Schizophrenia Associated With Bone Fragility and Fracture Risk

A comprehensive review and meta-analysis published in Translational Psychiatry has affirmed that individuals with schizophrenia have more fragile bones than those without the disorder, which carries an increased risk of fractures.

“Our findings regarding poor bone health in people with schizophrenia are concerning, given previous studies have indicated that this population experiences more adverse events following a fracture event, including longer length of hospitalization, higher risk of adverse perioperative events and acute post-operative complications, and in turn increased healthcare costs,” wrote Behnaz Azimi Manavi, Ph.D., of Deakin University in Geelong, Australia, and colleagues. “[I]t is not unrealistic to suggest that poorer outcomes associated with bone fragility contribute to the higher mortality rate in this population.”

Manavi and colleagues examined data from 29 studies that compared markers of osteoporosis in adults with schizophrenia with those of adults without the disorder; this included studies assessing bone mineral density, bone quality (strength and stiffness), bone turnover (the rate new bone is laid down and old bone removed), and/or risk of fracture. The studies encompassed 52,246 adults with schizophrenia along with over 4 million control individuals.

In total, the study data indicated that adults with schizophrenia have lower bone density (particularly at the hip), poorer bone quality, and higher rates of bone turnover; no significant differences between males and females were identified. A meta-analysis of seven studies that included fracture data found that adults with schizophrenia have a 32% increased risk of fracture, after adjusting for potential biases, again with no risk difference between males and females.

Manavi and colleagues noted that since schizophrenia is associated with premature mortality and the risks of osteoporosis increase with age, their findings may underestimate the true burden of schizophrenia on bone health in older adults.

“Further research is needed to evaluate the etiology of bone fragility in this population and recognize modifiable risk factors such as lifestyle or medications to reduce the potential risk for this patient group. Importantly, there is a need to develop guidelines for preventing risk factors and predicting fracture in people with schizophrenia,” they concluded.

For related information, see the Psychiatric News article “Study Calculates Disability Caused by Schizophrenia.”

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Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Placebo Response Strongest in Depression Trials, but Robust Across Multiple Psychiatric Disorders

In a meta-analysis published yesterday in JAMA Psychiatry, researchers found that people with major depression showed the strongest placebo response in clinical trials among nine psychiatric disorders assessed, followed by individuals with generalized anxiety disorder. However, the placebo response was significant across all nine disorders.

“A genuine placebo effect, by definition, encompasses improvements induced by suggestion, hope for effective treatment, and conditioning effects through the administration of medications,” wrote Tom Bschor, M.D., of the Technical University of Dresden, Germany, and colleagues. In the case of psychiatric illness, factors such as the episodic course of many disorders and the attentive and compassionate care that clinical trial participants often receive also influences the placebo response, they added.

“A better understanding of placebo responses may improve treatments, especially in psychiatric disorders where confidence, conditioning, and belief play a significant role,” the researchers wrote.

Bschor and colleagues assessed placebo response for nine psychiatric disorders commonly treated with medications: attention-deficit/hyperactivity disorder, generalized anxiety disorder, major depressive disorder, mania, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, schizophrenia, and social anxiety disorder.

For each disorder, they combined patient data from 10 high-quality placebo-controlled trials; their final sample included nearly 10,000 clinical trial participants who received placebo.

Overall, placebo group participants showed strong symptom improvements for all nine disorders assessed. The greatest placebo response was seen for major depression and generalized anxiety, which had effect sizes of 1.40 and 1.23, respectively. An effect size is a standardized value to quantify changes like symptom improvements; an effect size above 1.2 is considered a very large change. At the other end were patients with schizophrenia and obsessive-compulsive disorder, who had placebo response effect sizes of 0.59 and 0.65, respectively (medium-to-large changes).

“[P]atients with schizophrenia had the least benefit associated with placebo treatment, possibly due to episodic relapses and an unfavorable prognosis,” Bschor and colleagues wrote. “Impaired interpersonal functioning might reduce the impact of personal attention and nonspecific effects in placebo groups. Distorted reality perception and limited insight into illness may hinder the development of hope and belief in effective treatment.”

The researchers also found that females appeared to show a stronger placebo response than males on average, though this sex difference alone did not explain why the strongest effect sizes were found in the depression and anxiety clinical trials (whose participants were ~65% female). For example, 21% of the participants in the posttraumatic stress disorder trials were female, yet the effect size was still large (0.84).

For related information, thee the American Journal of Psychiatry article, “Patient Expectancy as a Mediator of Placebo Effects in Antidepressant Clinical Trials.”

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Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Study Finds ‘Psychiatric Ambulance’ Provides Safe and Uncoercive Transport of Individuals in Crisis

Individuals having a mental health crisis who were transported to a hospital by a “psychiatric ambulance” required fewer restraints or other coercive measures compared with individuals transported by the police, according to a report in Psychiatric Services.

Though police are often responsible for transporting patients in crisis who may be agitated or aggressive, they “usually receive limited training in managing psychiatric disorders and in responding to individuals experiencing psychiatric symptoms or crises, which may increase the risk for preventable escalation and the use of restrictive measures,” wrote Jeroen Zoeteman, M.D., of the psychiatric emergency service in Amsterdam, and colleagues.

In 2014, Amsterdam introduced a psychiatric ambulance service as an alternative approach. The yellow-colored vehicle—operated by a trained driver and psychiatric nurse—was indistinguishable from the city’s typical ambulance, but the interior was stripped of visible medical equipment to create a tranquil environment. Individuals could be seated upright or lie on a stretcher, with soft Velcro fastening as a method of restraint if necessary. If needed, sedative medication could be administered.

