Speed of Response to Visual Stimuli May Be Biomarker for Psychosis

Individuals at high risk of psychosis who later develop a full-blown psychotic illness respond more slowly on a test of response time than high-risk individuals who do not, according to a report published today in AJP in Advance. The differences in response time correlated to noticeable differences in the brain’s electrical activity.

Yongqing Hou, Ph.D., of Southwest University in Chongqing, China, and colleagues used electroencephalography (EEG) to measure brain activity of 223 participants during a computerized test in which they were shown square targets with different colors. The task required participants to press the space bar quickly and accurately only when they saw a red square, which appeared 15% of the time. During the rest of the time, they were shown an “interference” square, which was usually blue, but occasionally other colors.

The participants (who were all freshmen at Chinese universities) included 122 individuals with psychosis risk syndrome, 50 individuals with an emotional disorder (depression and/or generalized anxiety) but no psychosis risk syndrome, and 51 control subjects with no psychiatric illness. Individuals meeting criteria for psychosis risk were followed for 12 months and reclassified into three subgroups: those who converted to full-blown psychosis, those who did not convert but remained symptomatic, and those who experienced remission from symptoms.

Average response time on the test was highest for individuals in the psychosis risk group at 407.38 milliseconds; for participants with emotional disorders, it was 406.97 milliseconds, and for controls it was 389.88 milliseconds. There were also notable EEG differences in a brainwave signal called N2, which changed immediately after the red square appeared on screen. The degree of change, or the N2 amplitude, reflects how well an individual can pay attention and process new information. Individuals in the psychosis risk group had significantly smaller N2 amplitudes than control subjects and similar amplitudes to those of individuals with emotional disorders.

Next, the researchers compared the data for the three subgroups. They found that individuals who converted to full-blown psychosis had significantly smaller N2 amplitudes than individuals who remitted or remained symptomatic but did not convert, even though response times were not significantly different among the subgroups.

“[I]t is necessary to be cautious when using N2 as a single indicator for psychiatric risk assessment in clinical practice,” Hou and colleagues wrote. “However, the findings of this study indicate that N2 amplitude can still be used as a neuroelectrophysiological biomarker for individualized psychiatric risk assessment in psychosis risk syndrome; by increasing objective clinical information, the accuracy and reliability of psychiatric risk assessment can be improved.”

For related information, see the Psychiatric News article “Predicting Schizophrenia: Field Moves From Clinical Assessment of Risk to Search for Biomarkers.”

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Treatment for Opioid Use Disorder in 'Bridge' Clinics Offers Some Advantages, Study Finds

Hospitalized patients with opioid use disorder who were referred to an on-site clinic that provides wraparound services during the transition to outpatient care (a bridge clinic) reported fewer overdoses and more refills of medications like buprenorphine in the weeks following discharge, a study in JAMA Network Open found. However, the use of the bridge clinic was not associated with a faster discharge compared with usual opioid use disorder (OUD) care, nor did it reduce hospital readmissions or health care costs.

“Bridge clinics offer presumed care advantages, including timely provision of [medications] while a long-term clinician is identified, and notwithstanding other barriers, including stigma, they may offer the ability to discharge patients early,” wrote David Marcovitz, M.D., of the Vanderbilt University School of Medicine and colleagues.

Marcovitz and colleagues recruited 335 hospitalized adults with OUD (median age of 38) who were being seen in an addiction consultation service. Patients were randomized to receive usual care or care in the bridge clinic, which was co-located with the addiction consultation service. Patients assigned to the bridge clinic received enhanced case management during and after their hospitalizations, as well as a buprenorphine-naloxone prescription at discharge. They were asked to present weekly to the bridge clinic for the first eight weeks, then twice monthly based on their clinical presentations. Patients in the usual care group were referred to a community clinic and received a buprenorphine-naloxone prescription at discharge.

At 16 weeks, patients reported their recurrent opioid use, overdoses, and the number of buprenorphine-naloxone prescriptions they filled; they also reported whether they had been successfully linked to health care professionals who provided medications for OUD. Information on health care utilization was collected from the patients’ electronic medical records.

The median lengths of stay in the hospital did not differ between patients in the bridge clinic or in usual care (5.7 days compared with 5.9 days, respectively). After discharge, patients in the bridge clinic group had fewer hospital-free days, experienced more hospital readmissions, and had higher care costs. The total median cost of care was $9,482 in the bridge clinic group compared with $1,705 in the usual care group.

Eighty-eight patients completed the 16-week follow-up calls. Compared with the usual care group, those in the bridge clinic group were less likely to report having experienced an overdose and more likely to report linkage to health care professionals who provided medications for OUD. They also reported refilling more buprenorphine prescriptions.

The finding that the bridge clinic group incurred greater costs and more may be a result of patients utilizing care that they previously had not, wrote Marlene Martin, M.D., of the University of California, San Francisco, and Noa Krawczyk, Ph.D., of the NYU Grossman School of Medicine, in an accompanying commentary. “This finding may also reflect increased trust in the health care system associated with the bridge clinic group, as stigma often prevents patients with OUD from seeking and accessing care.”

For related information, see the Psychiatric News article “Bridge Clinic Cuts Emergency Department Use in Patients With OUD.”

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Risk of Self-Harm Higher in Adolescents With Stressed Parents

Children whose parents experience parenting stress and other parenting issues may have a higher risk of nonsuicidal self-injury in adolescence, a study in the Journal of the American Academy of Child & Adolescent Psychiatry has found.

