More Patients Take OUD Medications When Treatment Centers Offer Them Onsite

Individuals with opioid use disorder (OUD) are much more likely to take buprenorphine or methadone if their treatment center offers these medications onsite, according to an analysis appearing in Psychiatric Services in Advance.

“In July 2018, Philadelphia became the first U.S. municipality to mandate the availability of medications for opioid use disorder (MOUD) in publicly funded substance use disorder treatment agencies,” wrote Rebecca E. Stewart, Ph.D. of the University of Pennsylvania Perelman School of Medicine, and colleagues. However, treatment agencies could either provide medications onsite or have a documented plan to refer patients to external MOUD providers.

The researchers reached out to the leaders of all 53 public OUD treatment agencies in Philadelphia between March and July 2020 to ask whether their site provides medications onsite or coordinates with external providers. Forty-five leaders responded, of whom 34 reported providing methadone and/or buprenorphine onsite. Stewart and colleagues then used Medicaid data to calculate how many patients of these 45 sites received methadone or buprenorphine.

Overall, 43% of the patients who went to an onsite provider received an MOUD, compared to 28% of patients at referral agencies. The researchers noted that only two of the 11 referral agencies contacted said they provided naltrexone (an OUD medication that works differently on opioid receptors than methadone or buprenorphine), so the lower prescription rate at these centers was not because they were offering an alternative.

“Agencies that coordinate with external MOUD providers may be creating barriers that impede uptake, or the clients of these agencies may be less motivated to engage with MOUD treatment,” Stewart and colleagues concluded. “Regardless, these findings highlight the need for MOUD mandates specifying how care is provided at substance use disorder treatment agencies, as well as for efforts to build the capacity of these agencies to provide MOUD onsite.”

To read more about this topic, see the Psychiatric News article “Rutgers Grad Students RIOT for Opioid Education.”

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Were You Impacted by Recent Cybersecurity Attack?

In the wake of the Change Healthcare cybersecurity attack and resulting system outages, the AMA would like to assess the level of workflow disruptions and financial impact on practices through an informal, 11-question survey. The AMA will use the information to inform its advocacy efforts on this issue. The deadline to respond is noon CT on Wednesday, April 3.

Telehealth Treatment for Alcohol Use Disorder Associated With Patient Retention

Patients with alcohol use disorder (AUD) who receive treatment via telehealth are more likely to engage in more psychotherapy visits and have a longer duration of medication treatment compared with those who have only in-person visits, according to a study published this week in Alcohol, Clinical and Experimental Research.

“Evidence-based treatment for AUD differs from other substance use disorders in that it includes multiple psychotherapy and medication options,” wrote Ponni V. Perumalswami, M.D., of the VA Ann Arbor Healthcare System and colleagues. “Evaluating telehealth delivery of treatment to vulnerable patients, including those with AUD, is particularly important in the current context as the United States debates whether to sustain or revoke pandemic-era policies that decreased barriers to telehealth.”

Perumalswami and colleagues analyzed electronic health record data from the Veterans Health Administration (VHA) during the year following the start of the COVID-19 pandemic (between March 1, 2020, and February 28, 2021). They included 138,619 patients aged 18 or older who were diagnosed with AUD in the year prior to or during the study period and who had at least one AUD treatment visit. AUD treatment included an individual or group psychotherapy visit and/or AUD medication coverage (defined as the number of days covered by a filled prescription for AUD). The authors used VHA codes to determine whether patients received their treatments via video, telephone, or in person.

During the study period, 52.8% of participants had at least one video visit, 38.1% had at least one telephone visit but no video visits, and 9.1% had only in-person visits. Telehealth was associated with a greater number of psychotherapy visits and medication coverage days compared with in-person visits for both patients initiating and continuing treatment during the study period. Further, among those who received any treatment via telehealth, those who had video visits had a significantly greater number of psychotherapy visits compared with those who only had telephone visits.

Participants who had only in-person visits were more likely to be initiating AUD treatment and were older, male, Black, rural, homeless; they were also more likely to have an opioid and/or stimulant use disorder. Additionally, among participants who received any treatment via telehealth, those who were 45 years or older, Black, and diagnosed with a cannabis or stimulant use disorder or serious mental illness were less likely to receive video compared with telephone visits. The authors noted that this finding highlights “important disparities in AUD telehealth use.”

“Additional efforts to increase the engagement of certain VHA patient groups in telehealth use should be made, given its association with receiving more AUD treatment,” the authors concluded. “This study offers insights into patient characteristics associated with AUD treatment in an era of expanded telehealth and suggests that future policy changes in telehealth should be carefully considered given the potential to widen disparities in care.”

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

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Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

Safety Planning for Suicidal Patients in ED Linked to Lower Readmissions

Patients with suicidal behavior who received a safety plan—a set of suicide-prevention strategies—during an emergency department (ED) visit were less likely to be readmitted to the ED or the hospital for suicidal behavior or other mental health problems within 30 days of discharge than those who went to a hospital without routine safety planning. The finding appeared in a study published today in Psychiatric Services.

“Our findings support the notion of making safety planning universally available in EDs for patients with suicidal behavior and as a standard component of outpatient mental health care,” wrote Sara Wiesel Cullen, Ph.D., M.S.W., of the School of Social Policy and Practice at the University of Pennsylvania and colleagues.

Between May 2017 and January 2018, Cullen and colleagues mailed and emailed a survey about management of self-harm to a random selection of 665 hospitals that had recorded five or more ED episodes related to self-harm in the previous year. The contacted hospitals were linked with a patient population derived from a database of deidentified information on millions of individuals privately insured through UnitedHealthcare. The final sample included the 130 hospitals that had returned a completed survey and 2,328 patients who had continuous insurance eligibility 30 days before and after their ED visit.

The hospital survey included questions on how frequently EDs implemented the components of safety planning:

• Helping patients recognize the warning signs of an impending suicidal crisis.
• Providing strategies and identifying social activities to take patients’ mind off of their problems.
• Identifying family members or friends whom patients could ask for help.
• Providing a list of professionals or agencies to contact in a crisis.
• Developing an individualized plan to restrict access to lethal means at home.