Zoeteman and colleagues compared the use of restraints, incidents of aggression, and psychiatric hospitalization among 498 police transports in the four months prior to introduction of the ambulance and 655 psychiatric ambulance transports in the six months after introduction.

Among the individuals transported by ambulance, 86% had no restraints applied compared with 57% of those transported by police. The use of handcuffs was virtually absent among the ambulance group (less than 1%), while 42% of those transported by police were handcuffed. The occurrence of aggressive events was similarly low (2%) in both the ambulance and pre-ambulance groups.

The rates of hospital admission were similar between the two groups (36% vs. 33%), but significantly more admissions were voluntary in the ambulance group (39% vs. 27%).

The psychiatric ambulance is among several innovations—such as Crisis Intervention Teams (CIT) and the CAHOOTS (Crisis Assistance Helping Out On The Streets) program in Eugene, Ore.—designed to support police or relieve them of the burden of transporting agitated or possibly aggressive patients having a psychiatric emergency. The researchers noted that the CIT model in the U.S. has been successful at reducing the use of force or coercion, but CIT officers sometimes transport individuals to hospitals by police vehicle, which in many communities is accompanied by restraint with handcuffs.

“Thus, shifting to an ambulance system to transport persons in a mental health crisis could also improve care in communities in which the CIT model is active,” they wrote.

For more information see the Psychiatric News article “Street Crisis Teams in San Francisco Replace Police for 911 Psychiatric Calls.”

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Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Psychosocial Care Credited for Declining Suicide Rate Among Patients With Cancer

In contrast to the overall rise in U.S. suicide rates since 2000, the suicide rate among people diagnosed with cancer has been dropping since 1989, according a report in Translational Psychiatry. The authors suggest that improvements in psychosocial care for patients with cancer is partially responsible for this decline.

“The cancer-related suicide rate is estimated to be double that of the general population in the United States. Notably, the risk of suicide in men is significantly higher compared to women. This heightened cancer-related suicide risk remains elevated for up to 15 years following their diagnosis,” wrote Qiang Liu, M.D., and colleagues at the National Cancer Center at the Chinese Academy of Medical Sciences and Peking Union Medical College in Beijing, China.

Liu and colleagues analyzed a population database of nearly 5 million Americans who were diagnosed with cancer over a 40-year span to determine age-adjusted rates of suicide from 1975 to 2017. Lui and colleagues found that among the 8,114 cancer patients who died by suicide, the vast majority were male (82%), Caucasian (93%), and older (73% were between 50 and 79 years).

Among the overall U.S. population, average suicide rates increased 1.7% a year since 2000, researchers reported. By contrast, average cancer-related suicide deaths declined gradually between 1989 and 2013, followed by a sharper decline between 2013 and 2017, during which the rate dropped 27% a year on average.

“In addition to the promising advances in medical treatments for malignancies, this period witnessed an evolving role of psycho-oncology care, palliative care, and hospice care, leading to the promotion and increased utilization of these services by patients with cancer, enhancing their overall quality of life. Furthermore, the development of integrated care models, including collaborative care models, has provided a more comprehensive and coordinated approach to cancer care,” the researchers wrote.

For more information, see the Psychiatric News article “Integrated Care Improves Depression Symptoms in Cancer Patients.”

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Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Study Finds Evidence Why Autism, Schizophrenia Are Less Prevalent in Females

By analyzing genetic data from over 2,000 postmortem brain samples, researchers found that females with autism spectrum disorder (ASD), bipolar disorder, or schizophrenia had greater dysfunction in gene expression relative to males with these conditions. Gene expression relates to which proteins and other functional elements are turned on or off in a given sample.

These findings were published yesterday in Science Translational Medicine as part of a collection of studies from PsychENCODE—a consortium funded by the National Institute of Mental Health seeking to decipher the molecular and genetic architecture of the brain.

These results provide more evidence of a “female protective effect” for certain psychiatric disorders, wrote Yan Xia, Ph.D., of the Broad Institute of Harvard and MIT in Cambridge, Mass., and colleagues. The idea is that females are more resilient to disorders like ASD and thus require more biological and environmental adversity before symptoms manifest.

Xia and colleagues obtained gene expression data from postmortem prefrontal cortex tissue of 593 individuals with schizophrenia (204 female), 253 with bipolar disorder (107 female), 82 with ASD (16 female), and 1,232 control individuals without a history of psychiatric disorders (413 female).

The researchers found that for each of these three disorders, females with the disorder had significantly more gene expression differences relative to controls compared with male individuals and controls. Beyond individual genes, the researchers also examined gene networks—a series of genes that are typically regulated together because they are part of the same biological pathway. Once again, females with ASD, bipolar disorder, or schizophrenia had significantly greater disruptions in their gene networks than males relative to controls.

For both the individual gene and gene network analyses, the greatest male-female differences were observed for individuals ASD. Among the three disorders studied, ASD also has the most pronounced male-to-female disparity in prevalence.

As a further test, Xia and colleagues analyzed postmortem brain samples from individuals with major depression, which is slightly more prevalent in females. The gene expression data indicated that for this disorder, males had greater gene expression differences compared with females.

“Taken together, these results suggest that the differences in gene expression and [gene] connectivity between males and females may contribute to the sex differences in the prevalence, age of onset, and symptom severity of ASD, [schizophrenia], and [bipolar disorder],” Xia and colleagues wrote.

The full psychENCODE phase 2 collection is available here. To read about another project from the psychENCODE consortium, see the Psychiatric News article “Advanced Gene Sequencing Study Recognized by AJP Editors.”

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Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Warnings of Valproic Acid’s Fetal Risks Fail To Boost Concurrent Contraceptive Use

Among women who were treated with valproic acid, contraceptive use remained low and pregnancy rates have not declined since 2005, despite several safety communications and black box warnings about the drug’s risks during pregnancy, according to a study in JAMA Network Open.