Tove Wichstrøm, M.A., and Lars Wichstrøm, Ph.D., of the Norwegian University of Science and Technology in Trondheim, Norway, examined data from 759 Norwegian adolescents at age 12, 14, or 16 years to determine the adolescents' rate of nonsuicidal self-injury as measured by the Child and Adolescent Psychiatric Assessment. The researchers also examined data provided by the adolescents' parents, teachers, and the youth themselves collected when the adolescents were 6 years old. Childhood data included parental characteristics (parental stress, parental depression, perceived parental hostility, and perceived emotional availability), childhood characteristics (negative affectivity, emotion regulation, symptoms of emotional disorders, and symptoms of behavioral disorders), and negative childhood life events such as victimization by bullying.

Overall, 10% of the adolescents reported nonsuicidal self-injury during the preceding 12 months at 12, 14, or 16 years of age. Females had 11.6 times the odds of nonsuicidal self-injury compared with males. Adolescents whose parents reported parental stress when the adolescents were 6 years old had 4.8 times the odds of reporting nonsuicidal self-injury compared with adolescents whose parents did not report parental stress. Adolescents who perceived parental hostility and negativity at 6 years old had 1.8 times the odds of nonsuicidal self-injury compared with adolescents who did not. However, child characteristics and negative events did not appear to increase the odds of adolescents reporting nonsuicidal self-injury.

"Stress in parents is hypothesized to have widespread negative impacts on child development, including the development of behavioral problems and reduced social competence. It is therefore possible that increased stress contributes to the emergence of risk factors in children, which have implications for [nonsuicidal self-injury]-related vulnerabilities in adolescence," Wichstrøm and Wichstrøm wrote.

"[U]niversal or indicated interventions to reduce parenting stress and to improve parent‒child interactions during childhood may reduce the risk of [nonsuicidal self-injury] in adolescence," they concluded.

For related information, see the Psychiatric Services article, "Testing the Impact of a Peer-Delivered Family Support Program: A Randomized Clinical Effectiveness Trial."

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Calls to Poison Centers Involving Psilocybin on the Rise Among Young People

Since 2019, calls to U.S. poison centers involving youth or young adults who took the psychedelic psilocybin have risen sharply, according to a study published today in the Journal of Adolescent Health. The timing is notable as 2019 was the start of a psilocybin decriminalization movement across numerous states and cities.

Rita Farah, Ph.D., and colleagues at the University of Virginia School of Medicine analyzed data from the National Poison Data System, which collects de-identified poison exposure data from centers across the country. The researchers examined all cases of psilocybin exposure between 2013 and 2022 involving young people aged 13 to 25.

Over the 10-year period, the researchers identified 4,055 calls for psilocybin exposure, of which about 66% involved psilocybin alone. The poison calls generally included a visit to a health care facility due to hallucinations or delusions, agitation, elevated heart rate, or confusion. The calls included two reported deaths, but both involved a secondary substance (fentanyl and amphetamine).

Between 2013 and 2018, the number of psilocybin calls per year remained steady among both adolescents (aged 13 to 19) and young adults (aged 20 to 25). Starting in 2019, however, the rates increased each year. In 2022, psilocybin-related poison calls by young adults had more than doubled compared with 2018 (to nearly 300 calls), while calls by adolescents had more than tripled (over 450 calls). The researchers noted that overall call volume to poison centers did not fluctuate significantly between 2013 and 2022.

Farah and colleagues noted that their analysis could not assess how psilocybin-related poison calls changed in specific regions where this drug has been decriminalized. “As psilocybin might become more available, continued surveillance is critical to inform lawmakers and help guide public policy,” they wrote.

To read more on this topic, see the Psychiatric News article “Marijuana, Hallucinogen Use Reach Historic Levels Among Young Adults.”

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One in Five Who Attempt Suicide Have No Prior Mental Illness

Nearly one in five people who attempt suicide either have no history of prior mental illness or do not meet the criteria for a diagnosis of mental illness at the time of the attempt, a study in JAMA Psychiatry suggests.

“This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations,” wrote Past APA President Maria A. Oquendo, M.D., Ph.D., of the University of Pennsylvania and colleagues.

The researchers analyzed data from 1,948 adults (66.8% female) aged 20 to 65 years with a history of suicide attempts who were surveyed between April 2012 and June 2013 in the U.S. National Epidemiologic Study of Addictions and Related Conditions III.

The researchers found that 6.2% of the respondents did not have a diagnosis of mental illness at any time prior to attempting suicide or afterwards up to the point they completed the survey. They also found that an additional 13.4% made a first suicide attempt before the onset of mental illness, and some did not meet the criteria for a mental illness until several years after their suicide attempt. All told, an estimated 19.6% of adults reported a lifetime suicide attempt with no evidence of a mental illness prior to their first attempt; this prevalence was approximately the same in males and females.

“From a clinical standpoint, these findings suggest that a history of suicide attempts should be obtained regardless of whether the person has a psychiatric disorder, given that suicide attempts are associated with future attempts and future suicide,” Oquendo and colleagues wrote.

“[P]olicy makers, clinicians, and health systems should weigh the costs and benefits of expanding suicide risk screening beyond the current targets and consider universal screening to prevent suicide attempts, which have significant morbidity as well as medical and other costs,” they added.

For related information, see the Psychiatric News article “Half of Patients With Suicidal Thoughts Deny It.”

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Appetitive Traits in Children May Be Associated With Disordered Eating in Adolescence

Children who show greater food responsiveness in early childhood have a higher risk of experiencing eating disorder symptoms in early adolescence, while those who eat more slowly have a lower risk of such symptoms, according to a study published this week in The Lancet Child & Adolescent Health.

