Spanish Speakers Less Likely to Receive Timely Diagnosis of Mild Cognitive Impairment

Spanish-speaking adults may be less likely to receive a timely diagnosis of mild cognitive impairment compared with their English-speaking peers, suggests a study in the American Journal of Geriatric Psychiatry.

Jason A. Silva-Rudberg, M.D., of Yale University School of Medicine and colleagues analyzed data from the electronic medical records of 12,080 English- or Spanish-speaking patients who received an initial diagnosis of mild cognitive impairment or dementia between July 2017 and June 2019 when seeking care at the largest health system in Connecticut. Overall, 11,494 patients spoke English and 586 spoke Spanish. An initial diagnosis of mild cognitive impairment was classified as “timely,” and an initial diagnosis of dementia was considered “delayed.” The researchers also assessed the comprehensiveness of the evaluations that the patients received based on the presence of laboratory studies, neuroimaging, specialist evaluation, and advanced diagnostics six months before or after diagnosis.

During the study period, 3,096 patients were diagnosed with mild cognitive impairment, and 8,984 patients were diagnosed with dementia. At baseline, the mean age was 74.5 years for patients with mild cognitive impairment and 80.5 for patients with dementia.

Spanish speakers were 45% less likely to receive a timely diagnosis when compared with English speakers after adjusting for covariates such as sex, age, neighborhood disadvantage, ethnicity, and medical comorbidities. Despite being three years younger at presentation on average, only 18.6% of Spanish-speaking patients received a mild cognitive impairment diagnosis, compared with 26.0% of English-speaking patients.

English and Spanish speakers were equally likely to receive diagnostic services, except for referrals to geriatric services, which were more frequent among Spanish-speaking patients. A subgroup analysis of patients who identified as Hispanic/Latino revealed that Spanish speakers were 47% less likely to receive a timely diagnosis compared with English speakers.

“Our results demonstrate a significant inequity impacting Spanish-speaking patients and highlight the urgent need for interventions that increase access to interpretation services, health care, and improve cognitive evaluation for patients with [non-English language preference],” the researchers concluded.

For related information, see the Psychiatric Services article “Downward National Trends in Mental Health Treatment Offered in Spanish: State Differences by Proportion of Hispanic Residents.”

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APA National Election Polls Close Tonight

Today (January 31) is the last day to cast your ballot in APA’s 2024 national election. Vote now through 11:59 p.m. ET, using your election ballot (sent by email) or the APA election website. Detailed information about the candidates and campaigning guidelines can also be accessed on the site.

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1 in 4 Americans Lonelier Now Than Before Pandemic, APA Poll Finds

Experiencing consistent feelings of loneliness—defined as a lack of a meaningful or close relationship or sense of belonging—is common among U.S. adults, suggest the findings of APA’s latest Healthy Minds Monthly Poll. In early January, 30% of adults reported that they had experienced feelings of loneliness at least once a week over the past year, while 10% said they were lonely every day.

Younger people were more likely to experience feelings of loneliness, the poll found. Thirty percent of respondents aged 18 to 34 reported that they were lonely every day or several times a week. Additionally, when asked how their feelings of loneliness have changed since before the COVID-19 pandemic, 25% of respondents said they feel lonelier while 23% said they felt less lonely and 43% said their levels of loneliness had not changed.

“The Healthy Minds Monthly poll confirms loneliness is widespread, especially in young people,” APA President Petros Levounis, M.D., M.A., said in a news release. “Doctors and other clinicians can make a major difference in their patients' well-being and physical health when they ask about loneliness and how to mitigate its effects. Helping people feel less lonely is straightforward and deeply gratifying.”

The poll was conducted online January 10 to 12 among 2,200 adults by Morning Consult.

Additional findings from the poll include the following:

• Single adults were nearly twice as likely as married adults to report feelings of loneliness on a weekly basis over the past year (39% vs 22%).
• 50% of respondents said they ease their feelings of loneliness with distractions, such as TV, podcasts, or social media, while 41% said they go for a walk, and 38% said they reach out to family or friends.
• 13% said they use drugs or alcohol to ease their feelings of loneliness.
• Adults aged 18 to 34 were more likely (21%) to use drugs or alcohol when feeling lonely compared with adults aged 45 to 64 (8%).
• Selecting among several options, respondents ranked being among their families (65%), their friends (53%), or in their neighborhoods (20%) as where they felt the highest sense of community and belonging. Online communities and discussion forums (3%), sports and recreational teams (4%), and gym or fitness classes (5%) were the least likely to be selected in this category.
• Most respondents said they felt that technology helps them form new relationships (66%), helps them connect with others more frequently (75%), and is beneficial for forming and maintaining relationships (69%).
• 54% said they believed technology fosters meaningful relationships, while 46% said they believed it fosters superficial relationships.

“Clearly we believe technology can be used to connect with others,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the release. “In some cases, it seems to be helping us reach people who become part of our inner circles or to communicate with those who already are. However, distracting yourself when you’re feeling lonely with social media might be a double-edged sword: While it can connect, it can also lead to feelings of missing out, and we need to make sure we remain conscious of its effects on our mood. In this tech-heavy world, we should not forget the value of in-person interaction.”

For related information, see the Psychiatric News Alert “Healthy Minds Poll Provides Insight Into Americans’ Anxieties Over Past Year.”

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One More Day Left: Vote in APA’s 2024 National Election

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Dexmedetomidine Infusion After C-Section May Reduce Postpartum Depression

Women with prenatal depression who received an infusion of the sedative dexmedetomidine shortly after a cesarean delivery (C-section) had lower incidences of postpartum depression at one and six weeks postpartum compared with women who received a saline infusion after delivery. These findings were published in JAMA Network Open. The study was funded by grants from the Natural Science Foundation of Hunan Province.

Yingyong Zhou, Ph.D., of the Third Xiangya Hospital of Central South University and colleagues conducted the study at two hospitals in China from March 2022 to April 2023. Women 18 years or older with prenatal depression (defined as higher than 9 on the Edinburgh Postnatal Depression Scale, or EPDS) who underwent elective cesarean delivery and required postoperative patient-controlled intravenous analgesia were recruited for the trial. The researchers randomized 338 women (average age 31.5 years) to the dexmedetomidine group (n = 169) or the control group (n = 169).