Although widely used for epilepsy, bipolar disorder, migraines, and other conditions, valproic acid has been associated with fetal risks such as congenital defects, autism spectrum disorders, and cognitive deficits. “In a 2013 Drug Safety Communication, the FDA had stated valproic acid should only be used during pregnancy for epilepsy and bipolar disorder if there is no other viable medication for a patient,” wrote Nicole E. Smolinski, Pharm.D., of the University of Florida in Gainesville, and colleagues.

Smolinski and colleagues examined U.S. claims data for medical procedure and pharmacy visits for 70,000 females aged 12 to 44 who had private insurance and were treated with valproic acid at some point from 2005 through 2020. Researchers examined the indications for valproic use, prescription contraception overlap of at least one day with valproic acid treatment, and pregnancies during treatment.

Mood disorders were the most common indication for which valproic acid was prescribed to women during childbearing years (43% of treatment episodes), followed by migraines (20%), and epilepsy (15%), researchers found. However, just 22% of valproic acid treatment episodes overlapped with contraceptive use. Pregnancy rates among women taking valproic acid remained steady over the 15 years from 1.74 per 100 person-years in 2005 to 1.90 per 100 person-years in 2019.

Researchers identified 723 pregnancies among women taking valproic acid. Pregnancy rates were highest among those taking valproic acid for mood disorders (2.32 per 100 person-years) and lowest for epilepsy (1.22 per 100 person-years).

“With epilepsy providing the strongest favorable benefit to risk for use during pregnancy, the discovered lower pregnancy rates may seem surprising,” Smolinski and colleagues wrote. “We speculate that because most studies that demonstrate fetal risks were conducted in patients with epilepsy and typically published in neurology-centric journals, perhaps neurologists may be more informed than other specialties about the risks.

“Our findings indicate a need to enhance efforts to mitigate prenatal exposure to valproic acid, especially for indications where risk of use during pregnancy outweighs benefit,” they concluded.

For related information, see the Psychiatric News article “Exposure to Valproate in Utero May Increase Risk of Autism, ADHD.”

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Teens With Classmates Diagnosed With Mental Illness More Likely To Be Diagnosed Themselves

Teens who have one or more classmates with a mental disorder are more likely to be diagnosed with one themselves later in life than those who do not have any classmates with a mental disorder, according to a report in JAMA Psychiatry. The risk of a mental illness diagnosis was greatest in the first year following the diagnosis of a classmate.

Being exposed to a peer with a mental disorder may aid in “normalization of mental disorders through increased awareness and receptivity to diagnosis and treatment,” wrote Jussi Alho, Ph.D., of the University of Helsinki, Finland, and colleagues. “Similarly, having individuals with no diagnosis in the peer network might discourage seeking help for any underlying mental health problems.”

Alho and colleagues used Finnish national health and school registries to examine mental disorder diagnoses among more than 700,000 individuals born between 1985 and 1997. The cohort was followed from August 1 of the ninth grade (approximately age 16) until a diagnosis of mental disorder, emigration, death, or December 31, 2019. The researchers adjusted findings to control for a wide range of variables that might affect diagnosis—parental educational level, income, and mental health; area-level education, employment, and urbanicity; and school and class size.

Among the cohort, 47,433 individuals had a mental disorder diagnosis by the ninth grade. Of the remaining cohort members, 167,227 (25.1%) received a mental disorder diagnosis during the follow-up. There was no increased risk of a mental disorder diagnosis among teens with one diagnosed classmate across the whole follow-up, but a 5% increase with more than one diagnosed classmate.

During the first year of follow-up, teens with one diagnosed classmate had a 9% increased risk of a mental disorder diagnosis, while teens with multiple diagnosed classmates had an 18% increased risk. Mood, anxiety, and eating disorders were the most common diagnoses following exposure.

Alho and colleagues wrote that the heightened risk early in follow-up “challenges the likelihood of harmful contagion occurring without an already existing, undiagnosed disorder,” but acknowledged that for some diagnoses such as eating disorders, transmission could also occur through peer social influence.

“Prevention and intervention measures that consider potential peer influences on early-life mental health could substantially reduce the disease burden of mental disorders in society,” the researchers concluded.

For related information see the Psychiatric News article, “Teen ‘Social Media Induced’ Illness Requires Careful Workups.”

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Oxytocin May Increase Guilt, Shame When Thinking About Others Being Harmed

Oxytocin makes individuals more averse to deliberately harming others when considering moral dilemmas, according to findings published yesterday in Molecular Psychiatry. Vasopressin, another hormone involved in social behavior, has no such effect.

Individuals with disorders that are associated with social behavior problems—such as autism, borderline personality disorder, psychopathy, and obsessive-compulsive disorder—also tend to show differences in moral behavior compared with neurotypical individuals, wrote Xiaoxiao Zheng, M.S., Ph.D., of the University of Electronic Science and Technology of China and colleagues. Both oxytocin and vasopressin (neuropeptides that are expressed throughout the central nervous system) play roles in social cognition and motivation, the authors continued, but their influence on moral behavior is unclear.

Zheng and colleagues recruited 180 participants (50% male) aged 18 to 26 who did not have medical or psychiatric disorders. Participants were randomized to receive oxytocin, vasopressin, or a placebo intranasally 45 minutes before completing two tasks designed to assess moral emotions and moral judgment.

The moral emotions task presented the participants with 28 scenarios involving cartoons in different situations that depicted the figures causing either deliberate or accidental harm to others. Participants rated their feelings of guilt or shame in reaction to each scenario, imagining themselves as the agents or victims.