“Eating disorders frequently coexist with other psychiatric disorders and have high mortality rates,” wrote Ivonne Derks, Ph.D., of Erasmus Medical Center in Rotterdam, Netherlands, and colleagues. “Because these disorders are difficult to treat, focus is shifting towards prevention and early intervention when symptoms or episodes first arise, often in adolescence.”

Derks and colleagues used data from two population-based cohort studies: Generation R, which is based in Rotterdam, and Gemini, which is based in England and Wales. Parents reported their children’s appetitive traits by completing the Child Eating Behaviour Questionnaire (CEBQ) when children were aged four (Generation R) or five (Gemini). Youth self-reported eating disorder symptoms when they were aged 12 to 13 (Gemini) or 14 (Generation R). Eating disorder symptoms included restrained (restricted) eating, uncontrolled eating, emotional eating, binge eating, and compensatory behaviors (such as purging, extended fasting, or hiding or throwing away foods). A total of 3,670 participants from both studies were included in the final analysis.

The authors looked at seven appetitive traits measured by the CEBQ. Higher scores in three traits reflected a more avid appetite: food responsiveness (how responsive children are toward external food cues), food enjoyment, and emotional overeating. Higher scores in four traits reflected a poorer appetite: food fussiness, satiety responsiveness (how quickly children feel full), eating slowly, and emotional undereating.

Derks and colleagues found that greater food responsiveness in early childhood was associated with increased odds of all five eating disorder symptoms in adolescence, especially binge eating. A 1-unit increase in the food responsiveness scale in early childhood corresponded with a 47% increased risk of binge eating symptoms in early adolescence, the authors wrote.

“This finding is important because overeating and restrictive eating disorder symptoms often co-occur within eating disorders (e.g., in bulimia nervosa or anorexia nervosa binge/purge type) or might trigger one another (e.g., binge eating episodes are often preceded by restrained eating, which can drive binge eating episodes),” the authors wrote.

Additional findings include the following:

• Emotional overeating in early childhood was associated with an increased risk of engaging in compensatory behaviors in early adolescence.
• Slowness while eating in early childhood was associated with a reduced risk of engaging in compensatory behaviors and restrained eating in early adolescence.
• Greater satiety responsiveness during early childhood was associated with a reduced risk of engaging in compensatory behaviors and uncontrolled eating in early adolescence.

“Our findings could provide new opportunities for treatment and prevention of eating disorders,” the authors wrote. “[T]eaching parents and children how to recognize and respond to internal feelings of hunger and satiety, encourage slower eating at mealtimes, and not to offer or eat food for reasons other than homoeostatic hunger… are practices that support the development of healthy eating habits.”

For related information, see the Psychiatric News article “APA Releases Updated Guideline for Treating Eating Disorders.”

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Many Individuals at Ultra-High Risk of Psychosis Also Have Persistent Non-Psychotic Symptoms

More than a third of individuals at “ultra-high risk” (UHR) of psychosis who did not convert to psychosis over a 6- to 12- year period did develop a new, non-psychotic mental disorder, according to a report in Schizophrenia Bulletin. Further, more than a quarter of these individuals still met criteria for UHR. Ultra-high risk refers to youth or young adults who experience a range of brief intermittent psychotic symptoms and/or subthreshold psychotic experiences, putting them at greatly increased odds of developing a full-threshold psychotic disorder.

“Because this UHR sample never developed a full threshold psychosis, they would not have been targeted for prolonged intervention,” wrote lead author Anneliese E. Spiteri-Staines, Ph.D., of the University of Melbourne, Australia, and colleagues. “However, given their long-term impairment, this group would benefit from longer-term treatment both for their non-psychotic disorders and continuing [attenuated psychosis symptoms].”

The researchers evaluated 102 young people (62% female) enrolled in the Personal Assessment and Evaluation Clinic, a specialized clinic for high-risk youth at the Orygen Mental Health Center in Melbourne. All participants were between 15 and 30 years of age at baseline and met the criteria for UHR but had not converted to full-threshold psychosis at a follow-up assessment 6 to 12 years after their baseline assessment.

UHR status was determined using the Comprehensive Assessment of At-Risk Mental States (CAARMS). Mental disorder diagnosis was assessed using the Structured Clinical Interview for DSM-IV. Transition to psychosis was determined using both the CAARMS and DSM-IV.

Overall, 35% of participants were diagnosed with a new non-psychotic disorder during the follow-up period, while 44% participants had a non-psychotic disorder at baseline that remitted. A further 54% had a non-psychotic disorder that persisted from baseline to follow-up. Altogether, only 6% of participants had not received a diagnosis of any non-psychotic DSM-IV disorder at either baseline or the follow-up assessment. The disorder that was the most persistent over time was mood disorder.

Spiteri-Staines and colleagues also found that of the 84 patients for whom data was available on UHR status at follow-up, 29% continued to meet UHR criteria, and these individuals were more likely to have a co-occurring mental disorder.

“There is a need to better understand the risk factors for the persistence and incidence of non-psychotic disorders in the UHR population, in addition to those associated with risk for developing psychotic disorder,” the researchers wrote. “Sustained clinical attention to monitor and avert these outcomes is warranted.”

For related information, see the Psychiatric News article, “Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers.”

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Bilingualism May Protect Against Cognitive Impairment

People who speak more than one language may have a lower prevalence of dementia or mild cognitive impairment compared with those who speak only one language, according to a study published today in Alzheimer’s & Dementia.