After delivery, study participants in the dexmedetomidine group received 0.5 μg/kg of dexmedetomidine in 20 mL of 0.9% saline for 10 minutes. Those in the control group received 20 mL of 0.9% saline for 10 minutes. Following this infusion, women in the study were administered one of two infusions of the narcotic sufentanil, which were set for continuous infusion at a rate of 2 mL/h for 48 hours: The dexmedetomidine group received dexmedetomidine (2.0 μg/kg) + sufentanil (2.2 μg/kg); the control group received sufentanil (2.2 μg/kg).

Zhou and colleagues followed up with the study participants by telephone at 7 and 42 days after their C-section, again administering the EPDS. The participants were also asked about insomnia, pain, and other adverse events.

At 7 days, 12.6% of women in the dexmedetomidine group screened positive for postpartum depression versus 32.1% of women in the control group. At 42 days, 11.4% of the dexmedetomidine group versus 30.3% of the control group screened positive. Other findings included the following:

• The median insomnia scores of the dexmedetomidine group were significantly decreased from baseline to 1 and 2 days postpartum compared with the control group. However, there was no difference in insomnia scores between the groups at 7 and 42 days postpartum.
• Women who had received dexmedetomidine reported less pain while at rest at 6, 24, and 48 hours after delivery than women who received saline.
• The groups experienced similar adverse events, but those in the dexmedetomidine had a higher incidence of hypotension (systolic blood pressure less than 90 mm Hg or 20% lower than baseline).

“Given the serious negative consequences for mothers, young children, family members, and society, strategies to improve prevention [of postpartum depression] and treatment are a public health priority,” Zhou and colleagues wrote.

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

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More Than Half of New Stimulant Prescriptions at Pandemic’s Height Delivered Via Telemedicine

More than half of all first prescriptions for stimulant medications during the height of the COVID-19 pandemic were initiated via telemedicine, a study in Psychiatric Services has found. The study also suggests that telemedicine was more commonly used by psychiatrists than other health care providers and was associated with greater odds of receiving follow-up care.

Haiden A. Huskamp, Ph.D., of Harvard Medical School and colleagues analyzed data on commercially insured individuals recorded in the Optum Labs Data Warehouse from January 2019 through April 2022. The study used data from 535,629 children aged 2 to 17 years and 2,116,160 adults aged 18 to 64 years.

The percentage of adults who received their first prescription for stimulants (stimulant initiation) via telemedicine peaked at 52.7% in April 2020, then dropped to 27.9% by April 2022. The percentage of children who received their stimulant initiation via telemedicine peaked at 56.8% in April 2020, then dropped to 13.9% by April 2022.

Psychiatrists used telemedicine for 55.3% of their stimulant initiations for adults, whereas nonpsychiatrists used telemedicine for only 26.6% of their stimulant initiations for adults. Psychiatrists used telemedicine for 48.6% of their stimulant initiations for children, whereas nonpsychiatrists used telemedicine for only 17.5% of their stimulant initiations for children.

“Telemedicine initiation offered a way for adults and children to access ADHD [attention-deficit/hyperactivity disorder] treatment early in the pandemic when many clinics closed or curtailed in-person visits, and telemedicine may have helped reduce barriers to accessing care even after in-person visits became an option again,” Huskamp and colleagues wrote. They added that the drop in telemedicine use for stimulant initiations by 2022 was “not surprising” because many stimulant initiations are conducted by primary care physicians, who rapidly returned to providing in-person care.

For each month from January 2019 to April 2022, on average only 21.8% of stimulant initiations for adults and 26.6% of stimulant initiations for children were followed up with a visit with the prescribing health professional within 30 days. Patients were more likely to have a follow-up visit if they received stimulant initiation via telemedicine, received stimulant initiation from a psychiatrist, or had a co-occurring diagnosis other than ADHD.

“Future research is needed to understand the extent to which [the] patterns of stimulant initiation and follow-up care [that have been] observed since the onset of the pandemic represent high-quality care,” Huskamp and colleagues concluded.

For related information, see the Psychiatric News Alert “New Stimulant Prescriptions for ADHD Climbed During Pandemic, Study Shows.”

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Osteoporosis May Raise Risk of Depression in Older Adults

Adults aged 50 or older who have osteoporosis are nearly twice as likely as those without to experience depression, according to a study published this week in Public Health.

“The treatment of osteoporosis has been a growing public health concern worldwide,” wrote Keng Chen, M.D., of Sun Yat-sen University in Shenzhen, China, and colleagues. “In the [United States], about 14.1 million adults aged 50 years and older had osteoporosis, and the prevalence rate showed a steadily increasing trend. … However, there are few studies investigating depression status in people with osteoporosis.”

Chen and colleagues used data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative, ongoing program designed to assess the health and nutritional status of adults and children in the United States. The survey gathers data through both interviews and physical examinations. The researchers focused on data from NHANES participants who were aged 50 or older and completed the survey in the following two-year cycles: 2005 to 2006, 2007 to 2008, 2009 to 2010, 2013 to 2014, and 2017 to 2020.

The Patient Health Questionnaire-9 was used to determine if participants had depressive symptoms or probable depression. Those with scores of five or greater were considered to have depressive symptoms. Those with scores of 10 or greater were considered to have probable depression. Finally, participants were considered to have osteoporosis if their femoral neck bone mineral density was 2.5 or more standard deviations below the average for non-Hispanic White women aged 20 to 29 years in the study.

A total of 11,603 adults, 52.3% of whom were male, with an average age of 65 years were included. Additional findings of the study include the following:

• 5.2% of the participants had osteoporosis, 21.4% had depressive symptoms, and 6.9% had probable depression.
• Participants with osteoporosis were more likely to be older, female, non-Hispanic white, and current smokers.
• Of participants with osteoporosis, 31.9% had depressive symptoms and 10.0% had probable depression.
• After adjusting for confounding factors such as sociodemographic characteristics and lifestyle factors, participants with osteoporosis had a 73% higher risk of depressive symptoms and a 91% higher risk of probable depression, compared with those without osteoporosis.

“Our findings highlighted the importance of paying close attention to the psychological status of osteoporosis patients,” the authors concluded. “It may be necessary to evaluate the mental well-being of patients with osteoporosis in clinical and primary health care. Further studies are warranted to clearly establish the relationship between osteoporosis and depression.”