In the moral judgment tasks, participants were asked if they endorsed certain actions in response to moral dilemmas. For example, one scenario asked participants if, as the captain of a submarine, it is appropriate to kill a crew member who is fatally wounded if such an action would ensure that there is enough oxygen for the rest of the crew to survive.

Participants who received oxytocin reported significantly increased feelings of shame and guilt when they imagined deliberately harming others compared with the vasopressin and placebo groups. There was no significant difference between the treatments in response to scenarios involving accidental harm. Additionally, participants in the oxytocin group were less likely to endorse moral choices that involved deliberately harming others, even for the greater good, compared with those in the other two groups.

“[Oxytocin] may be acting to strengthen deontological moral decision-making where it is the morality of the action performed rather than its consequence which is important,” the authors wrote. They concluded that their findings suggest oxytocin has much more influence than vasopressin in promoting altruism and empathy, and that only oxytocin “may have therapeutic potential for disorders where moral behavior is influenced.”

For related information, see the American Journal of Psychiatry article “Neural Responses to Intranasal Oxytocin in Youths With Severe Irritability” and the Psychiatric News article “Oxytocin May Promote Empathy in BPD Patients.”

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Cannabis Legalization Linked to Cannabis Poisoning in Older People

Cannabis legalization may be associated with an increased risk of emergency department (ED) visits for cannabis poisoning in older people, a study in JAMA Internal Medicine has found.

Nathan M. Stall, M.D., Ph.D., of the Sinai Health and the University Health Network in Toronto and colleagues analyzed data from the Ontario Ministry of Health to examine ED visit rates for cannabis poisoning in adults aged 65 and older during three policy periods: prelegalization (January 2015 to September 2018); legalization period 1, which allowed the sale of dried cannabis flowers only (October 2018 to December 2019); and legalization period 2, which also allowed the sale of edible cannabis (January 2020 to December 2022).

Overall, there were 2,322 ED visits for cannabis poisoning in older adults (mean age 69.5 years) during the study period. After adjusting for age, sex, rurality, neighborhood, income, alcohol intoxication, cancer diagnosis, and dementia diagnosis, the researchers found that the rate of ED visits linked to cannabis poisoning among older people doubled in period 1 and tripled in period 2 compared with the prelegalization period.

The researchers offered several possible reasons for the increase following the legalization of edibles; these include a greater likelihood of accidental ingestion, easier access to cannabis products, and lack of age-specific dosing instructions. The researchers acknowledged, however, that they could not determine whether the continued increase was directly related to edible cannabis or a result of broader commercialization of nonmedical cannabis.

Stall and colleagues added that older people are at particularly high risk of adverse effects from cannabis because of age-related physiological changes, potential interactions with other medications, and multimorbidity.

“Overall, this study shows the health outcomes of cannabis legalization and commercialization for older adults and highlights the consequences associated with edible cannabis,” Stall and colleagues wrote. They said that jurisdictions with legalized cannabis should consider measures to mitigate unintentional exposure in older adults and provide age-specific dosing guidance.

For related information, see the Psychiatric Services article “Effects of Recreational Cannabis Legalization on Mental Health: Scoping Review.”

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Digital Self-Help Tool May Reduce Binge Eating

A web-based cognitive-behavioral self-help program helped adults in Europe with binge eating disorder reduce their frequency of binge eating episodes and clinical impairment, according to a report in JAMA Network Open.

“Binge eating disorder is a frequent and debilitating disorder with considerable societal and personal burdens,” wrote Luise Pruessner, M.S., of Heidelberg University in Germany, and colleagues. “However, traditional treatments have faced constraints, such as limited access, stigma, and high cost, underscoring the need to explore alternative intervention delivery methods.”

The study involved 154 German-speaking adults (96% women) in Europe; half received 12 weeks of the web-based program, while half were put on a wait list. A diagnosis of obesity was not required, but individuals with bipolar or psychotic disorders, substance dependence, anorexia or bulimia, severe depressive episodes, or suicidality were excluded. Researchers utilized a wide array of validated assessment tools to capture changes in eating behavior.

The web program consisted of six required modules focused on self-monitoring of binge eating, psychoeducation, and emotion regulation, followed by six elective modules of participants’ choosing.

After 12 weeks, participants with access to the web-based program reported an average of nine fewer binge eating episodes in the past month compared with baseline. Those on the wait list reported a past-month reduction of 0.68 episodes from baseline, a change deemed not clinically significant. Participants with access to the program also experienced a greater reduction in clinical impairment and greater improvement in well-being compared with the wait list group.

On average, participants with access to the intervention completed 7.65 of the 12 modules, and the researchers noted that completing more modules was associated with larger reductions in eating psychopathology. They also called for a future study with a 12-month follow-up to capture the program’s potential long-term effects. Pruessner and colleagues also noted the need for targeted strategies to engage male and older populations, who are often underrepresented in studies of web-based interventions for binge eating disorder.

“This randomized clinical trial demonstrated that offering access to a web-based intervention significantly enhanced the daily lives of participants with [binge eating disorder],” authors wrote. “The provision of accessible and effective treatment options holds promise for improving the everyday experiences of patients with [binge eating disorder], as well as for diminishing its adverse health effects.”

For more information, see the Psychiatric News article, "APA Releases Updated Guideline for Treating Eating Disorders."

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Suicidal Thoughts in Mothers Associated With Preschooler Aggression

Suicidal thoughts and behaviors in mothers are associated with aggressive behavior in their preschool-aged children, according to a study published this week in Psychiatry Research.

“Maternal history of suicidal thoughts and behaviors has been identified as a robust risk factor for offspring psychopathology and [suicidal thoughts and behaviors],” wrote Maureen Zalewski, Ph.D., of the University of Oregon and colleagues. “However, research in this area has focused almost exclusively on this risk pathway in adolescent and young adult samples, with very little work examining the impact of maternal history of [suicidal thoughts and behaviors] on their children early in development.”

