Job Placement Augmented by Cash Account Shows Benefits for Patients With Psychiatric Illness

Individuals with psychiatric illness who received a modest cash account in combination with their supported employment had better job outcomes than those who received supported employment only, according to a report published today in Psychiatric Services in Advance.

Those receiving the cash account for buying essential goods and services had more days of employment, higher earnings, and reported greater financial security than those receiving only supported employment. Supported employment—which provides counseling and assistance with job seeking, interviewing, and retention—is an essential component of Coordinated Specialty Care.

Judith Cook, Ph.D., of the University of Illinois College of Medicine and colleagues note that the cash account “may have enabled workers to remain at their jobs longer by addressing barriers to transportation, job training, work skill acquisition, and specific expenses that are difficult for low-wage earners to afford.”

Sixty individuals with varying psychiatric diagnoses (predominantly depressive and bipolar disorders) were recruited from the vocational center of a large community mental health center and randomly assigned to receive individual job placement and support only (n=32) or job placement plus a $950 cash account. Participants receiving the cash account met with staff to identify employment goals and create a budget for purchases directly tied to these goals.

The participants were followed for 12 months, with the primary outcome being competitive employment. Secondary outcomes included job tenure, days worked, total earnings, and financial wellbeing, as measured by the eight-item InCharge Financial Distress/Financial Well-Being Scale. The study took place between April 2019 and October 2022, during the height of the pandemic and associated period of job insecurity.

Overall, 15 participants in each group secured competitive employment. Compared to those receiving job placement only, those receiving job placement and the cash account had a higher average job tenure (92 days versus 60 days), higher average total days employed (109 versus 82), and higher average total earnings ($4,723 compared to $3,612). Financial well-being increased by 10% among intervention participants and decreased by 2% among control participants. After adjusting for demographic differences and the year of participation (to factor in pandemic effects), the researchers found that these differences were statistically significant.

“The increase in financial security may have been especially important when people were facing the economic uncertainty of the COVID-19 pandemic,” the authors wrote. “The greater number of days worked by intervention participants also may have helped them feel more financially secure in the context of high rates of job loss during the pandemic.”

For related information see the Psychiatric News article “Jobs Programs for People With SMI Continue Through Economic Uncertainty.”

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Bupropion Linked to Lowest Weight Gain Among Common Antidepressants

Individuals taking bupropion gained the least weight on average compared with those taking one of seven other first-line antidepressants, though overall weight differences were small, according to a population-level study issued Monday in Annals of Internal Medicine.

“Weight gain is a commonly reported side effect of antidepressant use that may affect patients’ long-term metabolic health, given the difficulty of achieving and sustaining weight loss,” wrote Joshua Petimar, Sc.D., of Harvard Medical School and Harvard Pilgrim Health Care Institute and colleagues. “Antidepressant-associated weight gain may additionally lead to increased medication nonadherence, which is associated with poor clinical outcomes, including increased risk for depression relapse and hospitalization.”

Researchers studied the electronic health records of 183,118 adults 20 to 80 years old with first-time initiation of one of eight common antidepressants (sertraline, citalopram, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, or venlafaxine) between July 2010 and December 2019. Patients’ weights were tracked at 6, 12, and 24 months, and results compared against the weight gained on sertraline, the most prescribed antidepressant of the group (20% of participants). The researchers excluded patients starting more than one antidepressant, those taking other common weight-changing medications (stimulants, steroids, or weight loss drugs), or those with recent history of cancer, pregnancy, or bariatric surgery.

The results at six months were as follows:

• Patients taking sertraline gained an average of 1.5 kg (3.3 pounds).
• Patients taking bupropion fared best, gaining 0.22 kg less weight than those taking sertraline.
• Patients taking fluoxetine gained about the same amount as those taking sertraline.
• Patients taking citalopram or venlafaxine gained between 0.1 and 0.2 kg more weight than those taking sertraline.
• Patients taking duloxetine, escitalopram, or paroxetine fared the worst, gaining between 0.3 and 0.4 kg more weight than those taking sertraline.