Possible responses were “never or rarely,” “sometimes,” “usually but not routinely,” and “on a routine basis.”

Of the 130 hospitals in the analysis, 55% routinely conducted safety planning. Of the patient sample, 62% visited EDs that routinely conducted safety planning.

Among patients who visited an ED that regularly provided a safety plan, 18% were readmitted to the ED and 12% were readmitted to the hospital within 30 days versus 22% and 15%, respectively, of patients who visited an ED that did not regularly provide safety planning. Among patients who had not received any mental health care in the 30 days prior to their ED visit, just 8% of those who went to an ED that routinely conducted safety planning were readmitted versus 14% of patients who were treated in an ED that did not routinely conduct safety planning.

“Safety planning may be more strongly associated with beneficial effects among individuals experiencing a new mental health crisis managed in the ED, perhaps by providing a clear roadmap of what to do when a crisis recurs and by teaching coping skills or strategies to help thwart subsequent crises,” the authors wrote.

For related information, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in at-Risk Patients.”

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Combining SSRIs With Oral Anticoagulants Found to Increase Risk of Major Bleeding

People who take serotonin reuptake inhibitors (SSRIs) and oral anticoagulants have an increased risk of multiple types of major bleeding compared with people who take only oral anticoagulants, a study in JAMA Network Open has found. The study findings also showed that bleeding risk differs depending on the type of anticoagulant.

Christel Renoux, M.D., Ph.D., of Jewish General Hospital in Montreal and colleagues examined data from 331,305 patients in the United Kingdom aged 18 years or older who had atrial fibrillation and began taking oral anticoagulants between January 2, 1998, and March 29, 2021. The researchers included anticoagulants that directly target blood-clotting proteins (apixaban, dabigatran, edoxaban, and rivaroxaban), as well as warfarin, which indirectly reduces clotting by inhibiting vitamin K. They also identified if these patients were being prescribed SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline) at the same time.

Patients were followed until a first major bleeding event, death, end of registration with the patient’s internal medicine practice, or end of the study period, whichever came first.

The researchers identified 42,190 patients who experienced a major bleeding event and matched each one with up to 30 similar adults taking an oral coagulant who did not experience bleeding (a total of 1,156,641 controls, though this included duplicates).

Compared with patients who took only oral anticoagulants, patients who took oral anticoagulants and an SSRI had a 33% increased risk of any major bleeding. Among subtypes of events, there was a 38% increased risk of gastrointestinal bleeding, a 56% increased risk of intracranial hemorrhage, and a 23% increased risk of other types of major bleeding. Overall, the risk of major bleeding was strongest in the first 30 days of taking both types of medications.

The researchers also found that the increased risk of major bleeding was higher in patients who took warfarin and an SSRI (36%) compared with those taking a direct oral anticoagulant and SSRI (25%). However, the risk of major bleeding was not higher in patients taking more potent SSRIs like fluoxetine, paroxetine, or sertraline compared with other SSRIs.

“In light of these findings, the risk of major bleeding may be a pertinent safety consideration for patients using SSRIs and [oral anticoagulants] concomitantly,” Renoux and colleagues wrote. “To minimize the risk of bleeding, individual modifiable risk factors should be controlled, and patients should be closely monitored, particularly during the first few months of concomitant use.”

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Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

CMS Offers Extensions in Wake of Cybersecurity Attack on Change Healthcare

Last month, Change Healthcare, a subsidiary of United Healthcare, experienced a massive cybersecurity attack that continues to impact insurance payments to hospitals and health practices. While Change Healthcare works to restore key systems to enable claim processing, the Centers for Medicare & Medicaid Services (CMS) has taken steps to assist impacted physicians.

• Physicians impacted by the cyberattack may request advance Medicare payments to help with cash flow disruptions. More details of the program, terms, and the steps needed to apply can be found in the CMS Fact Sheet and FAQ.
• CMS has also extended the 2023 MIPS (Merit-based Incentive Payment System) submission deadline until April 15. In addition, CMS has reopened the 2023 MIPS Extreme and Uncontrollable Circumstances hardship application, which likewise has a deadline of April 15 (the hardship exemption is not automatic). Physicians can make their submission by logging on to the CMS portal.

UnitedHealth Group/UnitedHealthcare is providing the latest updates and resources related to the cyberattack and how it’s managing the impacts on its website.

In addition, the Department of Health and Human Services has posted resources to assist providers with the aftermath of the cybersecurity attacks. The resource document includes a national contact person for each plan, though HHS urges providers to contact their health insurer’s regional contact first. If these contacts do not respond, contact HHScyber@hhs.gov.

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Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

Rural Adults With OUD and AUD Are Under-Prescribed Approved Medications

Fewer than one in 10 people in rural areas who have opioid use disorder (OUD) and alcohol use disorder (AUD) are prescribed medications for both of their disorders, a study in the Journal of Substance Use and Addiction Treatment.

“The present study reinforces the gaps in treatment for patients with OUD and/or AUD who live in rural areas and calls for a better understanding of these gaps as well as additional support for rural clinicians in providing pharmacological treatment,” wrote Emily Kan, Ph.D., of the University of California, Los Angeles, and colleagues.

The researchers analyzed data from 1,874 adult patients who visited one of six rural primary care sites in the Northeastern and Northwestern United States at least once from October 2019 to January 2021. The patients all had a diagnosis code for OUD and/or AUD. The researchers also reviewed medications prescribed for OUD or AUD from the clinics' electronic health records. Medications were grouped into five categories: buprenorphine, oral naltrexone, injectable naltrexone, AUD medications like acamprosate or disulfiram, and combination treatment (buprenorphine plus acamprosate or disulfiram).

Overall, 54.2 % of the adults in the sample were diagnosed with OUD only, 37.9 % with AUD only, and 7.9 % with OUD and AUD.

The researchers found that 85.3% of patients with OUD and AUD were prescribed at least one type of medication, compared with 63.7% of patients with OUD and just 10.3% of patients with AUD. Furthermore, patients with both OUD and AUD spent an average of 264.7 days on medication, compared with 220.5 days for those with OUD and 62.5 days for those with AUD. However, only 8.8 % of patients with OUD and AUD were prescribed combination treatment or some form of naltrexone (which is approved for both disorders).