For related information, see the Psychiatric News Alert “Lithium Associated With Lower Osteoporosis in Patients With Bipolar Disorder.”

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Cognitive-Behavioral Therapy May Reduce Overactivity in Some Brain Regions in Anxious Youth

Cognitive-behavioral therapy (CBT) may normalize activity in some parts of the brain that are overactive in youth with anxiety disorders, suggests a report published today in The American Journal of Psychiatry. After three months of CBT, youth with anxiety showed reduced activity in frontal and parietal brain regions (areas known to be involved with attention and emotional regulation).

“Understanding the brain circuitry underpinning feelings of severe anxiety and determining which circuits normalize and which do not as anxiety symptoms improve with CBT is critical for advancing treatment and making it more effective for all children,” said lead author Simone Haller, Ph.D., of the National Institute of Mental Health in a press release.

Haller and colleagues used functional MRI (fMRI) to analyze brain activity in 69 youth who were not taking medications (41% males, average age 13 years) and had been diagnosed with anxiety disorder. The youth underwent an fMRI at the start of the study as well as after 12 weeks of CBT. The researchers evaluated changes in the youth’s anxiety weekly using the Pediatric Anxiety Rating Scale and the Clinical Global Impressions Scale improvement scale.

After 12 weeks of therapy, 66% of youth with anxiety experienced a clinically significant decline in anxiety symptoms, Haller and colleagues reported.

The researchers compared the fMRI scans collected from youth with anxiety before and after CBT treatment; they also compared the fMRI scans with those from similarly aged youth who did not have anxiety. A second sample of 87 youth who were identified as high-risk for anxiety but received no treatment also underwent brain scans. 

Before CBT treatment, youth with anxiety disorder displayed hyperactivation in multiple brain regions, including the fronto-parietal network, compared with the youth without anxiety. After treatment, the activity in the fronto-parietal network declined to “levels comparable to (or lower than) those observed in healthy control youths,” the researchers wrote. In contrast, the sample of untreated youth at risk for anxiety continued to show fronto-parietal hyperactivity. “This provides preliminary evidence that the brain changes in children with anxiety were driven by CBT and that they may offer a reliable neural marker of anxiety treatment,” the NIMH release stated.

The researchers noted that several regions, including the right amygdala, remained hyperactive in youth with anxiety after treatment. (The amygdala plays a central role in controlling fear response.)

“While CBT is the current gold-standard intervention for pediatric anxiety, response rates are variable, leaving a large portion of treated youth with significant symptoms following treatment,” Haller and colleagues wrote. “Clinical outcomes may be improved by targeting fronto-parietal attention circuits and complementing CBT with adjunctive interventions that have a direct impact on subcortical structures.”

For related information, see the Psychiatric News article “Pediatric Anxiety Can Be Treated—The Challenge is to Recognize It.”

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Psychiatrists Desire More Training in How to Use AI in Practice, Survey Finds

Artificial intelligence (AI) tools powered by large language models (LLMs), such as OpenAI’s ChatGPT and Google’s Bard, have the potential to rapidly change the practice of medicine. An online survey of psychiatrists who participated in an APA webinar about AI suggests that many have experimented with the use of ChatGPT for answering clinical questions, but their opinions are mixed on whether the benefits of use outweigh the risks. A report on the survey results appears in the March issue of Psychiatric Research.

“Knowing how the field of psychiatry currently understands the potential of these tools and seeks to use them in the future can help guide the development of [large language models] and ensure they are implemented safely and in alignment with the field’s needs,” wrote Charlotte Blease, Ph.D., of Uppsala University in Sweden, Abigail Worthen of APA, and John Torous, M.D., M.B.I., of Harvard University.

Blease and colleagues invited more than 800 APA members and affiliates who attended an AI in psychiatry webinar last August to participate in an online survey. The survey asked participants to reflect on their use of ChatGPT and other LLMs in clinical practice, how strongly they agreed or disagreed with a series of statements about potential benefits of the tools, and the impact on the mental health of their patients. There was also a section for additional comments.

A total of 138 psychiatrists completed the online survey, including 75 men and 58 women (5 people preferred not to answer) of diverse ages (those aged 30 to 39 years comprised the highest percentage of those surveyed at 28%; those 29 and under comprised the lowest percentage, at 8%).

Over 40% of survey respondents reported using ChatGPT-3.5 to “assist with answering clinical questions” and 33% reported use of ChatGPT-4.0. Nearly 70% agreed that these AI tools already are making or will make documentation more efficient and 21% agreed the tools are or will improve diagnostic accuracy. Almost 90% agreed or somewhat agreed that clinicians need more support and training in understanding these tools.

Other survey findings included the following:

• 86% agreed or somewhat agreed with the statement that patients can use AI tools such as ChatGPT and Bard to better understand their medical records.
• 76% agreed or somewhat agreed with the statement that patients using these tools better understand their health.
• 79% agreed or somewhat agreed that patients using these tools worry more about their privacy.

“With respect to benefits and harms—echoing disparate opinions in the closed-ended questions about whether these tools would improve diagnostic accuracy or decrease disparities in healthcare—respondents offered mixed opinions,” Blease and colleagues wrote. “Some expressed optimism that these tools could strengthen patient safety, access, and the quality of care, while others pointed to the potential for harm urging that current models fabricate information, embed harmful biases, and risk patient privacy.”

The authors describe several limitations of the survey—for example, the convenience sample, restriction to participants who attended the APA webinar, and the low response rate of 18% “likely influenced results,” they wrote. “We recommend that future surveys strive for stratified sampling techniques that permit correlative analyses of participants experiences and opinions according to gender, age, and workplace environment.”

For related information, see the Psychiatric News articles “Harnessing AI for Psychiatric Use Requires More Nuanced Discussion” and “ChatGPT Not Yet Ready for Clinical Practice,” and the APA blog post “The Basics of Augmented Intelligence: Some Factors Psychiatrists Need to Know Now.” A recording of APA’s AI in psychiatry webinar is posted here.