Patients taking bupropion were also 15% less likely than those taking sertraline to gain at least 5% of their baseline weight after six months, whereas patients taking duloxetine, escitalopram, or paroxetine were 10-15% more likely to gain at least 5% of their baseline weight. Petimar and colleagues wrote that the favorable weight profile of bupropion may be related to its ability to activate the hypothalamic melanocortin system, which regulates feeding behaviors and energy balance.

Researchers noted that on average weight gain plateaued at around 12 to 18 months for the SNRIs duloxetine and venlafaxine, whereas weight gain continued among those taking SSRIs. However, due to rising medication nonadherence over time, long-term weight outcomes were less reliable.

Six months after initiation, only about 1 in 3 patients was still taking their initially prescribed antidepressant, with bupropion having the highest adherence (41%). At 24 months, only 4% to 5% of patients continued taking their initial antidepressant, and around 10% of them had added an additional medication.

For related information, see the American Journal of Psychiatry article, “Psychotropic Drug–Related Weight Gain and Its Treatment.”

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Many People Still Unaware That Primary Care Physicians Can Prescribe OUD Medications

Most patients do not know they can receive medication treatment for opioid use disorder (OUD) from their primary care physician, a research letter in JAMA Network Open has found.

Brandon del Pozo, Ph.D., M.P.A., M.A., of Brown University and colleagues examined data from 1,234 individuals who responded to a survey for the Justice Community Opioid Innovation Network in 2023.

Among all respondents, 61.4% did not know a primary care physician could treat people with OUD by prescribing medication, and 13.3% incorrectly believed a primary care physician could not prescribe OUD medication. The researchers identified both age and racial/ethnic differences in the responses; compared with White respondents, for example, respondents of other races were more likely to believe they could not receive medication for OUD from a primary care physician. Most respondents agreed (52.8%) or strongly agreed (24.2%) that a primary care physician’s office should be a place where people can receive OUD treatment.

Among respondents who reported misusing prescription or illicit opioids, 50.6% said they would be very comfortable and 30.7% said they would be somewhat comfortable personally seeking medications for OUD from their primary care physician. Of the respondents with no history of opioid misuse, 31.9% said they would be very comfortable and 42.0% said they would be somewhat comfortable referring someone they cared about to their primary care physician for medications for OUD.

Raising awareness that primary care physicians can provide medications like buprenorphine is critical to increasing effective treatment of OUD and reducing the race-and-ethnicity–based disparities observed in this study, the researchers wrote. They suggested the following:

• Messaging campaigns similar to those for HIV testing and cancer screening.
• Literature and signage in waiting areas and examination rooms at primary care offices.
• Proactive screening of patients for OUD by primary care physicians and offering medications for OUD when indicated.

In a viewpoint in JAMA, M. Allison Arwady, M.D., M.P.H., of the National Center for Injury Prevention and Control and colleagues noted a study in Morbidity and Mortality Weekly Report that found that of all individuals who needed treatment for OUD, only 55.2% received any treatment and only 25.1% received medication for OUD. They wrote that some health care professionals may be hesitant to prescribe OUD to patients who perceive a need for treatment or may continue to encourage only detoxification.

Arwady and colleagues offered five suggestions for all health care professionals to improve the cascade of care for patients with OUD as follows:

• Routinely screen for OUD, diagnose OUD, and educate patients about OUD.
• Routinely discuss medication options (methadone, buprenorphine, or naltrexone) with patients with OUD while connecting patients to available recovery support services.
• Prescribe buprenorphine themselves.
• Continue shared decision-making practices with patients around treatment initiation and retention.
• Share and reinforce harm reduction strategies with all patients with OUD, regardless of whether the patient is ready for treatment or not.

For related information, see the Psychiatric News Special Report “Opioid Use Disorder—Treatment in an Ever-Changing Crisis.”

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