“The low rates of naltrexone prescription are concerning given current evidence of the effectiveness of extended release-naltrexone in treating both disorders,” Kan and colleagues wrote. They added that greater support for rural primary care clinics, such as integrating specialty expertise in OUD and AUD in assessing and treating these disorders and implementing telemedicine to remotely deliver treatment for OUD and AUD, could be practical next steps for addressing the low rates of pharmacological treatment of these disorders in rural communities.

For related information, see the Psychiatric News article “Medications, Open Communication Vital to Treating Substance Use Disorders.”

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Social Determinants of Health Do Not Fully Account for Black-White Clozapine Gap

Even after accounting for variables such as access to care and social determinants of health, Black patients with schizophrenia are less likely than their White counterparts to receive a clozapine prescription, according to a study published this week in Psychiatric Services. Clozapine is considered the gold-standard medication for treatment-resistant schizophrenia, but data show it remains underused.

Spenser Barry, B.S., of the University of North Carolina Wilmington, L. Fredrik Jarskog, M.D., of North Carolina Psychiatric Research Center, and colleagues analyzed electronic health record (EHR) data from University of North Carolina Health, which comprises 16 hospitals and more than 500 clinics throughout North Carolina. They looked for adults (aged 18 to 64) diagnosed with schizophrenia between October 1, 2015, and November 30, 2021. The EHRs provided information on how long participants were in treatment, the number of antipsychotics other than clozapine they received, whether they received clozapine during the study period, and their recorded race.

To quantify participants’ social determinants of health, the authors used the 2018 census tract-level social vulnerability index (SVI), which measures the relative vulnerability of every U.S. Census tract. SVI uses four census variables: socioeconomic status; household composition and disability; minority status and language (English fluency); and housing and transportation (access to a vehicle). Higher scores indicate greater social vulnerability.

Among 2,857 participants (70% men), 14% received at least one clozapine prescription during the study period. Overall, 10% of all Black participants (159 of 1,521) received a clozapine prescription, compared with 19% of all White participants (206 of 1,091). After controlling for other demographic variables, SVI scores, and treatment history, White patients were 71% more likely to receive a clozapine prescription compared with Black patients. No other demographic variable analyzed in the study (gender, rurality, age at first diagnosis, or ethnicity) influenced participants’ likelihood of receiving clozapine.

SVI scores were higher among participants who did not receive clozapine compared with those who did. The authors noted that this finding was expected since initiating and maintaining clozapine treatment does require more resources than other antipsychotics.

“The reasons for the underprescription of clozapine among Black patients with schizophrenia are multifactorial and may include concerns about benign ethnic neutropenia, prescriber bias, prescribers’ anticipation of patients’ nonadherence to the treatment, and the notion that the medication is less effective for Black patients,” the authors wrote. “[N]ovel comprehensive approaches must be formulated that actively involve providers, patients, and health care systems (including payers) to address the many barriers that limit clozapine use.”

For related information, see the Psychiatric News article “FDA Reviewing Clozapine REMS to Determine if Monitoring Requirements Can Be Modified.”

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Body Dysmorphic Disorder or Appearance Preoccupation Common in Teens

Body dysmorphic disorder (BDD), defined as excessive preoccupation with perceived flaws in personal appearance, affects almost two in every 100 teens, according to a report in the Journal of the American Academy of Child and Adolescent Psychiatry. The report also found that BDD is much more common in girls than boys.

Moreover, children and adolescents with BDD are highly likely to have other psychiatric disorders—especially depression and anxiety—and to experience psychosocial problems, self-harm and/or suicide attempts.

“Since young people with BDD tend not to spontaneously disclose their symptoms unless directly asked, it is crucial that clinicians utilize BDD screening tools and ask young people directly about appearance concerns,” wrote lead author Georgina Krebs, Ph.D., D.Clin.Psy., of University College London, and colleagues. “Screening for BDD in young people with anxiety disorders and depression, the most common comorbidities, is likely to improve detection.”

The researchers analyzed data from 7,654 children and young people aged 5-19 who completed the 2017 Mental Health of Children and Young People in England survey with their parents/guardians. BDD was assessed using the Developmental and Well-Being Assessment, a standardized screening tool that includes a question on whether the child is ever concerned how he/she looks. Children who answered ‘A little’ or ‘A lot’ were presented with a series of other questions related to DSM-5 diagnostic criteria for BDD.

Among all children and teens aged 5-19, the prevalence of BDD was 1.0%. BDD was more common among teens ages 12-19 (1.9%) than among children ages 5-11 (0.1%). Across all ages, BDD was also more common in girls (1.8%) than in boys (0.3%).

Nearly 70% of young people with BDD met diagnostic criteria for at least one additional psychiatric disorder. The most common comorbidities were anxiety-related disorders and depressive disorders, occurring in 58.7% and 31.7% of those with BDD, respectively.

Further, 46% of young people with BDD reported a lifetime history of self-harm or suicide attempts, compared to 8% of those without BDD. Teens with BDD also reported higher levels of psychosocial impairment and healthcare utilization.

Excessive preoccupation with appearance that fell short of meeting criteria for BDD was also common among teens and showed similar patterns of comorbidity and impairment. “Appearance preoccupation is a significant clinical phenomenon in its own right, linked with substantial morbidity,” the researchers concluded. “Efforts are needed to raise awareness of BDD, improve screening practices, and reduce barriers to evidence-based treatment.”

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Strong Patient-Therapist Alliance Possible in Nontraditional Inpatient Settings, Study Finds

Individuals in nontraditional inpatient care settings such as residential care and virtual hospitalization can develop strong therapeutic alliances with their care providers, reports a study in Psychiatric Services in Advance.

“Although inpatient care is considered the standard approach for acute states, efforts have been made in recent years to develop alternatives to hospitalization,” wrote Avraham Friedlander, Ph.D., of Ariel University, Ariel, Israel, and colleagues.