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Prevalence of Substance Use Disorder Higher Among Some Cancer Survivors

Heavy alcohol use and tobacco use are known to increase the risk of some cancers, but less is known of what happens to people who have a substance use problem after surviving cancer. A report in JAMA Oncology now suggests that substance use disorder is more prevalent among survivors of head and neck cancer, esophageal and gastric cancer, cervical cancer, and melanoma than survivors of breast, prostate, and colon cancers.

“Our findings underscore the need to understand and address the needs of cancer survivors with comorbid [substance use disorder],” wrote Katie F. Jones, Ph.D., of the VA Boston Healthcare System and colleagues. “Our results also highlight certain populations of cancer survivors who would likely benefit the most from such interventions based on their higher prevalence of SUD, including those with a lifetime history of and those with recently diagnosed cervical and head and neck cancers.”

For the cross-sectional study of adult cancer survivors, Jones and colleagues analyzed data collected between 2015 and 2020 as part of the annual National Survey on Drug Use and Health (NSDUH). The researchers defined substance use disorder (SUD) as “meeting at least 1 of 4 DSM-IV criteria for abuse or at least 3 of 6 DSM-IV criteria for dependence.” The researchers calculated the weighted population prevalence of SUD by cancer type.

A total of 6,101 adult cancer survivors (about 57% aged 65 and older; 62% female) were included in the analysis. Across cancers, the weighted prevalence of active SUD was 3.83%, and alcohol use disorder was the most common SUD, with a weighted prevalence of 2.78%. The prevalence of SUD was higher among survivors of the following:

• Esophageal and gastric cancer (9.42%)
• Head and neck cancer (9.36%)
• Cervical cancer (6.24%)
• Melanoma (6.20%)

In a secondary analysis of 1,437 survivors who were diagnosed with cancer within 12 months of participating in the NSDUH, the overall prevalence of SUD was similar as the main cohort (3.81%); however, the prevalence of SUD among the survivors of head and neck cancer and cervical cancer was 18.73% and 15.70%, respectively.

The authors highlighted several limitations of the study—for instance, the overall SUD prevalence in cancer survivors was lower than previous reports of SUD prevalence in the general population; additionally, the authors noted that they did not have access to information about the prognosis of those who had been diagnosed with cancer.

“[T]he findings of the present study underscore the need for research on models of care that integrate addiction services and expertise into the care of cancer populations with a high prevalence of [substance use disorder] to address their complex and intersecting needs,” Jones and colleagues wrote.

For related articles, see the Psychiatric News article “Special Report: Psychiatrists Critical in Screening, Treatment of Alcohol Use Disorder.”

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Behavioral Activation, Medication Equally Effective for Depression in Patients With Heart Failure

Behavioral activation psychotherapy may be just as effective as antidepressants at reducing symptoms of depression in patients with heart failure, a study in JAMA Network Open has found. Behavioral activation psychotherapy, a form of cognitive-behavioral therapy, encourages patients to engage in activities that they enjoyed before developing depression so as to improve their mood.

“Approximately 50% of people with [heart failure] experience depressive symptoms,” wrote Waguih William IsHak, M.D., of Cedars-Sinai Medical Center in Los Angeles and colleagues. Previous studies show that the greater the severity of depression in people with heart failure, the greater the risk for functional decline or death at six months.

The study included 416 adults (mean age, 61 years) who had been diagnosed with heart failure and depression. The patients were randomized to receive either behavioral activation psychotherapy or antidepressant medications. The patients were followed for up to one year.

Behavioral activation therapists and medication care managers facilitated a 50-minute introductory session with patients followed by 12 weekly sessions, then 3 monthly sessions, then contact as needed for an additional 6 months. Behavioral activation sessions lasted 50 minutes and medication management sessions (which did not include psychotherapy) lasted 15 minutes. All sessions were delivered using video or telephone because patients with heart failure may face challenges that make it harder for them to attend sessions in person. The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9).

At baseline, the patients’ mean PHQ-9 scores were 14.54 in the behavioral activation group and 14.31 in the medication group. At the 6-month follow-up, researchers found that the severity of depressive symptoms decreased by nearly 50% for both groups of patients: The mean PHQ-9 scores were 7.53 in the behavioral activation group and 8.09 in the medication group. At 12 months, the mean PHQ-9 scores were 7.62 in the behavioral activation psychotherapy group and 7.98 in the medication group. Patients in the behavioral activation group also experienced small improvement in physical health–related quality of life at 6 months, had fewer emergency department visits, and spent fewer days in the hospital compared with those in the medication group.

“The improvement in physical health–related quality of life, lower likelihood of [emergency department] visits, and fewer hospitalization days observed in the [behavioral activation] group compared with the [medication] group suggest secondary advantages for [behavioral activation], especially that patients with [heart failure] and depression may be reluctant to add more medications to their already large pill burden,” IsHak and colleagues wrote.

“Our findings demonstrate that both interventions are comparably effective in reducing depression for patients with [heart failure], giving patients, caregivers, and health care practitioners the choice between [behavioral activation] and [medication], thus improving patient-centered depression care in [heart failure],” they concluded.

For related information, see the Psychiatric News article “Collaborative Care Improves Quality of Life in Patients With Heart Failure.”

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Healthy Minds Poll Provides Insight Into Americans’ Anxieties Over Past Year

Over the past year, U.S. adults reported the greatest anxiety about inflation, a recession, and gun violence, according to analysis of monthly data collected from APA’s Healthy Minds Poll in 2023.

The poll is conducted each month throughout the year to track mental health and anxiety among U.S. adults. The most recent poll was fielded by Morning Consult from December 2 to 4 among 2,202 adults.

According to the December poll, many adults (38%) reported being anxious about their mental health, which has been a consistent finding over the past year. Forty-four percent of adults said they expect to experience the same level of stress at the start of 2024 as they did at the start of 2023, while a quarter of respondents expect to experience more stress. Further, 54% of respondents reported feeling anxious about the uncertainty of the next year.

The December poll also asked about anxiety about international conflicts, such as the Russia-Ukraine war, and inflation. Anxiety about these issues has been consistent all year. Sixty-seven percent of respondents reported being somewhat or very anxious about current events, while 80% expressed anxiety about inflation. Additionally, 72% of respondents expressed anxiety about a recession and 70% of respondents expressed anxiety about gun violence.