Zalewski and colleagues recruited 178 mothers of 3-year-old children. Mothers were assessed for suicidal thoughts or behaviors at baseline and during follow-up assessments four months, eight months, and 12 months later. At these assessments, the mothers also reported on their child’s internalizing problems, attention problems, aggressive behavior, and temperaments. The authors also contacted the children’s preschool teachers or daycare providers, who completed online questionnaires assessing the emotions and behaviors they observed in the preschool or daycare settings. The final analysis included 158 mothers with complete data.

About 55% of the mothers had histories of suicidal thoughts and behaviors, and 20% had scores that indicated clinically significant suicidal risk. Maternal history of suicidal thoughts and behaviors was significantly associated with mother-reported negative affect and aggressive behavior in their children, but not internalizing or attention problems. Additionally, maternal history of suicidal thoughts and behaviors was significantly associated with child aggressive behavior as reported by preschool teachers or daycare providers.

“Importantly, these associations were observed during a developmental window that typically precedes the onset of [suicidal thoughts and behaviors], which has important implications for etiological models of suicide risk transmission,” the authors concluded. “Encouraging practitioners who are treating high-risk mothers of young children to screen for child emotional and behavioral problems as well as parenting quality may be particularly important during the preschool period.”

For related information, see the Psychiatric News article “Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions.”

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Study Underscores Need for Sustained Intervention for Schizophrenia, Other Psychotic Disorders

Few individuals with schizophrenia or other psychotic disorders were in remission or recovery 25 years after diagnosis, according to a report in AJP in Advance today. For individuals with schizophrenia spectrum disorders (schizophrenia, schizoaffective, and schizophreniform disorders), almost none experienced stable remission or recovery across 25 years.

The “stability of symptoms across the follow-up period indicates that more effective treatments are needed to influence the course of remission and recovery for individuals with schizophrenia spectrum disorders and illuminates the need for sustained intervention and support for this population,” wrote Sara Tramazzo and Wenxuan Lian, M.S., of Stony Brook University, and colleagues.

The authors analyzed recovery and remission data from 591 individuals with schizophrenia spectrum disorders or other psychotic disorders (bipolar disorder with psychosis, major depression with psychosis, drug-induced psychotic disorders) enrolled in the Suffolk County Mental Health Project.

Participants were recruited between 1989 to 1995 following their first hospital admission for psychosis. This was before the development of coordinated specialty care, which has proven effective in the treatment of first-episode psychosis.

In-person follow-up interviews were conducted at six months, 24 months, 48 months, 10 years, 20 years, and 25 years to assess participants’ remission (minimal or no symptoms) or recovery (moderate symptom but good functioning) status.

Among individuals with schizophrenia spectrum disorders, just 14.2% were in recovery at the 25-year follow-up, and only 7.4% were in remission. Among individuals with other psychotic disorders, 28.1% were in recovery and 20.0% were in remission at the 25-year follow-up.

Across all assessments, individuals with schizophrenia spectrum disorders were most likely to experience a trajectory of no remission or no recovery at any time point. Zero individuals with schizophrenia spectrum disorders experienced stable remission across all time points, and just 0.6% experienced stable recovery.

Individuals with other psychotic disorders were most likely to experience intermittent remission or recovery, transitioning in and out of these states over 25 years. Among this population, 15.1% and 21.1% experienced stable remission or recovery, respectively.

“Our findings highlight the often chronic or recurring course of psychosis and highlight outstanding questions beyond the peri-onset period,” the researchers wrote. “Treatment disengagement is common among individuals with psychotic disorders. Over the course of illness, social function declines, weakening ties that facilitate continued treatment engagement. Research on moderators of treatment engagement could provide valuable targets for improving long-term physical and mental health.”

For related information, see the Psychiatric News article, “More Data on Duration of Untreated Psychosis Needed.”

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Cytisinicline May Help People Quit Vaping

Cytisinicline—a plant-based chemical—can help people stop using e-cigarettes when paired with behavioral support, a study in JAMA Internal Medicine reports. Compared with individuals who received placebo along with behavioral support, those who received cytisinicline had twice the rate of vaping abstinence after 12 weeks.

“While these findings warrant confirmation in a phase 3 trial with a larger sample size and longer follow-up, they are consistent with the demonstrated efficacy of cytisinicline for cigarette smoking cessation,” wrote Nancy Rigotti, M.D., of Harvard Medical School and colleagues. “For individuals seeking to quit vaping, cytisinicline might fill the existing gap in pharmacologic treatments and enhance the emerging evidence of efficacy of behavioral treatments for vaping cessation.”

Rigotti and colleagues enrolled 160 adults who used e-cigarettes but not regular cigarettes and wanted to quit vaping. Of these participants, 107 took 3 mg of cytisinicline three times daily for 12 weeks while the other 53 took identical placebo pills. All participants received 10 minutes of vaping-cessation support each week from trained counselors. At these weekly visits, the participants also reported their e-cigarette use over the prior week and provided a saliva sample to measure cotinine, a nicotine metabolite.

After 12 weeks, 31.8% of the participants who took cytisinicline achieved continuous vaping abstinence (defined as four weeks without vaping, confirmed with cotinine measurements), compared with 15.1% of those who took placebo. The researchers found no evidence that variables like age, sex, race, degree of e-cigarette dependence, or preferred e-liquid flavor affected the participants’ ability to abstain.

Four participants left the study because of adverse events; the most common side effects reported were abnormal dreams, insomnia, anxiety, headache, and fatigue. Cytisinicline did not appear to contribute to cigarette smoking. Rates of regular cigarette smoking were similar in the cytisinicline and placebo groups at the end of the study.