“Because alternatives to psychiatric hospitalization ground their treatment approach in therapeutic principles that differ from those of traditional inpatient care, whether the alliance will develop in a similar manner remains unclear.”

Friedlander and colleagues recruited 188 patients from three treatment settings:

• A standard inpatient psychiatric ward at a medical center.
• A residential care center known as Soteria House, which has a full professional staff but aims to create “a nonhierarchical and nondiagnostic environment … with medication not considered a first-line treatment.”
• A telepsychiatry-based hospitalization in which patients recover at home but have ongoing monitoring and online access to psychiatrists, nurses, and other professionals 24/7.

Each patient and therapist (the psychologist, social worker, or psychiatric nurse who spent the most regular time with the patient) completed the Session Alliance Inventory following the first therapy session and again at discharge or treatment termination. The Session Alliance Inventory tracks how both participants in the therapeutic relationship feel on issues such as being appreciated, agreement on therapy goals, and development of a bond.

Patients in all three settings reported a strengthening of the therapeutic alliance over time, with no significant differences among the groups. Therapist responses, however, showed some differences, with therapists at the online hospital reporting a stronger therapeutic alliance at baseline compared with therapists in the other two settings. Friedlander and colleagues suggested that the novelty of online patient care and its nonstigmatizing nature may have helped therapists engage more rapidly with their patients, but more research is needed.

The Soteria therapists reported significant strengthening of bonds over time, however, and by the time of patients’ discharge, the therapist-reported therapeutic alliance at Soteria was almost as strong as for the online therapists.

“These findings suggest that alternatives to psychiatric hospitalization enable alliance to develop in a manner similar to that in traditional psychiatric hospitalization,” the researchers concluded. “To further advance research and clinical care, additional studies are needed to assess the effects of these dynamics on recovery, stigma, social inclusion, and therapeutic outcomes.”

To read more on this topic, see the Psychiatric News article “When Prescribing, Remember the Power of the Doctor-Patient Relationship.”

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Biden Signs Spending Bill That Reverses Part of 2024 Medicare Physician Fee Cut

On March 9, President Biden signed into law the Consolidated Appropriations Act, 2024 (HR 4366) to avert a partial government shutdown. The $460 billion spending package includes a 1.68% reduction to the 3.4% cut to the Medicare Physician Fee Schedule conversion factor that took effect on January 1.  (The conversion factor is an element in the equation that determines physician reimbursement for every payment code.)

The new payment rate went into effect on March 9; it is not retroactive to January 1. APA continues to work for full repeal of the physician pay cut, which was automatically enacted to offset overall increases in Medicare payment.

The impact of the remaining overall payment reduction on individual psychiatrists depends on what kinds of services they provide. The fee schedule, released last November, did include some good news for psychiatrists; positive provisions included an increase in reimbursement for providing psychotherapy as an add-on to evaluation and management (E/M) services and the extension of some telepsychiatry provisions into 2024.

The appropriations act also reauthorizes some substance use disorder treatment programs that were created under the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act.

Other provisions in the appropriations act include the following:

• A requirement that the Department of Health and Human Services provide guidance to states on how they can improve behavioral and primary care integration, including via the Collaborative Care Model.
• Indefinite extension of the requirement that state Medicaid plans cover the costs of medication assisted treatment for substance use disorders.
• A provision that prohibits termination of Medicaid and CHIP (Children’s Health Insurance Program) coverage because of incarceration.
• A provision making permanent the state Medicaid option to cover treatment at a residential or inpatient substance use disorder program with over 16 beds.
• An extension of the Geographic Practice Cost Index (GPCI) floor related to physician work through December 31. The GPCI accounts for differences in practice expenses among different regions of the country.
• An extension of Alternative Payment Model bonus payments at 1.88% for performance year 2024.
• An extension of funding for the Teaching Health Center Graduate Medical Education Program through December 31.

For related information see the Psychiatric News article “Psychiatrists Win Important Gains in 2024 Fee Schedule.”

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Medication Treatment for ADHD Linked to Lower Two-Year Risk of Dying

People with attention-deficit/hyperactivity disorder (ADHD) who begin taking medications for the condition within three months of their diagnosis may have a lower risk of dying within two years compared with their peers who do not take ADHD medications, a study in JAMA has found.

Zheng Chang, Ph.D., of the Karolinska Institutet in Stockholm and colleagues examined data from 148,578 Swedish individuals aged 6 to 64 years who had an incident diagnosis of ADHD from 2007 through 2018 and no ADHD medication dispensation for at least 18 months prior to their diagnosis. They followed the patients from ADHD diagnosis for two years or until death, emigration, or December 31, 2020, whichever came first. The researchers categorized mortality into natural causes (that is, physical conditions) and unnatural causes (that is, suicide, accidental injuries, accidental poisoning, and other external injuries).

Overall, 56.7% of the patients initiated ADHD medication. This was defined as receiving any of the six licensed ADHD medications (methylphenidate, amphetamine, dexamphetamine, lisdexamfetamine, atomoxetine, and guanfacine) within three months of diagnosis.

The researchers found that patients who initiated ADHD medication had a 21% lower risk of dying of any cause and a 25% lower risk of dying from unnatural causes compared with patients who did not initiate ADHD medication.

“ADHD medication may reduce the risk of unnatural-cause mortality by alleviating the core symptoms of ADHD and its psychiatric comorbidities, leading to improved impulse control and decision-making, ultimately reducing the occurrence of fatal events,” Chang and colleagues wrote. “There is also evidence showing that ADHD medications were associated with lower risk of accidents, substance use, and criminality, which in turn could lead to lower rates of unnatural deaths.”

There was no statistically significant difference in death by natural causes between the two groups. The researchers said that this was reassuring given concerns about the cardiovascular safety of stimulants.

The researchers added that their results cannot conclusively establish a cause-and-effect relationship between initiating ADHD medications and lower risk of dying because they did not measure certain confounders, such as lifestyle factors, that could affect risk.

For related information, see the Psychiatric News article “ADHD Meds Linked to Cardiovascular Risk.”