“A large body of literature has focused on studying the protective effects of bilingualism against cognitive decline and dementia in clinical settings,” wrote Aparna Venugopal, M.Sc., and Avanthi Paplikar, Ph.D., of the National Institute of Mental Health and Neurosciences in Bengaluru, India, and colleagues. However, the authors noted that only a few community-based studies have investigated the protective role of bilingualism. “India offers a unique opportunity to study bilingualism, cognition, and dementia since the population is non-immigrant and linguistically diverse,” they wrote.

Venugopal, Paplikar, and colleagues conducted a door-to-door community survey in Jayanagar, South Bengaluru, India, from January to December 2021 among individuals aged 60 years or older. Each participant received a clinical examination by a general physician, after which a clinical psychologist and speech-language pathologist administered neuropsychological tests to assess dementia status. Participants completed the language use questionnaire to determine the number of languages in which they were proficient.

A total of 1,234 participants with a mean age of 71 years were included in the study. Among all participants, 1.9% were diagnosed with dementia and 6.5% were diagnosed with mild cognitive impairment. Further, 65% of participants were considered bilingual. Additional findings include the following:

• Dementia prevalence was lower in bilingual participants (0.4%) than in monolingual participants (4.9%).
• The prevalence of mild cognitive impairment was lower in bilingual participants (5.3%) than in monolingual participants (8.5%).
• Bilingual participants had a lower prevalence of dementia compared with monolingual participants regardless of their education levels.
• Bilingual participants both with and without cognitive impairment had higher average scores on Addenbrooke’s Cognitive Examination (ACE-III, a measure of general cognitive function on which higher scores indicate better functioning) compared with their monolingual counterparts. Bilingual participants also scored higher in all five ACE-III subdomains: attention, memory, fluency, language, and visuospatial. These findings were true even after controlling for confounding variables like age, sex, or occupation.
• There was no difference in general cognitive function between participants who spoke two languages compared with those who spoke three or more languages.

“Overall findings indicate that bilingualism promotes healthy aging and protects against cognitive decline and dementia,” the authors wrote. “Our study has implications for public health interventions, highlighting the importance of promoting bilingualism and multilingualism as potential cognitive reserve factors that may delay or slow down cognitive decline.”

For related information, see the Psychiatric News article “COVID-19 Takes Cognitive Toll on Older Patients.”

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Suicide Risk Among Patients With Depression Highest First Three Days After Discharge

Patients with depression who have been discharged from psychiatric hospitals have the highest risk of dying by suicide in the first three days after discharge, with some risk factors increasing that risk further, according to a study published this week in JAMA Psychiatry.

Of all people dying by suicide, more than half had depression, and approximately 40% had been recently hospitalized, wrote Kari Aaltonen, M.D., Ph.D., of the University of Helsinki and colleagues. Therefore, people hospitalized for depression are at significant risk of suicide following their discharge. “Such a population with a distinct high-risk period in contact with psychiatric care forms a prioritizable target for selective suicide prevention,” they wrote.

Aaltonen and colleagues used data from Finnish registers such as the Care Register for Health Care and Statistics Finland, which included information on hospital admissions, discharges, diagnoses, and causes of death. They identified all psychiatric hospitalizations for depression among participants aged 18 years and older from 1996 to 2017; patients with comorbid major psychotic disorder or bipolar disorder were excluded. Each patient was followed for up to two years after discharge. For those with multiple hospitalizations, each discharge marked the beginning of a new follow-up period.

A total of 193,197 hospitalizations occurred during the study period among 91,161 participants (56.2% female; mean age 44 years). A total of 1,219 men and 757 women died by suicide during the study period. Additional findings included the following:

• During the first three days after discharge, the suicide incidence rate was 6,062 per 100,000 person-years. The authors noted that this rate exceeded the rate within the general population in Finland by 330-fold.
• The suicide rate remained high throughout the first week after discharge (3,884 per 100,000 person-years on days four to seven), but then fell steadily, dropping to 478 per 100,000 person-years after one year.
• Individuals who were admitted to the hospital due to a suicide attempt by firearm or hanging had the highest risk of death by suicide in the first three days after discharge. Other factors associated with immediate suicide risk included severe or psychotic depression, severe illness with impaired function, a history of attempted suicide, male sex, and age 40 and above.
• Some factors showed temporal trends. Having a higher household disposable income was associated with immediate suicide risk after discharge, but later it was associated with a lower risk compared with those with lower income. Individuals hospitalized with comorbid alcohol use disorder had a lower immediate suicide risk than those without, but then a higher risk over time.

“Although we found a decreasing trend over time, the high-risk post-discharge period still requires intensified attention,” the authors wrote. “Continuity of care and access to enhanced psychiatric outpatient care within days of discharge should be imperative.”

For related information, see the Psychiatric News article “Army STARRS Study Finds Risks to Progression From Suicidal Ideation to Attempts.”

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Discrimination of Mexican Youth Linked to Mental Health, Sleep Problems

Nearly 9 in 10 Mexican-origin youth living in Northern Indiana reported experiencing discrimination, according to a study published in the Journal of the American Academy of Child & Adolescent Psychiatry. These findings reflect the first wave of a three-wave longitudinal study, Seguimos Avanzando, which is examining the effects of discrimination as well as family support on the mental health of Mexican-origin youth in regions experiencing new migration.

“In new migration areas, Latinx individuals are often portrayed as having criminal tendencies, perpetuating negative stereotypes and increasing marginalization,” wrote Margarita Alegria, Ph.D., of Massachusetts General Hospital and colleagues. “Previous research has not studied risk and protective factors among Latinx individuals living in a predominantly White population state, and few studies used longitudinal designs barring rare exceptions.”