“While the present trial is an important step toward developing effective e-cigarette treatments, there is much more to be done,” wrote Suchitra Krishnan-Sarin, Ph.D., and Lisa Fucito, Ph.D., of Yale School of Medicine in an accompanying editorial. “E-cigarette technology is constantly evolving to include novel nicotine forms, flavorants, and device configurations to deliver nicotine palatably, rapidly, and at high levels, which likely exceeds delivery of nicotine from cigarettes. The efficacy of medications like cytisinicline for people with greater addiction from the use of these novel e-cigarettes may be diminished.”

For related information, see the Psychiatric News special report, “Vaping—A Call to Action for Psychiatrists.”

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Open Payments Review and Dispute Period Ends Tomorrow

Open Payments, CMS’ national disclosure program, promotes transparency into financial relationships between pharmaceutical and medical device companies and health care providers. The program allows providers an opportunity to review, affirm, and if necessary, dispute payments attributed to them by these companies before they are made public. The review and dispute period ends on Wednesday, May 15.

Open Payments encourages all covered providers to review the reported data to ensure their information is accurate prior to publication. Get started by registering here and learn more at OpenPaymentsData.cms.gov.

Adults Recently Released from Jail Account for One in Five Adult Suicide Deaths

Adults who are incarcerated have nearly nine times the risk of dying by suicide within a year of their release than those who have never been in jail, according to a study in JAMA Network Open. The study also found that people who were released from jail within the year accounted for nearly 20% of all adult deaths by suicide.

“The results suggest that better integration of suicide risk detection and prevention across health and criminal justice systems (including 911 calls, police contacts, pretrial jail detention, criminal courts, jail sentences, probation, and parole) is critical to advancing population-level suicide prevention efforts,” wrote Ted R. Miller, Ph.D., of the Pacific Institute for Research and Evaluation and colleagues.

The researchers collected data from 10 different studies that examined the causes and rates of mortality among formerly incarcerated individuals. The researchers then used that data to estimate the rate of death by suicide among the nearly 7.1 million adults who had been released from jail at least once in 2019 and compare that with suicide rates of the general population.

They found that compared with adults who had never been in jail, those who had been released from jail had 8.95 times of dying by suicide within one year of release and 6.98 times the risk of dying by suicide within two years of release. The researchers’ model calculated people who were released from jail within the year accounted for an estimated 19.9% of all adult deaths by suicide, but only 2.8% of the adult population.

The researchers noted that it is now possible for health systems to link jail release data (which are typically publicly available) to their patient or plan participant list and are capable of systematizing supportive outreach to patients who were recently released.

“Health systems, including federally qualified health centers, are increasingly positioned to manage care coordination during high-risk transitions from jail to the community and should be recognized as important partners in building the cross-sector infrastructure necessary for identifying high-risk adults and providing comprehensive community-based suicide screening and prevention,” Miller and colleagues concluded.

For related information, see the Psychiatric Services article “Recommended Mental Health Practices for Individual Interacting With U.S. Police, Court, Probation, and Parole Systems.”

(Image: Getty Images/iStock/MivPiv)

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Open Payments Review and Dispute Period Ends Wednesday

Open Payments, CMS’ national disclosure program, promotes transparency into financial relationships between pharmaceutical and medical device companies and health care providers. The program allows providers an opportunity to review, affirm, and if necessary, dispute payments attributed to them by these companies before they are made public. The review and dispute period ends on Wednesday, May 15.

Open Payments encourages all covered providers to review the reported data to ensure their information is accurate prior to publication. Get started by registering here and learn more at OpenPaymentsData.cms.gov.

Researchers Reconstruct 3D Fragment of Human Brain

By combining high-powered microscopy with AI-guided illustration software, researchers reconstructed a 1 cubic millimeter fragment of living human brain tissue; these findings were published in today’s issue of Science.

“We reconstructed thousands of neurons, more than a hundred million synaptic connections, and all of the other tissue elements that comprise human brain matter, including glial cells, the blood vasculature, and myelin,” wrote Alexander Shapson-Coe, M.B. B.Chir., Ph.D., of Harvard University and colleagues.

This detailed 3D rendering required 1,400 terabytes of data. By comparison, today’s high-end computer games typically contain around 0.1-0.2 terabytes of data.

The researchers obtained their brain tissue sample during a surgical procedure on a patient with epilepsy. To gain access to the pathological site, surgeons removed a tiny portion of the patient’s frontal cortex, which the researchers quickly preserved and then imaged with an electron microscope. The removed fragment was around 4 mm long and just 0.17 mm thick, and since the sample was vertically oriented it contained multiple layers of frontal cortex tissue.

Next, the researchers used AI algorithms developed by Google to identify and color-code all the different cell types present in the sample, providing a vivid reconstruction of the cellular composition of this fragment of brain tissue, as well as the extensive electrical wiring.

The reconstructed sample included about 16,000 neurons, 32,000 neuronal support cells called glia, and 8,000 blood-vessel related cells. Combined, these 16,000 neurons formed over 150 million synaptic connections amongst each other. In nearly 97% of instances a pair of neurons would form a one-to-one connection; however, the researchers identified exceedingly rare cases where two neurons were connected by 50 or more synapses.

“Without question, approaches to uncovering the meaning of neural circuit connectivity data are in their infancy, but this… dataset is a start,” Shapson-Coe and colleagues wrote.

“Because the dataset is large and incompletely scrutinized, we are sharing all of the data in an online resource and also providing tools for analysis and proofreading,” they added.

For related information, see the Psychiatric News article, “Are Brain Organoids the Next Big Thing?”