Additional findings include the following:

• Respondents expressed anxiety over hate speech and hate crimes throughout the year, with 64% reporting such anxiety in December.
• Concern about the future of reproductive rights reached 54% in December.
• 58% of respondents reported being very or somewhat anxious over artificial intelligence in December. This concern has stayed relatively unchanged since August, when it was 55%.
• 43% reported being very or somewhat anxious about the COVID-19 pandemic, which has consistently been the topic on which respondents have been the least anxious over the past year.

For more information, see the Psychiatric News Alert “More Than 1 in 4 U.S. Adults Plans to Make Mental Health a Priority in 2024.”

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Lower Income Associated With Greater Treatment Delays for People With First-Episode Psychosis

An individual’s personal income appears to play a role in the amount of time between the onset of psychosis and receipt of services to treat first-episode psychosis (FEP), suggests a study in Psychiatric Services. FEP programs offer a team-based approach to support people recently diagnosed with schizophrenia spectrum disorders.

“The findings of our study highlight the relevance of individual income level as a determinant of health care access for persons with FEP,” wrote Shruthi Venkataraman, M.D., M.Sc., of McGill University and colleagues. “Early detection efforts should measure and target personal income and other [socioeconomic status] indicators to improve access for all individuals who may benefit from FEP services.”

The researchers analyzed data from patients enrolled in two first-episode treatment programs—the Program for Specialized Treatment Early in Psychosis (STEP) in New Haven, Conn., and the Prevention and Recovery in Early Psychosis (PREP) in Boston. While STEP relies on an early detection awareness campaign (called Mindmap) to connect patients with FEP services, PREP does not have this type of early detection campaign.

The study included a total of 218 people (average age, 22 years; 70% male). About 79% of the participants reported a personal monthly income of less than $1,000, about 13% reported a personal monthly income between $1,000 and $2,000, and 8% reported a personal monthly income more than $2,000. (Personal income, rather than household income, was chosen as a proxy for socioeconomic status because a significant number of participants declined to disclose or did not know household income.)

Three measures of days of untreated psychosis were collected: the interval from the onset of psychosis to enrollment in an FEP service, the interval from the onset of psychosis to first use of an antipsychotic medication, and the interval from the first use of an antipsychotic medication to enrollment in an FEP service.

Lower personal income was significantly associated with longer time between onset of psychosis and enrollment in an FEP service after accounting for age, race, and exposure to an early detection campaign. “Additionally, although Mindmap significantly reduced [the interval from the onset of psychosis to enrollment in an FEP service] across all income groups, the campaign was more effective as personal income increased, thereby amplifying disparity in access delays due to low personal income,” Venkataraman and colleagues wrote.

The researchers noted that lower income may be associated with a longer duration of untreated psychosis in a variety of ways: low income has been associated with more severe psychopathology, poorer general medical health, higher stress, and lower levels of social support (friends and family, health care providers, and public services).

“Lower socioeconomic status has also been associated with lower quality of health care services, less opportunity for social participation, less access to knowledge about social services and how to access them, and self-stigma that can impede help seeking,” they wrote.

For related information, see the Psychiatric News article “New Network Collects Real Time Data to Improve Treatment of Early Psychosis.”

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Review Explores Role of Orbitofrontal Cortex in Depression

The orbitofrontal cortex (OFC)—a region of the brain involved in processing emotions and reward—plays a key role in major depressive disorder, wrote the authors of a review article in Molecular Psychiatry. They describe evidence supporting the different ways that dysfunction in the OFC contributes to major depression and how conventional antidepressants only mitigate some of these problems.

“Despite strong evidence for anatomic and functional heterogeneity within the OFC, some studies have treated this region as a unified whole,” wrote Bei Zhang, M.D., of Fudan University in China and colleagues. “Our proposal, which distinguishes between the medial and lateral OFC in a reward and non-reward/punishment framework, describes functional differentiation within the OFC, and importantly, proposes how this differentiation is associated with different symptoms of [major depressive disorder].”

The authors reviewed numerous neuroimaging studies comparing the brain structure and brain activity of people with or without depression. They reported that people with major depression have reduced connectivity between the medial OFC (the middle segment of the region) and other brain regions that are involved in emotional learning, such as the amygdala. Zhang and colleagues suggested that lower connectivity between these regions may reduce individuals’ sensitivity to positive rewards, leading to greater anhedonia (inability to experience pleasure). In contrast, people with major depression tend to have increased connectivity between the lateral OFC (left and ride sides) and regions that regulate attention and decision making, such as the anterior cingulate cortex. Zhang and colleagues suggested that higher connectivity between these regions may increase individuals’ sensitivity to aversive stimuli, leading to negative bias (the tendency to dwell on negative events).

Zhang and colleagues described other studies that show that antidepressants such as selective serotonin reuptake inhibitors mainly restore normal connectivity in the lateral OFC but have minimal impact on the medial OFC. However, emerging data suggest that ketamine—which targets glutamate rather than serotonin—may boost connectivity in the medial OFC and may be a more promising option when anhedonia is a primary symptom. Psychedelics may also improve connectivity to and from the medial OFC, though to date, only one study has demonstrated this.

“[A]lthough we have underscored the critical role of the OFC in depression, it is unlikely that depression can be solely attributed to impairments in a single brain region due to its complexity and heterogeneity,” the authors concluded. “More evidence is needed to examine how these other brain regions interact with the orbitofrontal cortex in MDD or different subtypes of MDD.”

To read more on this topic, see The American Journal of Psychiatry review, “Toward a Better Understanding of the Mechanisms and Pathophysiology of Anhedonia: Are We Ready for Translation?”

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Women With Certain Mental Disorders Less Responsive to CBT When Facing Infertility Problems

Women with adjustment disorders who face fertility problems as part of a couple may have a higher risk of a poor prognosis in response to cognitive-behavioral therapy (CBT), a study in BMC Psychiatry suggests.

Mahbobeh Faramarzi, M.D., of Babol University of Medical Sciences in Babol, Iran, and colleagues conducted a secondary analysis based on a previous randomized, controlled trial of women with adjustment disorders who had received fertility treatments and were facing fertility problems as part of a couple.

The original study compared the efficacy of an internet cognitive behavioral program (ICBT) with face-to-face CBT for 152 women diagnosed with adjustment disorders who were facing the couple’s fertility problems. Treatment was offered in eight 50-minute individual sessions by two therapists, and follow-up took place at three and six months. The programs included psychoeducation, principles of CBT, restructuring techniques, behavioral techniques, changing schemas, and reviewing goals. The researchers defined adherence as receiving at least four of the eight sessions.