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Genetic Factors Largely Shape Cold or Callous Child Behaviors at Younger Ages

Symptoms of callousness and emotional coldness in children—which can be risk factors for conduct disorder and antisocial personality disorder—are more likely influenced by genetics rather than harsh or poor parenting, according to a report in AJP in Advance.

The findings suggest that one-time interventions aimed at teaching better parenting skills alone may be insufficient, wrote Patrizia Pezzoli, Ph.D., of University College London and colleagues. “Rather than discouraging parenting interventions, these findings suggest that combining parent support with child-focused strategies targeting behaviors that may elicit negative responses represents a promising approach,” the researchers wrote.

Pezzoli and colleagues analyzed data on 9,260 twin pairs (12,029 fraternal twins and 6,491 identical twins) from the Twin Early Development Study, a longitudinal study of twins born in England and Wales between 1994 and 1996 that included assessments when the children were 7, 9, and 12. Twin studies are useful because they can help distinguish genetic and environmental influences on behavior.

The researchers measured callous and unemotional (CU) traits in children using the Strengths and Difficulties Questionnaire and the Antisocial Process Screening Device. They assessed negative parental discipline to deal with child misbehavior, such as hitting and shouting, using a semi-structured interview and negative parental feelings with the Parental Feelings Questionnaire. They explored what may contribute to these outcomes based on the genetic similarity of identical vs. fraternal twins and the shared vs. different experiences of these twins at home, school, or elsewhere.

At age 7, genetic factors accounted for 67% of the difference in CU traits among these children, whereas environmental differences between twins accounted for the remaining 33%. By age 12, the influence of genetic factors on CU traits was still strong but dropped to 55%. Environmental differences accounted for 25% while shared environment that promotes twin similarity accounted for 20% of CU traits at age12.

Similarly, the children’s genetic factors accounted for 58% of the differences in negative parental discipline when children were 7; shared environment accounted for just 15%. However, at age 12 shared environment accounted for 84% of the differences in negative parental discipline among the families.

“An increase in shared environmental influences on negative parenting indicates that parents rated their own parenting as distinct for each of their twins in mid childhood, but less so in late childhood,” Pezzoli and colleagues wrote. “These results suggest that parental discipline may become less tailored to children’s characteristics as they grow older.”

The researchers note that environmental risk factors outside the home—such as exposure to violence at school or in the community—should be addressed in family interventions. “More clinical research is needed to determine the adequate intensity and duration of support for parents of children with varying levels of CU traits,” they conclude. “…[I]nterventions addressing multiple environmental risk factors, rather than parenting alone, are better suited to influence the development of CU traits.”

For related information see the Psychiatric News article, “Early Childhood Behavior Predicts Adult Temperament, 26-Year Study Finds.”

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MRI May Predict Which Patients Will Develop Treatment-Resistant Schizophrenia

A neuromelanin-sensitive MRI (NM-MRI) may successfully predict which patients with first-episode psychosis will eventually develop treatment-resistant schizophrenia, according to a study published today in AJP in Advance. Neuromelanin is a brain pigment that is a by-product of dopamine metabolism and therefore can be a visual indicator of healthy dopamine functioning.

“[T]here is an urgent need for markers to identify treatment nonresponders in schizophrenia at an early stage and facilitate timely initiation of clozapine, the only antipsychotic with proven efficacy in nonresponders,” wrote Marieke van der Pluijm, Ph.D., of the University of Amsterdam and colleagues. Patients with treatment-resistant schizophrenia do not show increased dopamine function, unlike patients who respond to treatment, van der Pluijm and colleagues continued. This suggests that neuromelanin levels—a proxy of dopamine function—may be an early marker for treatment resistance.

The researchers recruited 62 patients aged 18 to 35 years with first-episode psychosis whose primary diagnosis was on the schizophrenia spectrum. They also recruited 20 healthy controls. All participants were assessed at baseline with an NM-MRI scan, a clinical interview, and an IQ test. Symptom severity was assessed using the Positive and Negative Syndrome Scale (PANSS). Patients received antipsychotic treatment from their psychiatrists throughout the study.

Treatment response was assessed with a clinical interview at six months. Participants were considered nonresponsive if they continued to show moderate or higher symptoms on at least one of five PANSS domains (delusions, conceptual disorganization, hallucinatory behavior, mannerisms and posturing, and unusual thought content) following two trials of antipsychotics; if they showed a complete absence of response or experienced severe side effects following one antipsychotic trial; or if they were switched to clozapine during the follow-up period.

Fifteen patients were classified as nonresponders, while the remaining 47 were considered responders. In the baseline NM-MRI, nonresponders showed significantly lower NM-MRI signal compared with responders, predominantly in a brain region called the substantia nigra. This region is rich in dopamine neurons and regulates movement as well as emotions and reward behaviors. Based on the neuromelanin composition, the researchers could predict whether a patient would respond to treatment with up to 68% accuracy.

Among 28 responders and 9 nonresponders who participated in a follow-up scan, the NM-MRI signal did not change over six months in either group. This indicates that neuromelanin accumulation might reflect a stable trait, rather than a variable that is dependent on an individual’s state.

“[T]his study demonstrates the potential of NM-MRI as a noninvasive marker for treatment resistance in schizophrenia at an early stage,” the authors concluded. “Eventually, an adequate prediction model could lead to early identification of treatment resistance in schizophrenia and thereby substantially reduce delays in effective treatment and improve outcomes.”

For related information, see the Psychiatric News Alert “Speed of Response to Visual Stimuli May Be Biomarker for Psychosis.”

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Many 12th Graders Found to Use Potentially Risky Products With “Legal” THC Variant

A study published today in JAMA reports that many high school seniors are using products containing Δ8-tetrahydrocannabinol (THC), a variant of the main psychoactive compound of marijuana, Δ9-THC. The analysis also showed that Δ8-THC use was elevated in states where recreational marijuana was illegal.

“Gummies and other edibles, electronic vaping devices, and combustible flower containing Δ8-THC are marketed as providing a user experience comparable to marijuana in a product that is federally legal,” wrote Alyssa F. Harlow, Ph.D., of the University of Southern California and colleagues. “Δ8-THC exposure may pose risks to adolescents, including addiction, neurodevelopmental changes, acute psychiatric reactions from accidental overdosing, and exposure to toxic byproducts generated during Δ8-THC synthesis.”

