in 2022 dropped below 2018 levels.

“[O]ur results highlight an alarming public health issue that may require a combination of policy changes,” Ayyala-Somayajula and colleagues wrote. “Increased screening efforts for harmful drinking with systematic integration and rapid linkage to behavioral health treatments by health care professionals, in tandem with community-based interventions for at-risk populations, should be considered to mitigate the public health consequences of the pandemic-related increase in alcohol use.”

For related information, see the Psychiatric News articles “Pandemic May Be Accelerating Problematic Trends in Alcohol Use” and “NIAAA Director Hopeful About Growing Awareness of Risks, Harms of Alcohol.”

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Hallucinogen-Related ED Visits Associated With Schizophrenia Risk

Individuals who require emergency care after using hallucinogenic drugs have an increased risk of developing a schizophrenia spectrum disorder (SSD), according to a report issued yesterday in JAMA Psychiatry.

“Results from randomized clinical trials suggest that psychedelic-assisted psychotherapy may be beneficial for treatment-resistant depression, posttraumatic stress disorder, and alcohol use disorder,” wrote Daniel Myran, M.D., M.P.H., of the University of Ottawa, and colleagues. “However, there are ongoing concerns that hallucinogen use may increase the risk of serious adverse mental health outcomes, including psychosis, particularly when used outside supervised clinical settings and in populations at elevated risk of psychosis, who have historically been excluded from clinical trial.”

Myran and colleagues analyzed medical record data from 9.2 million individuals ages 14 to 65 enrolled in Ontario’s universal health insurance program between January 2008 and December 2021. The researchers identified 5,217 individuals who had an ED visit involving hallucinogen use, which encompassed both dissociative drugs like ketamine and psychedelics like LSD or psilocybin. Those who had an ED visit, hospitalization, or outpatient visit for psychosis in the five years prior to the hallucinogen-related ED visit were excluded.

The primary outcome was the development of an SSD, which was defined as a diagnosis of schizophrenia or schizoaffective disorder.

Individuals who had visited the ED due to hallucinogen use had a 21 times greater risk of developing an SSD within three years compared with the general population. After accounting for sociodemographic characteristics and comorbid mental and substance use disorders, those who had a hallucinogen-related ED visit still had a 3.5 times greater risk of developing an SSD. Additional findings included:

• The most common reasons for ED visits involving hallucinogen use were harmful use (36.6%), intoxication (22.2%) and poisoning from a substance other than LSD (16%).
• Individuals who visited the ED for hallucinogen-induced psychosis (3.5% of all visits) had the greatest risk of developing an SSD.
• Compared with the general population, those who visited the ED for hallucinogen use were younger and more likely to be male and live in low-income neighborhoods.
• The rate of individuals who visited the ED due to hallucinogen use was largely stable from 2008 to 2012, then increased by 86.4% between 2013 and 2021.

The authors noted that the data they studied did not include detailed information on the type of hallucinogens used. They also noted that the study did not establish a causal link between hallucinogen use requiring care in the ED and developing an SSD. “Nonetheless, our findings revealed a group that may have high risk of development of SSD who may benefit from close follow-up and intervention or preventative efforts,” they wrote.

For related information, see the Psychiatric News article “Marijuana, Hallucinogen Use Reach Historic Levels Among Young Adults.”

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‘Institutional Betrayal’ During Psychiatric Hospitalization Leads to Patient Distrust

Individuals who report experiencing negative or harmful effects during psychiatric hospitalization—such as concerns about care being minimized or hearing serious news delivered in an insensitive manner—are less likely to trust mental health providers afterward and less likely to participate in follow-up care or undergo voluntary hospitalization, according to a report in Psychiatric Services.

Such experiences of “institutional betrayal” are also more likely to be reported by patients in for-profit facilities, according to the study.

“Institutional betrayal occurs when an institution creates an environment where harm is likely to occur or when the institution normalizes, minimizes, or fails to respond to reports of harm,” wrote Alicia Lewis, B.S., of Washington University in St. Louis, and colleagues.

Lewis and colleagues surveyed 814 adults who had been treated in any adult psychiatric inpatient unit in the United States between 2016 and 2021, collecting data on patients’ demographics, experiences of institutional betrayal, and the impact of psychiatric hospitalization on their engagement with mental health care post-discharge. The researchers used the Institutional Betrayal Questionnaire to identify various types of institutional betrayal and linked responses to data on facility ownership type.

Among respondents whose inpatient facility could be identified, 27% were admitted to a for-profit hospital, 15% to a government hospital, and 57% to a nonprofit hospital.

More than one-third of the sample (38%, N=307) had not experienced a betrayal, 38% (N=308) had experienced one to five types of betrayal, and 25% (N=199) had experienced more than five types of betrayal. Compared with individuals who had not experienced institutional betrayal, those who did were:

• 25% more likely to report that the hospitalization had reduced their trust in mental health providers.
• 45% more likely to report a reduced willingness to voluntarily undergo hospitalization in the future.
• 30% more likely to report a reduced willingness to disclose future distressing thoughts to a mental health provider.
• 11% less likely to report having a 30-day post discharge follow-up visit.

Compared with participants hospitalized at a nonprofit facility, those who were hospitalized at a for-profit facility were 14% more likely to report having experienced an institutional betrayal.

“…[P]olicy makers and payers need to more closely monitor the impact that profiteering might have on care quality and should identify ways to … better support patients’ well-being and outcomes,” the researchers wrote. “[S]urveying people on the extent to which they felt respected and supported during their inpatient hospitalization and providing these metrics to the public could be an important step in incentivizing a high quality of care.”

For more information, see the Psychiatric News article “Study Identifies Adverse Event Factors Linked to Psychiatric Hospitalization.”

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