For wave 1, Alegria and colleagues surveyed an ethnically homogeneous sample of 344 Mexican-origin adolescents (aged 12 to 15) and their primary caregivers. Measures on the youth-reported surveys included past two-week depressive symptoms (Child Depression Inventory-2 Short Form), past three-month anxiety symptoms (Generalized Anxiety Disorder Scale of the Screen for Child Anxiety Related Emotional Disorders), past-month sleep quality (Pittsburgh Sleep Quality Index global scores), and lifetime perceived racial discrimination (Perceptions of Racism in Children and Youth).

After completing the wave 1 survey, 317 youth also completed a one-time 21-day diary in which they reported items including their daily stress, daily perceived racial discrimination, and previous night’s sleep quality.

The researchers found that 88.1% of youth reported at least one incident of lifetime discrimination. Furthermore, 29.7% had elevated depressive symptoms, 44.5% had probable generalized anxiety disorder, and 50.9% had poor sleep quality. Across both the survey and diary reports, Alegria and colleagues found a consistent correlation between increased perceived racial discrimination and worse mental health and sleep quality.

“Contributing factors [for these outcomes] for Mexican American youth could be acculturative stress, associated with worse mental health outcomes, the recent COVID-19 pandemic, exposure to food insecurity, and housing instability,” the researchers wrote. “Discrimination and uneasiness in social situations responding to racism could also cause elevated risk.”

For related information, see the Psychiatric Services article “Leveraging Latinx and Spanish-Language Media to Achieve Mental Health Equity.”

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Machine Learning Algorithm Successfully Predicts Response to Antidepressant Sertraline

A machine learning program that analyzes patients’ brain imaging data along with many clinical variables of major depression—such as symptom severity—predicted whether patients with major depressive disorder would respond to the antidepressant sertraline, according to a report in AJP in Advance.

Machine learning is a type of artificial intelligence that combines a very large number of patient variables—more than a single physician could collect—to try to reliably predict an outcome of interest for individual patients. With each new piece of data, the computer “learns” to refine its prediction—hence the term “machine learning.

Maarten G. Poirot, M.S., and Henricus G. Ruhé, M.D., Ph.D., of the University of Amsterdam and colleagues used data from 229 patients with major depression who had enrolled in the Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study, a randomized controlled trial designed to evaluate variables that predict antidepressant response. Brain MRI images and a wide variety of socioeconomic, behavioral, and neuropsychiatric variables were collected before and one week after treatment with sertraline.

The researchers first tested their machine learning program on 105 patients who received sertraline and found the program could predict treatment response after 8 weeks using both pretreatment data (patient baseline variables) or early treatment data (changes after one week) significantly better than random chance; accuracy ratings ranged from 62% to 68%. The machine learning program did not generally perform as well when assessing whether patients in the placebo group responded to treatment, indicating that the prediction tool was specific to sertraline.

Moreover, the analysis was able to pinpoint which variables were most important in the prediction. “The algorithm suggested that blood flow in the anterior cingulate cortex, the area of brain involved in emotion regulation, would be predictive of the efficacy of the drug. And at the second measurement, a week after the start, the severity of their symptoms turned out to be additionally predictive,” said Ruhé in a press release. In the article, the researchers noted that since their program would likely not need input from a second session of MRI scanning to be accurate, the cost and burden on patients would be lowered in clinical practice.

The researchers concluded, “With additional external validation, these findings will contribute toward the use of predictive modeling in individualizing clinical sertraline treatment of patients with MDD.”

For related information, see the Psychiatric News article “Research Using Machine Learning in Psychiatry Expands Rapidly.”

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Preventive Intervention for Youth Shows Intergenerational Effects

At-risk youth whose parents were enrolled in a behavioral intervention as children use fewer inpatient and outpatient mental health services than their peers, according to a report in AJP in Advance. The intervention, known as Fast Track, combines cognitive and social skills training for children and child behavior management training for parents.

“Preventive interventions like Fast Track delivered in one generation may reduce use of some of the highest-demand and most expensive health services for children in the next generation,” wrote W. Andrew Rothenberg, Ph.D., of Duke University and colleagues. “Potential mechanisms that might explain these reductions include a decreased risk for internalizing psychopathology and decreased use of corporal punishment to create a more optimal family environment for the next generation.”

The initial Fast Track cohort included 891 children in grades 1 through 5 and families recruited from elementary schools in areas of high crime and poverty in the early 1990s. Half of the children were provided the Fast Track intervention, and the other half were in the control group. Participants in both groups were subsequently interviewed at age 25, which included assessments of internalizing and externalizing problems and whether the participants, if parents, spanked their children. The participants with children were contacted again at age 34 and asked to complete a survey about their children’s mental health and health service use.

In total, 398 parents filled out these surveys at age 34; 209 of the parents were in the Fast Track group and filled out measures for a combined 581 children. The remaining 189 parents were in the control group and filled out these measures for a combined 476 children.

Rothenberg and colleagues found that compared with the children whose parents were in the control group, those whose parents were in Fast Track were 3.29 times less likely to have used inpatient mental health services, 1.85 times less likely to have used outpatient mental health services, and 1.38 times less likely to have used general inpatient health services. However, there were no differences between the groups in the use of general outpatient services, school-based services, and overall mental health symptoms.

“[A]lthough there were no significant differences between the intervention and control groups on … mental health scores, both groups appear to be functioning as well as or better than children from a ‘normative’ population whose parents were not at high risk for conduct problems,” the authors wrote.