The researchers assessed the women’s mental health through measurements such as the Adjustment Disorder new Module-20, the Hospital Anxiety and Depression Scale, the Cognitive Therapy Awareness Scale, and the Automatic Thought Questionnaire. They defined nonresponse to treatment as less than a 50% reduction in the anxiety and depression total scores. Among the principal diagnoses, the prevalence of adjustment disorder with depressed mood was 37.5%, adjustment disorder with anxious mood was 21.7%, and adjustment disorder with mixed anxiety and depressed mood was 40.8%.

The secondary analysis revealed that women who had high anxiety and/or depression scores before beginning the CBT or ICBT programs had 1.4 to 2 times the risk of not responding to treatment compared with those whose scores were lower before beginning treatment. Women who did not respond to treatment were older and experienced higher levels of adjustment disorder, psychological distress, fertility adjustment problems, and infertility stress compared with women who had been responsive at the end of treatment and at the six-month follow-up. A lower education and longer marriage duration appeared to decrease the risk of nonresponse to treatment.

“The current research recommends early recognition and adequate treatment at the symptom onset for gaining a better response,” Faramarzi and colleagues wrote. “Therefore, these results not only encourage clinicians to use demographic and clinical variables in the early stages of treatment planning but also help track treatment response and patients’ perceptions of treatment.”

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New Stimulant Prescriptions for ADHD Climbed During Pandemic, Study Shows

While new prescription rates for most medications to treat behavioral health conditions was steady during the COVID-19 pandemic, prescriptions for attention-deficit/hyperactivity disorder (ADHD) medications rose sharply, a study published yesterday in JAMA Psychiatry found. The largest increases in ADHD medication prescriptions were among women and people aged 20 to 39.

“During the COVID-19 pandemic, widespread concerns arose regarding increased behavioral health needs and unprecedented challenges in health care access,” wrote Grace Chai, Pharm.D., M.P.H., of the Food and Drug Administration’s Center for Drug Evaluation and Research and colleagues. “[P]andemic-related stressors and early mitigation measures such as stay-at-home orders, virtual schooling, and economic stressors contributed to concerns of increased behavioral health needs.”

Chai and colleagues analyzed data from the National Prescription Audit, which captures 94% of prescriptions dispensed at outpatient pharmacies in the United States. Drugs in five classes were included: antidepressants, benzodiazepines, Schedule II stimulants, nonstimulant ADHD drugs, and buprenorphine labeled as a medication for opioid use disorder. To capture changes in medication initiation before and during the COVID-19 pandemic, the authors looked at new prescriptions dispensed from April 2018 to March 2022.

In the two years before the pandemic (April 2018 to March 2020), 51.5 million prescriptions in the five classes were dispensed compared with 54 million during the pandemic (April 2020 to March 2020). Additional results include the following:

• Compared with the two years before the pandemic, rates of prescriptions dispensed during the pandemic increased by 10% for antidepressants, 14% for Schedule II stimulants, and 32% for nonstimulant ADHD drugs. The authors noted that the increased rates of Schedule II stimulants and nonstimulant ADHD drugs were significant and exceeded prepandemic trends, whereas the increased rate of antidepressant prescriptions followed the increasing trend that started before the pandemic’s onset.
• Among patients aged 20 to 39, Schedule II stimulant prescriptions increased by 30%, and nonstimulant ADHD drug prescriptions increased by 81%.
• Among women, Schedule II stimulant prescriptions increased by 25% and nonstimulant ADHD drug prescriptions increased by 59%.
• For all patients, the rates of benzodiazepines and buprenorphine decreased by 9% and 2%, respectively.
• Prescriptions written by nurse practitioners increased across all drug classes, ranging from 7% for benzodiazepines to 78% for buprenorphine.

“The lack of significant changes in the trends of incident prescriptions dispensed for antidepressants, benzodiazepines, and buprenorphine … during the COVID-19 pandemic suggests that a unique set of drivers may have contributed to the differential use of ADHD medication,” the authors wrote. “Additional research is needed to differentiate increases due to unmet need vs overprescribing, highlighting the need for further ADHD guideline development to define treatment appropriateness.”

For related information, see the Psychiatric News articles “Stimulant Prescriptions Spiked During Pandemic, CDC Finds,” and “Months Later, Stimulant Shortage Persists.”

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Mindfulness Training Reduces Opioid Use, Craving Among Military Experiencing Chronic Pain

Military personnel and veterans who have been taking opioids for chronic pain may experience greater benefits from group therapy that integrates mindfulness techniques than from supportive psychotherapy, according to a report published today in The American Journal of Psychiatry.

The randomized clinical trial, which compared outcomes in veterans and military from Utah, found that those who received Mindfulness-Oriented Recovery Enhancement (MORE) reported greater reductions in chronic pain symptoms and opioid use than those who received supportive psychotherapy.

“The pain-relieving effects of MORE were coupled with reductions in pain catastrophizing and an increased capacity to mindfully reinterpret pain as an innocuous sensory signal that does not necessarily signify harm,” wrote Eric Garland, Ph.D., of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah and colleagues.

Garland and colleagues recruited past and current military personnel from the Salt Lake City Veterans Affairs Medical Center, the Utah Army National Guard, and Salt Lake Valley for the study. To be eligible, the participants were required to be 18 years or older, have a chronic pain–related diagnosis, and were taking daily prescribed opioids for at least three months. A total of 230 participants were randomized to receive eight weekly two-hour group sessions of MORE or supportive psychotherapy. Group sessions were initially held in person but switched to remote teleconferencing during the COVID-19 pandemic.

Participants in the MORE group received training in mindfulness (for example, mindful breathing), reappraisal (reframing reaction to pain), and savoring techniques (focusing on pleasant events and pleasurable sensations) as well as psychoeducation about opioid misuse and chronic pain. The participants were also instructed to practice a three-minute mindfulness technique (mindful breathing) before taking opioids each day to help reduce use and delay taking as-needed opioids.

Participants in the supportive psychotherapy group were invited to share with the group about their experiences of coping with chronic pain, opioid use, and emotional distress; no mindfulness training or education was provided.