(Image: GOOGLE RESEARCH AND LICHTMAN LAB)

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Technology Addictions Are Real, but Treatable

Yesterday, as the 2024 Annual Meeting wound down, outgoing APA President Petros Levounis, M.D., M.A., capped his presidential theme of “confronting addiction” with a presentation titled “Technological Addictions: The New Frontier in Addiction Medicine.” During the session, he outlined some of the parallels between technological addictions and substance use disorder (SUD) in terms of assessment, diagnosis, and treatment.

Levounis said that technological addictions (such as video/internet gaming, cybersex, and online gambling addiction) have several characteristics in common with other addictions such as SUD, as follows:

• Tolerance, such as needing to use technology increasingly more often to get the same mood-enhancing effect, and withdrawal, such as feeling anxiety or irritability upon stopping use of the technology abruptly.
• Internal concerns, such as being preoccupied with the technology, being unable to cut down on using the technology when desired, and using the technology as a way of relieving negative moods.
• External consequences, such as giving up other activities, jeopardizing relationships, or losing a job.

Treatments for technological addictions are similar to those used for other addictions, namely cognitive behavioral therapy (CBT) and motivational interviewing, said Levounis, professor and chair of psychiatry and associate dean for professional development at Rutgers New Jersey Medical School.

Levounis said that cognitive behavioral therapy is better suited to patients who already recognize they have a problem and want to address it. “CBT does require some motivation. There’s a lot of structure and there’s homework.”

In contrast, motivational interviewing may work best early in the process, he said.

“Motivational interviewing does its best job with people in the precontemplation and contemplation stage of change,” Levounis said. “It can help people who are either highly ambivalent about their use or who think there is nothing wrong with what they’re doing.”

Levounis noted that there are currently no approved medications for any technological addictions, but there are a few potential options. He said that opioid antagonists such as naltrexone or nalmefene may help patients whose technological addiction is characterized by arousal and impulsivity. He added that these medications decrease dopamine function by blocking opioid receptors, which may reduce the “high” patients get from using the technology.

He added that serotonin enhancers like SSRIs may help patients whose technological addiction is characterized by problems with control or compulsivity because these medications may decrease obsessiveness.

Psychiatrists who treat patients with technological addictions should be sure to treat any co-occurring mental disorders aggressively, Levounis said.

“Do a very thorough diagnostic assessment. See if there are other psychiatric disorders for which we have robust pharmacological treatments and treat them in order to help the person both with the other psychiatric disorder and the technological addiction,” Levounis said.

For related info, see Dr. Levounis’ Psychiatric News special report: “Be Prepared to Address Technological Addictions in Psychiatric Practice.”

(Image: Getty Images/iStock/audioundwerbung)

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Open Payments Review Period Ends Next Week

Open Payments, CMS’ national disclosure program, promotes transparency into financial relationships between pharmaceutical and medical device companies and health care providers. The program allows providers an opportunity to review, affirm, and if necessary, dispute payments attributed to them by these companies before they are made public. The review and dispute period ends on Wednesday, May 15.

Open Payments encourages all covered providers to review the reported data to ensure their information is accurate prior to publication. Get started by registering here and learn more at OpenPaymentsData.cms.gov.

Evidence Base for Pharmacogenetic Tests Still Lacking, APA Workgroup Finds

There is still not enough evidence to support the use of pharmacogenetic tests in the treatment of depression, according to updated recommendations from APA’s Workgroup on Biomarkers and Novel Treatments. The recommendations were published in AJP in Advance.

Pharmacogenetic tests analyze an individual’s genes (obtained via blood, saliva, or cheek swabs) to find genetic variants that may influence how fast antidepressants are metabolized or how well they attach to their receptors. Using special algorithms, the tests then calculate the combined impact of all the variants and offer readouts of antidepressants that might be effective and others to avoid.

In 2018, APA’s Council on Research organized a workgroup to examine the available data on pharmacogenetic tests for depression; the workgroup concluded that there was insufficient evidence to support the widespread use of pharmacogenetic tools in clinical practice. Subsequently, both the FDA and International Society of Psychiatric Genetics voiced concerns about these tests.

“Despite expert opinions, warnings, and policy statements regarding their limitations for predicting antidepressant treatment response, the popularity of [pharmacogenetic] testing products has grown, with at least 35 U.S. commercial entities providing them by 2020,” wrote the APA workgroup members in their updated recommendations.

The workgroup examined data from 11 pharmacogenetic clinical trials conducted between 2017 and 2022, as well as six meta-analyses that combined individual results. “The main new contribution of these studies is one of numbers: several trials have included relatively large sample sizes, and >4,000 patients have now participated in [pharmacogenetic] studies,” they wrote.

Though most of the trials demonstrated that using a pharmacogenetic test increased the likelihood that a patient would respond to their antidepressant, these new studies did not address previous shortcomings, the workgroup continued. None of the new trials were fully blinded (neither patients nor investigators were aware who was receiving a test), which increases the risk of bias in decision making. Further, the control group in these studies was to provide treatment as usual, but little attention was given to ensuring clinicians were providing the best standards of depression care.

Finally, all studies were fully or heavily supported by the pharmacogenetic industry. “[A]lthough industry support is not in itself problematic and historically has often been integral in completing large, well-designed, definitive trials, its coexistence with the methodological concerns reviewed above augments the concern about bias,” the workgroup wrote.

“Genetic approaches remain promising, and we look forward to future studies and advances in the field,” the APA workgroup concluded. “However, we advise devoting greater attention to implementing study designs consistent with other studies of treatment interventions.”

For related information, see the Psychiatric News story, “Pharmacogenomics Can Inform ‘Big Data’ Projects.”

(Image: Getty Images/iStock/Alena Butusava)

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Have You Gotten Email Requests from the AMA?