For related information, see the Psychiatric News article “Group School Intervention Helps Girls Cope With Internalized Trauma.”

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APA Announces Results of 2024 Election

At its meeting on February 9, APA’s Committee of Tellers approved the following results for APA’s 2024 national election. Please note that these results are considered public but not official until approved by the Board of Trustees at its meeting on March 9 and 10.

President-elect
Theresa M. Miskimen Rivera, M.D.

Treasurer
Steve Koh, M.D., M.P.H., M.B.A.

Trustee at Large
Patricia Westmoreland, M.D.

Early Career Psychiatrist Trustee
Sudhakar K. Shenoy, M.D. 

Area 1 Trustee
John C. Bradley, M.D.

Area 4 Trustee
Dionne Hart, M.D.

Area 7 Trustee
Mary Hasbah Roessel, M.D.

Resident-Fellow Member Trustee-Elect
Nicolas K. Fletcher, M.D., M.H.S.A.

“Our profession faces multiple challenges,” Miskimen Rivera said in a news release. “We need a cohesive, actionable, multi-year strategy to enact effective and permanent change. As president, I will focus on the workforce challenges facing psychiatry, with the ultimate goal being to reverse these challenges, enabling greater fulfillment in our practices and achieving better patient outcomes.”

Miskimen Rivera is chair and medical director of the Department of Psychiatry at Hunterdon Medical Center in Flemington, N.J. A speaker of English and Spanish, she has worked for 30 years to improve access and delivery of psychiatric care to bilingual and bicultural communities. She has held appointed positions under the three past governors of New Jersey to address mental health issues spanning the intersection of technology and the delivery of psychiatric care, mental health in university settings, and youth suicide prevention.

Miskimen Rivera is an APA delegate on the AMA’s Section Council on Psychiatry and is a member of the American College of Psychiatrists. She is also a clinical professor of psychiatry at Robert Wood Johnson Medical School.

“Congratulations to everyone who has been elected to APA’s Board of Trustees,” said APA President Petros Levounis, M.D., M.A. “I look forward to working with all of them to lead APA’s efforts as we continue to innovate, advocate, and research on behalf of the doctors who serve millions of patients and families with substance use and mental health disorders.”

Commented APA CEO and Medical Director Saul Levin, M.D., M.P.A., “I’m so pleased for Dr. Miskimen Rivera, a longtime colleague and friend of APA, to become our president,” said “With her long track record of leadership throughout the organization and in her home state, she is a proven leader and will bring much experience to her year as president.”

Miskimen Rivera’s term as APA president-elect will begin in May at the conclusion of APA’s 2024 Annual Meeting, when President-Elect Ramaswamy Viswanathan, M.D., begins his one-year term as president. The other newly elected trustees will also begin their terms of office then as well.

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Antidepressants May Help Cognitive Function in Adults With Late-Life Depression

Taking antidepressants for late-life depression may improve certain aspects of cognitive function, particularly memory and learning, a review and meta-analysis in the American Journal of Psychiatry suggests.

Nicholas J. Ainsworth, M.D., of the Centre for Addiction and Mental Health in Toronto and colleagues analyzed data from 22 studies (totaling 3,019 participants) of antidepressant therapy for older adults (study participants had a minimum age of 50 or average age of 65 or older) with depression that included cognitive testing. The researchers categorized cognitive tests in the following domains: global cognition, executive function, processing speed, verbal memory and learning, immediate memory, attention and working memory, and verbal fluency.

Ainsworth and colleagues sought answers to three questions:

• Does pharmacological treatment of late-life depression lead to improved cognition, either globally or in specific cognitive domains?
• Do specific antidepressants improve cognition more than others?
• Are improvements in cognition after pharmacotherapy associated with improvements in depressive symptoms?
• The researchers classified a study as reporting “improvement” in a cognitive domain when an antidepressant showed statistically significant differences from baseline to posttreatment (compared with placebo or another antidepressant, if applicable) in one or more cognitive tests.

For the first question, a meta-analysis of eight relevant studies found that treatment with an antidepressant did lead to modest, but statistically significant, improvements in learning and memory in adults with late-life depression. Several studies reported cognitive improvement in processing speed with antidepressant therapy, but the findings did not reach statistical significance.

There were not enough data to address the other two questions with a meta-analysis, but a qualitative review suggested sertraline had the most consistent evidence of benefit; all five studies involving sertraline reported an improvement in at least one cognitive domain. The researchers also found that seven of eight relevant studies found some association between improvements in depression and cognition.

“Future prospective [late-life depression] research studies should systematically test cognitive outcomes in multiple domains, while including a nontreatment comparator group to account for possible practice effects,” the researchers concluded.

For related information, see the American Journal of Psychiatry article “Optimizing the Treatment of Late-Life Depression.”

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Federal Government Makes Telehealth Buprenorphine Prescribing Permanent

On February 2, the Substance Abuse and Mental Health Services Administration issued a final rule that permanently allows patients to begin treatment with buprenorphine via telehealth. The rule also allows for increased flexibility related to methadone take-home doses, reducing the number of times patients must visit clinics. These are both provisions for which APA had advocated to be included in the final rule, arguing that they would improve access to care while reducing stigma and disruptions to patients’ daily lives.

The rule goes into effect on April 2, with a compliance deadline of October 2. The rule marks the first time in 20 years that the U.S. Department of Health and Human Services (HHS) has substantially updated its opioid treatment program (OTP) regulations.