The researchers tracked the participants’ chronic pain, measured by the Brief Pain Inventory, and opioid misuse, measured by the Current Opioid Misuse Measure, from the start of the study through eight months. Other outcomes evaluated included the participants’ daily opioid dose, catastrophizing, positive affect, and craving.

MORE was superior to supportive psychotherapy through the eight-month follow-up in reducing pain interference, pain severity, and daily opioid dose, Garland and colleagues reported. “There was a 20.7% reduction in the mean opioid dose (18.88 mg, SD=8.40 mg) in the MORE condition compared with a 3.9% reduction (3.19 mg, SD=4.38 mg) in the supportive psychotherapy condition,” they wrote. MORE also reduced anhedonia (the inability to experience pleasure), pain catastrophizing, craving, and increased positive affect to a greater extent than supportive psychotherapy. Opioid misuse decreased significantly in both groups.

“MORE facilitated opioid dose reduction while preserving adequate pain control and preventing disturbances in mood, suggesting the utility of MORE as an adjunctive therapy for safe opioid tapering among veterans and military personnel,” the researchers wrote. “[R]esearch should assess how to best deliver MORE to individuals across the Veterans Health Administration and the Department of Defense.”

For related information, see the Psychiatric News article “Meditation, CBT May Ease Opioid-Treated Pain.”

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Risk of Suicide Higher Among Women Diagnosed With Perinatal Depression

Women who experience perinatal depression (depression during pregnancy or in the year following delivery) are at an elevated risk of suicide compared with women who do not experience depression during this time, according to a report published today in JAMA Network Open. The cohort study, based on analysis of records of nearly 1 million women in Sweden, found that this risk was highest during the first year after a diagnosis, though the risk remained elevated up to 18 years later.

“The findings highlight the pressing need for vigilant clinical monitoring and prompt intervention for this vulnerable population to prevent such devastating outcomes, regardless of prepregnancy history of psychiatric disorders,” wrote Han Yu, M.Sc., of Karolinska Institutet and colleagues.

For the study, Yu and colleagues analyzed data from multiple Swedish registers, including those containing records of prenatal care and delivery, diagnoses, filled prescriptions, and death. Women were categorized as having perinatal depression if they had a depression diagnosis recorded during pregnancy or within one year after delivery, or filled prescriptions for antidepressant medication during either period.

The researchers focused on women who gave birth between 2001 and 2017, including 86,551 women with perinatal depression. The researchers matched each woman with perinatal depression with 10 women who did not have perinatal depression (matched on age and year of delivery). Women were followed up from the matching date until the first suicide attempt and/or completion, death, emigration, or December 31, 2018, whichever occurred first.

Compared with the women who did not have perinatal depression, those with perinatal depression had a three times higher risk of suicidal behavior (hazard ratio [HR], 3.15). “Notably, the association was greater among women without a history of psychiatric disorders,” Yu and colleagues wrote.

Women with perinatal depression had a seven times higher risk of suicidal behavior during the first year after being diagnosed with perinatal depression, they continued. “Although declining over time, the risk remained doubled 5 or more years later (HR, 2.34).”

The authors concluded, “[T]he sustained risk over 18 years necessitates a paradigm shift in how we should approach [perinatal depression], advocating for extended monitoring and support beyond the perinatal period. Most importantly, the striking risk elevation of suicidal behavior within 1 year after [perinatal depression] reinforces the necessity of strategies that effectively detect early signs and act in a timely manner for suicide prevention.”

For related information, see the American Journal of Psychiatry article “Perinatal Mental Health: Advances and Opportunities.”

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Wegovy, Ozempic Associated With Lower Risk of Suicidal Thoughts Than Related Drugs

Patients taking semaglutide for obesity or diabetes appear to have a lower risk of suicidal ideation than those who are taking other drugs for these conditions, according to a report in Nature Medicine. 

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist that was initially approved to treat diabetes (brand name: Ozempic) but was subsequently approved at a higher dose as a weight loss medication (brand name: Wegovy). 

“Instructions for Wegovy include recommended monitoring for suicidal ideation. However, the association of semaglutide with suicidal ideation compared with non-GLP1R agonist medications has not been investigated,” wrote William Wang of Case Western Reserve University; Nora Volkow, M.D., director of the National Institute on Drug Abuse; and colleagues.

Wang, Volkow, and colleagues conducted a retrospective cohort study of electronic health records from the TriNetX Analytics Network, which includes data from more than 100 million patients across the United States. They identified 240,618 patients who were prescribed either semaglutide or a non-GLP1R anti-obesity medication (for example, bupropion) between June 2021 (when Wegovy was approved) and December 2022. They also identified 1,589,855 patients who received semaglutide or a non-GLP1R medication for type 2 diabetes (for example, metformin) between December 2017 (when Ozempic was approved) and May 2021. For both populations, the researchers examined the incidence of either a first or recurrent episode of suicidal ideation within six months of starting treatment.

Overall, patients who took semaglutide for overweight or obesity had a 73% reduced risk of new suicidal ideation compared with patients taking a non-GLP1R medication. Among the subset of patients with a history of suicidal ideation, those taking semaglutide had a 56% reduced risk of recurrent suicidal ideation compared with those taking a non-GLP1R medication. Semaglutide’s reduced risk of suicidal ideation was evident in both males and females, Black and White individuals, and across age groups.  

A similar pattern of reduced suicidal ideation was seen among patients taking semaglutide for diabetes compared with non-GLP1R medications (64% reduced risk of new suicidal ideation and 49% reduced risk of recurrent ideation). Additional analysis revealed that the lower risk of suicidal ideation in patients taking semaglutide for diabetes persisted for up to three years after initiating treatment.

Wang, Volkow, and colleagues noted several limitations of the study, including missing information in the electronic health records about dosages of the medications taken and medication adherence. “Future controlled trials are necessary to assess any causal relationships between semaglutide with suicidal ideation,” they wrote.

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Certain Antidepressants May Increase Risk of Impulse Control Disorder in Parkinson’s Patients

Taking serotonergic antidepressants such as serotonin and norepinephrine reuptake inhibitors (SNRIs) or selective serotonin reuptake inhibitors (SSRIs) may increase the risk of patients with Parkinson’s disease developing impulse control disorder, a study in The American Journal of Geriatric Psychiatry has found.