Harlow and colleagues examined data from the 2023 Monitoring the Future study, a nationally representative classroom-based survey of 8th, 10th, and 12th grade students. The 2023 survey included a question for a subset of 12th graders on whether they used Δ8-THC in the past year, and, if yes, how many times. The students also answered a similar question on past-year marijuana use. The final sample included 2,186 responses.

Overall, 11.4% of seniors in the U.S. reported past-year Δ8-THC use and 30.4% reported past year marijuana use. Of seniors who reported using Δ8-THC, 35.4% used it at least 10 times in the past year, while 16.8% used it at least 40 times.

Other findings from the survey included the following:

• Geographically, Δ8-THC use was lowest in the Western U.S. census region (the 13 states west of Texas) at 5.0% compared with the Northeast (10.1%), South (14.3%), and Midwest (14.6%).
• Δ8-THC use was lower in states where marijuana is legal for adults (8.0%) versus states where marijuana is not legal (14.0%).
• Δ8-THC use was lower in states where Δ8-THC was banned or restricted (5.7%) versus states with no Δ8-THC regulation (14.4%).

“The unregulated proliferation of Δ8-THC represents a potential threat to the public’s health,” wrote Jennifer M. Whitehill, Ph.D., of the University of Massachusetts, Amherst, and colleagues in an accompanying editorial. “As health professionals, we need to improve our capacity for addressing the evolving cannabinoid marketplace by instituting centralized and coordinated systems for monitoring cannabis products.”

To read more on this topic, see the Psychiatric News article “Nicotine Gummies, Tablets Popular Among Adolescents.”

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One in Six Firearm-Related Homicides and Suicides in Women Found To Be Related to Pregnancy

About one in six intentional firearm-related deaths in women of childbearing age occur during or shortly after pregnancy, a study in the American Journal of Preventive Medicine has found.

Naima T. Joseph, M.D., M.P.H., of Boston Medical Center and colleagues analyzed data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System from 2008 to 2019. Women aged 15 to 44 years who died by suicide or homicide involving a firearm were included. The researchers defined pregnancy-associated deaths as deaths that occurred during pregnancy or within one year of childbirth.

Over the study period, there were 4,204 firearm-related homicides and deaths by suicide: 2,098 were homicides, of which 22% were associated with pregnancy; and 2,106 were deaths by suicide, of which 11% were associated with pregnancy. Women and girls who died by pregnancy-associated homicide had an average age of 22.2 years, and 54.8% were Black; the average age of those who died by pregnancy-associated suicide was 28.5 years, and 80.5% were White.

The researchers also found the following notable differences where relevant circumstances were known:

• 83.5% of pregnancy-associated suicides occurred in a metropolitan county versus 72.8% of suicides unrelated to pregnancy.
• 61.6% of pregnancy-associated homicides were related to ongoing conflict with or violence by a current or former partner versus 51.9% among homicides unrelated to pregnancy.
• 4.2% of pregnancy-associated deaths by suicide occurred in women who experienced intimate partner violence within a month of death versus 1.3% of deaths by suicide that were unrelated to pregnancy.

“The findings are concerning and indicate that enhanced strategies supporting mental health treatment, effective interventions addressing interpersonal violence, and strategic public health interventions addressing firearm safety are urgently needed to prevent needless pregnancy-associated violent deaths,” Joseph and colleagues wrote. “There is concern that the current national political landscape will serve to worsen the risks of intimate partner violence for pregnant individuals both through restriction of access to abortions and limiting states’ abilities to restrict firearms.”

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

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Mirtazapine and Vitamin B6 May Be Best Options for Antipsychotic-Induced Akathisia

APA’s Good Faith Estimates Survey: Please Respond Today The No Surprises Act requires clinicians to provide patients who are uninsured or are insured but choose not to submit claims through their health plan with a Good Faith Estimate of the cost of care. The Centers for Medicare and Medicaid Services has asked APA for your feedback on efforts to comply with these requirements and any educational support you may need from CMS. The deadline is today, March 8. TAKE SURVEY

Akathisia—a feeling of restlessness that is often accompanied by movements like rocking or pacing—is a common side effect of antipsychotic medications. A meta-analysis published in JAMA Network Open suggests that biperiden, mirtazapine, and vitamin B6 are the three most effective treatment options for antipsychotic-induced akathisia.

Cyril Gerolymos, M.D., of Aix-Marseille Université in Marseille, France, and colleagues compiled data from 15 randomized clinical trials testing potential pharmacotherapies for akathisia in people taking antipsychotics. The combined data included 492 patients, 324 of whom received an active drug and 168 received placebo. Ten medications were evaluated: biperiden, clonazepam, cyproheptadine, mianserin, mirtazapine, propranolol, trazodone, valproate, vitamin B6, and zolmitriptan.

The researchers noted that clinicians should be prudent about interpreting their results due to the small sample size, but offered the following findings:

• Six medications were found to be effective. They were the following, in decreasing order of strength: mirtazapine, biperiden, vitamin B6, mianserin, trazodone, and propranolol.
• Cyproheptadine may also be potentially effective, but there was not enough evidence to make a firm conclusion.
• Clonazepam, valproate, and zolmitriptan did not show effectiveness and are not recommended.

“[M]irtazapine consistently ranked first in both the main analysis and all subgroup analyses. However, mirtazapine may be poorly tolerated due to its sedative effects and the potential for weight gain,” Gerolymos and colleagues wrote. Rather, they suggested that vitamin B6 may be the best option in terms of risk-benefit ratio, as it is very well tolerated. However, for patients with akathisia who also have depressive symptoms and insomnia, mirtazapine may be preferred.

Gerolymos and colleagues also cautioned that “trazodone should be avoided in men who have specific hematologic or neurologic diseases (such as sickle cell anemia, multiple myeloma, leukemia, hypercoagulable states, or autonomic nervous system disorders) or in men with anatomical deformations of the penis.”