“This final rule represents a historic modernization of OTP regulations to help connect more Americans with effective treatment for opioid use disorders,” Miriam E. Delphin-Rittmon, Ph.D., the HHS assistant secretary for mental health and substance use, said in a news release. “While this rule change will help anyone needing treatment, it will be particularly impactful for those in rural areas or with low income for whom reliable transportation can be a challenge, if not impossible. In short, this update will help those most in need.”

The rule makes permanent some of the temporary flexibilities that the federal government put in place during the COVID-19 Public Health Emergency. It allows patients to access methadone treatment via audiovisual technology and buprenorphine treatment via audiovisual or audio-only technology. It also allows patients up to seven days of take-home methadone doses during the first two weeks of treatment, up to 14 days of take-home doses starting on day 15 of treatment, and up to 28 days of take-home doses starting on day 31. Prior, patients were initially required to visit clinics daily to get their methadone doses.

The new rule also expands access to interim treatment (allowing patients to begin medication treatment while waiting for more comprehensive services), thus reducing waitlist barriers. Additionally, the rule removes the requirement that patients must have a history of opioid use disorder for one full year before becoming eligible for treatment. This regulatory change, for which APA also advocated, helps prevent further harm caused by requiring patients to wait before they can access effective treatment.

Finally, another major update ensures that medication continuity is not contingent upon involvement in counseling services, allowing practitioners and patients to tailor treatment collaboratively. “At HHS, we believe there should be no wrong door for people who are seeking support and care to manage their behavioral health challenges, including when it comes to getting treatment for substance use disorder,” HHS Deputy Secretary Andrea Palm said in the release. “The easier we make it for people to access the treatments they need, the more lives we can save.”

For related information, see the Psychiatric News article “Federal Telehealth Policy Changes After COVID-19 Public Health Emergency.”

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Omega-3 Supplementation May Reduce Symptoms of Schizotypal Personality Disorder in Children

Community-dwelling children with schizotypal personality disorder may benefit from dietary supplementation with omega-3 fatty acids, according to a report in Schizophrenia Bulletin. Schizotypal personality disorder (or “schizotypy”) is marked by symptoms of aggression and interpersonal and cognitive problems that can be precursors to schizophrenia.

“Poor nutrition has long been associated with schizophrenia-spectrum disorders, including schizoid personality and schizotypal personality,” wrote Adrian Raine, D. Phil., of the University of Pennsylvania and colleagues. One of the researchers’ previous studies found that providing youth with a fish-rich dietary intervention could improve brain function and reduce schizotypy symptoms. “[W]e hypothesized that omega-3 could be the active ingredient in the enrichment that reduced schizotypy.”

In the current study, 290 community-dwelling children aged 11 and 12 years were randomly assigned to receive three months of daily omega-3 supplementation alone, cognitive-behavioral therapy (CBT) alone, or omega-3 supplementation plus CBT or were placed in a control group. All children met criteria for conduct disorder or oppositional defiant disorder or had higher-than-average scores on a standardized test for aggression.

The omega-3 supplement consisted of a daily 200 ml fruit-flavored drink containing 1,000 mg of various omega-3 fatty acids along with two chewable multivitamin tablets. CBT was delivered in 12 weekly one-hour sessions, supplemented with weekly home exercises. Schizotypy was assessed at baseline, and 3, 6, and 9 months after treatment using the self-report Schizotypal Personality Questionnaire-Child (SPQ-C19). It assesses three aspects of schizotypy—interpersonal factors, disorganized factors, and cognitive factors.

In the omega-3 only and omega-3 plus CBT groups, total schizotypy was reduced by 28.0% and 21.3%, respectively, by the end of treatment, and by 25.7% and 36.6%, respectively, at 3 months after treatment. Children in both groups showed greater improvement than children in the control group at 3 and 6 months, with the greatest improvements seen in children who reported higher omega-3 intake. Children receiving omega 3 plus CBT also showed statistically greater improvements than the CBT alone group at 6 months.

The strongest improvements were seen for interpersonal features, with both omega-3 groups showing sustained improvements compared with controls at 9 months.

The researchers wrote that the findings “highlight the potential for increasing efforts to both assess and recognize schizotypy in children and to consider how these children can be better supported through benign interventions that could reduce the incidence of schizophrenia-spectrum disorders.”

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Exposure to Gun Violence Increases Risk of Suicidality in Black Adults

Black adults who have been exposed to gun violence at any point in their lives may have a higher risk of suicidal ideation, planning a suicide, or attempting a suicide, a study in JAMA Network Open has found.

In April and May 2023, Daniel C. Semenza, Ph.D., of Rutgers University and colleagues assessed survey responses of 3,015 Black adults in the U.S. with a mean age of approximately 46 years. The researchers measured suicidal ideation using eight items from the self-report version of the Self-Injurious Thoughts and Behaviors Interview; they also measured suicide attempt preparation if participants indicated they had done something to prepare a suicide attempt such as gaining access to a method or writing a suicide note.

The researchers also asked participants four questions related to gun violence exposure:

• Have you ever been shot on purpose by another person with a firearm?
• Have you ever been threatened with a firearm by another person?
• Do you personally know someone such as a friend or family member who has been shot on purpose by another person with a firearm?
• Have you ever witnessed or heard about someone being shot intentionally by another person with a firearm in your neighborhood?

Overall, 56% of participants reported being exposed to at least one type of gun violence, and 12% reported being exposed to at least three types of gun violence. Participants who were exposed to one or two types of gun violence had 1.69 times the odds of reporting lifetime suicidal ideation, whereas those who were exposed to three or more types of gun violence had 2.27 times the odds of reporting lifetime suicidal ideation.