Impulse control disorders—which include a range of behaviors such as excessive gambling, spending, cleaning, and eating—are one of “the most challenging psychiatric syndromes” affecting people living with Parkinson’s disease, wrote Christopher B. Morrow, M.D., M.H.S., of the Johns Hopkins University School of Medicine and colleagues.

Morrow and colleagues examined data from 1,045 individuals (mean age, 63 years) who were participating in the Parkinson’s Progression Markers Initiative (PPMI). The researchers ascertained the presence of impulse control disorder via the Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease (QUIP). Antidepressant use was defined based on medication logs for each participant. Depressive symptoms were captured using the Geriatric Depression Scale. Participants were in the PPMI study for a mean of 7.2 years and had a mean of 7.4 visits during the study period. Data for the current study were collected between July 2010 and June 2023.

Impulse control disorder was present in 10% of participants at visit one and in 27% of participants at some point during the study. In addition, 39% of participants were prescribed an antidepressant during the study.

Patients who took serotonergic antidepressants had a 40% greater risk of having impulse control disorder compared with those who did not take antidepressants. Dopamine agonist use, depression, disease duration, and male sex were also associated with an increased probability of impulse control disorder. The findings also suggest that bupropion, which is not serotonergic, was not associated with an increased risk of impulse control disorder. However, the researchers noted that there were relatively few participants taking bupropion prior to assessments for impulse control disorder compared with those taking serotonergic antidepressants (4% versus 21%), so it is possible their analysis was underpowered to detect the true relationship between impulse control disorder and bupropion.

Morrow and colleagues noted that while one strength of the study is that the data are “from a large, geographically diverse, longitudinal dataset,” there are several limitations to consider, including the use QUIP to define impulse control disorder (they wrote, “a definitive diagnosis of ICD requires a more detailed clinical assessment than the QUIP provides”).

“[C]linicians making treatment decisions for patients with depression/anxiety and co-existing [impulse control disorder] may consider alternatives to serotonergic antidepressants like bupropion, brain stimulation techniques, psychotherapy, or other novel treatment strategies,” the researchers wrote. “Prospective studies are ultimately needed to expand upon our findings, confirm a causal link between antidepressant use and [impulse control disorder], and clarify the neurobiological changes giving rise to these symptoms.”

For related information, see The American Journal of Psychiatry article “Impulse Control Disorders in Parkinson’s Disease.”

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Poor Quality Sleep in Midlife May Be Associated With Poor Cognition Later in Life

Individuals whose sleep is characterized by high restlessness at about 40 years of age may have a higher risk of poor cognitive functioning 11 years later compared with individuals whose sleep is better, according to a prospective cohort study published yesterday in Neurology.

“Since Alzheimer’s disease pathology begins to accumulate in the brain many years before symptom onset, it’s possible that sleep disturbances identified in late life—close to the time when memory loss becomes apparent—is actually the consequence of this pathology that has been developing silently over the years,” said Yue Leng, Ph.D., of the University of California, San Francisco, in a news release.

Leng and colleagues used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, during which participants were assessed every two to five years over 30 years. The current study took place from 2003 to 2005 and included 526 White and Black adults with a mean age of 40 years (58%/42% women/men and 66%/44% White/Black). Participants wore wrist activity monitors for three consecutive days and nights on two occasions about one year apart. The wrist monitors measured both sleep duration and each participant’s sleep fragmentation index, a measure of restlessness during their sleep calculated by measuring the amount of time they spent moving and the amount of time they were still for one minute or less. Participants also reported the times they went to bed and woke up and the quality of their sleep by completing the Pittsburgh Sleep Quality Index.

Cognitive assessments were conducted about 11 years later. Interviewers administered tests that assessed the participants’ processing speed, executive function, working memory, verbal memory, fluency, and global cognitive function.

Participants slept an average of about six hours a night, and 45.6% reported poor-quality sleep. While there was no relationship between sleep duration and cognition, participants with the greatest amount of sleep fragmentation were two to three times more likely than participants with moderate or low sleep fragmentation to have poor cognitive performance 11 years later on nearly all the cognitive measures except verbal memory. These findings did not differ by race or sex.

“This research contributes to a body of literature that underscores the need to evaluate modifiable risk factors associated with cognitive aging,” said the study’s senior author Kristine Yaffe, M.D., in the news release. “Future research is needed to study the link between sleep disturbances and cognition at different stages of life and to identify whether there are critical life periods when sleep is more strongly associated with cognition. ... This might open up new opportunities for the prevention of Alzheimer’s in late life.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Specific Sleep Health Domains as Predictors of Executive Function in Older Adults.”

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Wearable Technology Could Change Depression Care, Review Suggests

About a third of U.S. adults use a wearable device (for example, a smartwatch) to track their health and fitness. These devices (also known as “wearables”) capture a large amount of information that could be used one day to enhance how depression is diagnosed, monitored, and treated, wrote Szymon Fedor, Ph.D., of MIT Media Lab and colleagues from Massachusetts General Hospital in a review article in the New England Journal of Medicine.

As the authors explained, the diagnosis and monitoring of depression today is based largely on symptoms reported by patients, which is subjective. However, wearables provide objective information by passively collecting physiological and behavioral information—that is, users do not need to input this information.

“Complementing patient self-reports, … measurements [from wearables] increase the information available for differential diagnosis or treatment planning,” they wrote. Additionally, “[l]ongitudinal measurements help establish patient-specific behavioral and physiological baselines and support identification of personalized factors that result in deviations from these norms.”

Data obtained from a patient’s wearable could also influence how clinicians structure their time during visits with the patient, they continued. “In this proposed scenario, clinicians could use their limited time with patients more efficiently, gathering insights not provided by a wearable, thus forming a better therapeutic relationship and delivering personalized treatment.”

The authors shared insights on how to analyze data from wearables and presented a case study of wristband data collected from a 21-year-old woman diagnosed with major depressive disorder who recently began a new treatment. They concluded the article with a summary of obstacles limiting the use of wearable technology in clinical practice and how to overcome these obstacles.

For related information, see the Psychiatric Services article “Digital Mental Health and Its Discontents: Assumptions About Technology That Create Barriers to Equitable Access.”

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