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Veterans With PTSD May Benefit From Transcranial Direct Current Stimulation Plus Virtual Reality

Transcranial direct current stimulation (tDCS) may augment virtual reality–guided exposure therapy for veterans with posttraumatic stress disorder (PTSD), according to findings published yesterday in JAMA Psychiatry. In the study, veterans with war zone–related trauma had significantly greater improvements in PTSD symptoms when receiving virtual reality combined with tDCS compared with veterans who received virtual reality and sham stimulation.

Mascha van ’t Wout-Frank, Ph.D., of the VA Providence (R.I.) Healthcare System and colleagues recruited 54 participants (94% male; mean age 46 years) from the system who had PTSD related to war zone experiences. Participants were randomized to receive up to six 25-minute sessions of active tDCS plus virtual reality or sham tDCS plus virtual reality over 10 business days, with at least one day between sessions. The stimulation started simultaneously with the virtual reality program, which provided the participants with visual, auditory, haptic, and olfactory immersion into Iraq or Afghanistan war scenes. Participants were presented with 12 virtual reality scenarios, beginning with a low-intensity experience of riding in a mine-resistant ambush-protected vehicle. From there, the exposures became more intense by the addition of a distant gun battle, a Black Hawk flyover, or an improvised explosive device that caused the leading vehicle to flip.

The primary outcomes were self-reported PTSD symptoms as assessed through the PTSD Checklist for DSM-5 (PCL-5) at baseline, after three sessions, after the last session, and at one- and three-month follow-up. A decrease of 10 or more points was defined as clinically meaningful. To measure changes in psychophysiological arousal, the authors measured skin conductance with electrodes on the participants’ nondominant hands.

Average PCL-5 scores did not meaningfully differ between the two groups at baseline (48.6 among the active tDCS group compared with 45 in the sham group). After completing the six virtual reality sessions, participants in the tDCS group had an average PCL-5 score of 36, representing a clinically meaningful reduction in symptoms, compared with an average score of 38.9 in the sham group. At the one-month follow-up, PCL-5 scores fell to 31.4 in the tDCS group compared with 37.9 in the sham group, representing a statistically significant difference.

Further, there were greater reductions in skin conductance across the six sessions in the tDCS group compared with the sham group, suggesting that those in the tDCS group were getting more accustomed to the virtual exposures, the authors wrote.

“This intervention imposed low participant burden, had modest technical cost, and yielded clinically meaningful improvements in an otherwise difficult-to-treat patient population,” the authors concluded. “This reflects an important step forward in the use of combined brain stimulation and contextual control and underscores the innovative capability of these technologies.”

For related information, see the Psychiatric News article “Virtual Exposure Therapy Found Effective for PTSD.”

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APA’s Good Faith Estimates Survey: Please Respond Today The No Surprises Act requires clinicians to provide patients who are uninsured or are insured but choose not to submit claims through their health plan with a Good Faith Estimate of the cost of care. The Centers for Medicare and Medicaid Services has asked APA for your feedback on efforts to comply with these requirements and any educational support you may need from CMS. The deadline is Friday, March 8. TAKE SURVEY

Menopause Not Associated With Universal Risk for Depression, Review Shows

APA’s Good Faith Estimates Survey: Please Respond Today The No Surprises Act requires clinicians to provide patients who are uninsured or are insured but choose not to submit claims through their health plan with a Good Faith Estimate of the cost of care. The Centers for Medicare and Medicaid Services has asked APA for your feedback on efforts to comply with these requirements and any educational support you may need from CMS. The deadline is Friday, March 8. TAKE SURVEY

The transition into menopause by itself does not appear to raise the risk of depression in women, according to a review in The Lancet. However, a subset of women with a history of depression and/or certain menopause-related risk factors may be vulnerable to depressive symptoms during this period.

“Clinicians should not assume that psychological symptoms during the menopause transition are always attributable to hormonal changes,” wrote Lydia Brown, Ph.D., M.Psych., of the University of Melbourne and colleagues. “Potential misattribution of psychological distress and psychiatric disorders to menopause could harm women by delaying accurate diagnosis and the initiation of effective psychotropic treatments, and by creating negative expectations for people approaching menopause.”

Brown and colleagues analyzed 12 prospective studies reporting depressive symptoms, major depressive disorder, or both for more than 25,000 women during the menopause transition. Only two of the studies, totaling around 600 women, used structured clinical interviews to diagnose major depressive disorder.

They found that the risk of first lifetime major depressive disorder is not increased during menopause, but individuals with previous major depressive disorder might be at increased risk of recurrence. Additionally, women are not universally at risk of depressive symptoms during menopause.

Vulnerability to depressive symptoms during menopause may be due to menopause-related risk factors including severe vasomotor symptoms such as hot flashes and night sweats, sleep disturbance, a long transition, or significant hormone fluctuations. Psychosocial risk factors such as a depression history, stressful life events, or lack of social support can also increase the risk for depressive symptoms.

Brown and colleagues offered the following recommendations:

• Provide individuals with evidence-based information about menopause, including clear statements that most individuals are not at risk of mental health problems.
• Be aware of who is at risk of experiencing depressive symptoms and major depressive disorder; if present, consider treating modifiable risk factors such as severe hot flashes and night sweats and sleep problems.
• Be cautious about discontinuing treatments for major depressive disorder during the menopause transition due to the possible increased risk of recurrence.

In an editorial accompanying the review, Lancet editors wrote: “We need to send a realistic, balanced message to women and to society: menopause does not herald the start of a period of decay and decline but is a developmental life stage that can be negotiated successfully with access to evidence-based information as well as appropriate social and medical support.”

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Frequent Cannabis Use Raises Risk of Heart Attack and Stroke

Frequent cannabis use may raise the risk of heart attack and stroke, a study in the Journal of the American Heart Association has found.

Abra Jeffers, Ph.D., M.S., M.Phil., of Massachusetts General Hospital and colleagues examined data from the Behavioral Risk Factor Surveillance Survey (BRFSS) between 2016 and 2020. The BRFSS is an annual telephone survey of adults in which participants report on their health behaviors and whether health care professionals had ever diagnosed them with a health condition. Jeffers and colleagues drew data from 434,104 adults aged 18 to 74 years across 27 states and two territories to assess the association of cannabis use with self-reported cardiovascular outcomes.