Although the study did not identify the mechanisms to explain the path from cumulative gun violence exposure to suicidal thoughts, the researchers posited that exposures to such traumatic experiences are associated with increased hopelessness and diminished social and community connections. They added that such exposures are also associated with diminished sense of value, such as diminished employment and wealth-generation opportunities.

“The disproportionate burden of [gun violence exposure] borne by Black communities and exacerbated by numerous structural inequities may represent an even more substantial injustice than previously understood, as it may be influencing suicide rates within those same communities,” Semenza and colleagues wrote.

For related information, see the Psychiatric News article “Gun Violence Is an Underrecognized Social Determinant of Health.”

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Telemental Health Availability Varies Across U.S., but Robust Overall

A large majority of mental health treatment facilities in the U.S. have continued to offer telehealth services since the pandemic, according to the results of a survey published in JAMA Health Forum. While telehealth availability varied by geographic location and facility ownership (public vs. private), there were no significant differences in availability based on patient characteristics.

The survey findings “are encouraging insofar as we did not observe a systematic bias in which available services differed based on perceived race and ethnicity of the client, stated clinical condition of the client, or county-level sociodemographic characteristics,” wrote Jonathan Cantor, Ph.D., of the RAND Corporation in Santa Monica, Calif., and colleagues. “However, our findings indicate that a prospective client may face several hurdles finding a facility that offers comprehensive telehealth services.”

The researchers posed as prospective new patients and randomly called 1,938 mental health facilities between December 2022 and March 2023. The facilities included psychiatric hospitals, Veterans Affairs medical centers, certified community behavioral health clinics, outpatient facilities, and more. Using a standardized script, they inquired about what telehealth services were available and when an appointment could be made. To identify potential biases from staff, the callers were randomly given a specific condition –major depression, generalized anxiety disorder, or schizophrenia—as well as an identifiable Black, White, or Hispanic name.

The researchers received responses from 1,404 facilities, of which 1,221 (87%) were accepting new patients. Of this group, 980 provided some telehealth services:

• 937 facilities (97%) offered counseling via telehealth.
• 726 facilities (77%) offered medication management via telehealth.
• 626 facilities (69%) offered diagnostic services via telehealth.

Overall, compared with public mental health facilities, private for-profit facilities were 1.75 times as likely to offer mental telehealth services, while private nonprofit facilities were 2.20 times as likely.

Service availability also varied by state; less than half of the facilities contacted in Mississippi and South Carolina provided telehealth while every facility contacted in Delaware, Maine, New Mexico, and Oregon did. Median wait times also varied greatly, from four days in North Carolina to 75 days in Maine. Across the whole sample, however, there was no evidence to suggest facilities were biased against individuals with a specific condition or perceived race/ethnicity.

While the researchers said the overall findings were encouraging, they were concerned with the significant number of facilities that did not respond to multiple phone call attempts.

To read more about this topic, see the Psychiatric News article “North Carolina’s Telepsychiatry Program Expands Reach, Saves on Costs.”

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Playing Music, Singing Linked to Better Brain Health Later in Life, Study Shows

Playing a musical instrument and/or singing in a group may improve brain health later in life, according to a report in the International Journal of Geriatric Psychiatry. Specifically, the study found that playing a musical instrument, singing, and overall musical ability was associated with significantly better performance in working memory and executive function.

“Promoting the exposure to music during life can increase cognitive reserve and reduce the risk of cognitive impairment in older age,” wrote Gaia Vetere and Gareth Williams, M.D., of the Institute of Psychiatry at Kings College, London, and colleagues. “Public health interventions to promote healthy aging and dementia risk reduction should consider including advice for adults on engaging with music.”

The researchers analyzed data from the PROTECT Study, a project to study aging and brain health in the United Kingdom. As part of PROTECT, participants completed three computerized tests for working memory and one test for executive function, up to three times a year between 2019 and 2022.

Vetere, Williams, and colleagues focused their analysis on a group of 1,107 PROTECT participants who completed the 15-item Edinburgh Lifetime Musical Experience Questionnaire, which asked participants about their experiences playing a musical instrument, singing, listening to music, and self-reported musical ability. The cohort was 83% female with a mean age of 67.82 years.

A total of 89% of participants had experience playing a musical instrument, with 44% playing currently. The majority of participants who reported playing an instrument played either a keyboard or woodwind instrument, and the majority played either one (28%) or two (23%) instruments, although 4% reported playing five or more. The majority of participants had played for a limited number of years in their lives, most commonly five or less (27%).

Participants who reported having played a musical instrument performed significantly better in working memory and executive function tasks, with effect sizes exceeding 0.2. The effect on working memory was particularly seen in individuals who reported playing the keyboard (either alone or in combination with other instruments), with these participants showing significantly more favorable performance in all three working memory tasks.

There was also a significant association between singing and executive function, with an effect size of 0.15. Higher self-reported musical ability was associated with better performance on the working memory test. No associations were seen between listening to music and cognitive performance.

The authors highlighted several limitations of the study, including the overrepresentation of women and musicians. “Future research could make use of a more in-depth capture of musicality, … to investigate other aspects of cognition including attention and episodic memory to explore how they are affected by music,” they wrote.

“There is considerable evidence for the benefit of music group activities for individuals with dementia, and this approach could be extended as part of a health aging package for healthy older adults to enable them to proactively reduce their risk and to promote brain health,” they concluded.

For related information, see the Psychiatric News article “Music Therapy Provides ‘Visceral’ Experience in Patients.”

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