If so, the simple message is please respond. The AMA has sent out weekly reminder emails from PPISurvey@mathematica-mpr.com with the email subject line of “Reminder: The AMA needs your input to support fair and accurate physician payment.” If you have received these emails, it is urgent that you or your office staff respond as it will help the AMA gather accurate data on practice costs and the hours of patient care that physicians provide to support fair and accurate physician payment.

The study relies on financial experts in physician practices to complete the online financial information survey. The number of direct patient care hours is a critical component of the Medicare payment methodology. Participation will ensure that practice expenses and patient care hours are accurately reflected.

Arizona Legislator Amish Shah, M.D., M.P.H., Receives APA’s Javits Award for Public Service

Amish Shah, M.D., M.P.H., an emergency medicine physician and member of the Arizona House of Representatives, was awarded the 2024 APA Jacob K. Javits Public Service Award for his dedication to improving access to quality care, and his advocacy for mental health reform. The Javits Award is APA’s highest honor for contributions to the field of mental health by a federal or state public official.

“Not only in hospitals but also in the Arizona House of Representatives, Dr. Shah has left his mark as a distinctly skilled and dedicated voice for mental health,” said APA President Petros Levounis, M.D., M.A., in a statement. “His tireless efforts include working across the aisle to pass legislation like ‘Jake’s Law,’ promoting important mental health interventions such as the Collaborative Care Model and advocating for youth to more easily access mental health care services.”

Jake’s Law, signed into law by Arizona Gov. Doug Ducey in 2020, authorizes the state division of insurance to enforce the Mental Health Parity and Addiction Equity Act and ensure insurance companies are complying with parity requirements. The law also allocated $8 million to support behavioral health services for children who are uninsured or underinsured. The law is named in honor of Jake Machovsky, an Arizona teen who lost his life to suicide in 2016.

"I am deeply honored to receive the Jacob K. Javits Public Service Award from the American Psychiatric Association,” Shah said in a statement. “This recognition not only reflects my commitment but also underscores the urgent need to address mental health with the same dedication as we do physical health. As we continue to remove the barriers to mental health services, we must also push for healthcare reforms that recognize mental health as essential to overall well-being. I am excited to collaborate with APA to make this happen."

Since 2019, Shah has represented Arizona’s 24th District serving Central Phoenix, Sunnyslope and South Scottsdale. He is currently running as a Democrat for the United States House of Representatives from Arizona’s 1st District.

Gagan Singh, M.D., president of the Arizona Psychiatric Society, said Shah has been an exemplary physician and a champion for enhanced access to equitable mental health care. “He has worked tirelessly to decrease the shame often associated with mental illness, streamline the path to accessing mental health care, and improve the holistic health of Arizonans in his district and beyond,” Singh said.

Each year, APA confers the Javits Award on a state or federal public servant for outstanding contributions to the profession of psychiatry and to mental health advocacy. APA established the award in 1986 in honor of Sen. Jacob K. Javits, who represented New York state in the U.S. Senate from 1957 to 1981.

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Have You Gotten Email Requests from the AMA?

If so, the simple message is please respond. The AMA has sent out weekly reminder emails from PPISurvey@mathematica-mpr.com with the email subject line of “Reminder: The AMA needs your input to support fair and accurate physician payment.” If you have received these emails, it is urgent that you or your office staff respond as it will help the AMA gather accurate data on practice costs and the hours of patient care that physicians provide to support fair and accurate physician payment.

The study relies on financial experts in physician practices to complete the online financial information survey. The number of direct patient care hours is a critical component of the Medicare payment methodology. Participation will ensure that practice expenses and patient care hours are accurately reflected.

Many U.S. Adults Anxious Over Election, Other Current Events, APA Poll Finds

Forty-three percent of U.S. adults said that they feel more anxious now than they did last year, compared with 37% in 2023 and 32% in 2022, according to APA’s 2024 annual mental health poll.

The annual poll was conducted by Morning Consult from April 9 to 11. A total of 2,204 adults were surveyed online, a similar sample to those surveyed in APA’s 2023 and 2022 annual polls. The annual poll complements APA’s Healthy Minds Monthly series.

In the poll, 70% of respondents said they were somewhat or very concerned about current events, especially the economy (77%), the upcoming U.S. election (73%), gun violence (69%), hate speech/crimes (65%), and climate change (56%).

“Living in a world of constant news of global and local turmoil, some anxiety is natural and expected,” APA President Petros Levounis, M.D., M.A., said in a news release. “But what stands out here is that Americans are reporting more anxious feelings than in past years. This increase may be due to the unprecedented exposure that we have to everything that happens in the world around us, or to an increased awareness and reporting of anxiety. Either way, if people have these feelings, they are not alone, and they can seek help from us.”

Overall, 24% of respondents said they had talked with a mental health care professional in the past year. Younger adults aged 18 to 44 were three times more likely than seniors aged 65 or more to have done so.

Ahead of this year’s presidential election, 59% of respondents who have used mental health care in the past year said they are worried about losing access to that care, 45% said they are worried about their health insurance coverage changing, and 39% said they are worried about losing their health insurance entirely.

The vast majority of respondents (83%) agreed that untreated mental illness has a significant negative impact on families. However, 66% agreed that treatments for people with mental illness are better now than they were in the past, and 55% agreed that there is less stigma against people with mental illness than there was 10 years ago.

“Over the past 10 years, we’ve grown more comfortable talking about mental health, and that’s absolutely key to helping us through the current crisis,” APA CEO and Medical Director Saul Levin, M.D., M.P.A., said in the release. “The continued work of APA is to ensure that people can access care when they need it, especially in areas that need it badly, like child and adolescent psychiatry.”

For related information, see the Psychiatric News Alert “Americans Feel Worried About Their Safety, APA Poll Finds.”

(Image: Getty Images/iStock/suken)

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