In the BRFSS, participants were asked how often they had used cannabis in the previous 30 days and whether they had any diagnoses of coronary heart disease or angina, myocardial infarction (heart attack), or stroke. Jeffers and colleagues adjusted for tobacco use and other characteristics, including the participants’ age, sex, race, body mass index, diabetes, physical activity levels, and socioeconomic status.

Among all participants, 4% reported using cannabis daily, and 7.1% reported using cannabis nondaily. Among participants who reported any cannabis use, nearly 75% reported that they mainly used cannabis by smoking it, and approximately 25% reported using cannabis by some method other than smoking, such as vaping, drinking, or eating it.

The researchers found that participants who used cannabis daily by any means had a 25% increased likelihood of heart attack and a 42% increased likelihood of stroke compared with participants who did not use cannabis.

The researchers wrote that although the mechanisms linking cannabis to heart disease are unclear and were not explored in the current study, multiple factors could play a role. In addition to toxins, endocannabinoid receptors—the part of cells responsible for recognizing tetrahydrocannabinol (THC), the main psychoactive ingredient in cannabis—are widespread in the body’s cardiovascular tissues and might increase heart risks. They also noted that smoking, the predominant method of cannabis use, may pose additional cardiovascular risks via inhalation of particulate matter.

“Cannabis has strong, statistically significant associations with adverse cardiovascular outcomes independent of tobacco use and controlling for a range of demographic factors and outcomes,” the researchers wrote. “Patients and policymakers need to be informed of these potential risks, especially given the declining perception of risk associated with cannabis use.”

For additional information, see the American Journal of Psychiatry article “Risks and Benefits of Cannabis and Cannabinoids in Psychiatry.”

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APA’s Good Faith Estimates Survey: Please Respond Today

The No Surprises Act requires clinicians to provide patients who are uninsured or are insured but choose not to submit claims through their health plan with a Good Faith Estimate of the cost of care. The Centers for Medicare and Medicaid Services has asked APA for your feedback on efforts to comply with these requirements and any educational support you may need from CMS. The deadline is Friday, March 8.

TAKE SURVEY

Low-Frequency TMS Improves Schizophrenia-Related Psychomotor Symptoms

Low-frequency transcranial magnetic stimulation (TMS) can improve symptoms of psychomotor slowing in individuals with schizophrenia, reports a study in JAMA Psychiatry. Psychomotor slowing involves impairment of both fine and gross motor movements, making tasks like walking or talking difficult.

“Psychomotor slowing often comes with multiple disadvantages, such as cognitive impairment, sedentary behavior, cardiometabolic risks, poor quality of life, lower subjective well-being, and impaired functioning,” wrote Sebastian Walther, M.D., and colleagues at the University of Bern, Switzerland. The researchers noted that there are no specific treatments for psychomotor slowing but hypothesized that targeting the supplementary motor area of the brain with TMS might be a promising approach.

Walther and colleagues enrolled 88 adults (aged 18 to 60) with schizophrenia spectrum disorder and severe psychomotor slowing, defined as a score of 15 or more on the Salpêtrière Retardation Rating Scale. The participants were evenly divided to receive low-frequency repetitive TMS (rTMS at 1 hertz), high-frequency intermittent theta burst stimulation (iTBS at 50 hertz), or sham stimulation or to be placed on a waiting list. All stimulation protocols involved 15 sessions across three weeks; after three weeks, the wait list group received rTMS. Participants were allowed to continue taking their existing medications.

After three weeks, 68% of adults who received rTMS responded to treatment, defined as at least a 30% improvement in Salpêtrière Retardation Rating Scale scores. By comparison, 36% of iTBS recipients, 32% of sham participants, and 18% of adults on the waitlist responded. After adjusting for demographic variables and medication use, the researchers estimated someone receiving rTMS had more than 80% greater odds of responding than someone receiving iTBS or sham.

Walther and colleagues also noted that 63% of the waitlist group responded to rTMS once they got the treatment. Additionally, no participants reported experiencing severe adverse events, with the most common side effects being fatigue and head/neck pain.

To read more about psychomotor problems, see the Psychiatric News article “Comprehensive Catatonia Guideline Released.”

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Pet Ownership Has a Positive Impact on Mental Health, APA Poll Finds

A large majority of U.S. adults who have pets feel that their pets have a positive impact on their mental health, according to the latest findings from APA’s Healthy Minds Poll released today.

“It’s easy to overlook the role of pets when we’re talking about mental health,” said APA President Petros Levounis, M.D., M.A., in a news release. “But for people who do enjoy the company of animals, they can be a source of companionship, comfort, love, and friendship. I routinely encourage adoption of a pet to my patients who struggle with addiction to alcohol, drugs, or technology. We’re also starting to see more and more research around the role that animals can play in recovery from depression and other psychiatric disorders.”

The poll was conducted online by Morning Consult from February 6 to 9 with a sample of 2,200 adults. The results were released jointly with the American Veterinary Medical Association.

Among all survey respondents, 72% reported having pets at home—52% had dogs; 37% had cats; 7% had fish; 4% had birds; and less than 3% had turtles, chickens, horses, snakes, lizards, rabbits, guinea pigs, or hamsters. Eighteen percent of pet owners said one or more of their pets were certified as an emotional support animal.

Among pet owners, 84% said their pets have a mostly positive impact on their mental health, compared with only 1% of pet owners who reported a mostly negative impact. Those who said their pets positively affect their mental health offered the following reasons:

• 65% said pets offer companionship
• 64% said pets provide unconditional love and support
• 62% said pets provide a calming presence
• 62% said pets help reduce stress and anxiety
• 35% said pets encourage them to be physically active
• 29% said pets add structure to their schedule
• 19% said pets increase social connections with others.

When asked how much they worried about various stressors related to pets, 76% of respondents said they worried about their pets aging or passing away, 67% worried about their pet’s health conditions, and 67% worried about their pet’s care when traveling.

For related information, see the Psychiatric News special report “How Companion Animals Can Participate in Treatment of Mental Illness.”

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