Psychiatrists With Autism Share Their Journey of Self-Discovery With Researchers

Psychiatrists who are unaware that they themselves are autistic may fail to recognize the condition in their patients, according to a study issued in British Journal of Psychiatry Open that interviewed autistic psychiatrists and compared their experiences.

“The diagnostic criteria for autism remain deficit focused and do not appear to include the possibility of an autistic person thriving. Therefore, successful psychiatrists may fail to see themselves reflected in these criteria,” wrote Mary Doherty, M.D., of University College Dublin in Ireland, and colleagues.

Doherty and colleagues examined the question “what are the experiences of autistic psychiatrists in relation to recognizing autism?” They recruited eight autistic psychiatrists in the United Kingdom from a psychiatry-specific subgroup of Autistic Doctors International and conducted loosely structured Zoom interviews, averaging 88 minutes each. The researchers extracted and analyzed experiential statements from transcripts and constructed a table of personal experiential themes for each participant. Next, they developed group experiential themes, which highlighted areas of similarity among participants as well as areas of divergence.

The researchers uncovered three themes: recognizing oneself as autistic, recognizing colleagues as autistic, and recognizing patients as autistic. Only one of the psychiatrists had been diagnosed with autism as a young child; others found out through personal experiences, such as their child’s diagnosis, or by recognizing similarities between themselves and their autistic patients. Some conferred with their colleagues to confirm what they suspected. Some were even identified as autistic by their patients.

All participants reported the ability to quickly recognize autistic patients, including those missed by colleagues, and to develop good rapport with them, once they were aware of their own autistic identity. However, several participants recounted challenges earlier in their journey, prior to becoming aware of their diagnosis. Once self-recognition occurred, the psychiatrists began to notice that many of their colleagues—especially those specializing in autism or attention deficit/hyperactivity disorder—might also be autistic but unaware.

“The need for autism training across all health care settings and professional groups is undisputed,” the researchers wrote. “The experiences, perspectives, and insights of autistic psychiatrists have potential to inform such practice, yet ableism in medicine and the stigma associated with an autism diagnosis may impede recognition; this may have negative implications for patients. Increasing visibility of traditionally under-recognized groups of autistic people, particularly women, those from ethnic minority backgrounds, and multiply neurodivergent individuals, may also assist self-recognition by autistic psychiatrists.… Self-recognition and disclosure by autistic psychiatrists may be facilitated by reframing the traditional deficit-based view of autism towards a neurodiversity-affirmative approach, with consequent benefits for autistic patients.”

For related information, see the Psychiatric News article “Peer Specialists With Autism Have Insight Few Others Possess.”

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Prenatal Exposure to Cannabis Tied to Aggression, Poorer Executive Function at Age 5

Children exposed to cannabis in the womb may have poorer attention skills and be more prone to aggression at age 5 than children who are not exposed prenatally to cannabis, according to a report in JAMA Pediatrics. The associations observed in the study appeared to be directly related to cannabis exposure, not to the post-natal home environment.

“These outcomes are relevant to long-term academic and adaptive functioning,” wrote Sarah A. Keim, Ph.D., of Nationwide Children’s Hospital in Columbus, Ohio, and colleagues. “These results may be considered in refining clinical recommendations regarding cannabis use during pregnancy.”

Keim and colleagues looked at 250 children of families participating in the Lifestyle and Early Achievement in Families (LEAF) study cohort. The LEAF study included in-person visits at a behavioral research facility at Nationwide Children’s Hospital when the children were between 5 and 6 years of age.

Urine samples taken during mothers’ pregnancy were assayed for tetrahydrocannabinol (THC), the primary psychoactive component of cannabis. Children were considered exposed to cannabis if they had at least one urine specimen with THC higher than 15 ng/ml, their mother self-reported cannabis use on a questionnaire, or cannabis use was noted in the clinical obstetric record. Of the 250 children, 80 (32%) were classified as having been exposed to cannabis prenatally.

The researchers assessed the children’s executive function, such as attention, planning, and memory, at age 5 using a variety of validated measurements. They also assessed children’s aggression with the inflatable Bobo Doll task; the proportion of hits to the doll’s face using a fist was the measure of observed aggression. The children’s caregivers also filled out reports rating the child’s executive function and aggression.

Overall, children exposed to cannabis prenatally had lower test scores on attention and planning than those not exposed. Those exposed to cannabis prenatally also exhibited more aggressive behavior, with 17% more fisted hits to the doll’s face observed. (There were no differences between groups in caregiver ratings of executive function and behavior.)

The researchers noted that cannabis use during pregnancy is increasing in the United States, from 3.4% of pregnant people reporting past-month use in 2002 to 7.2% in 2021. “Many perceive the drug as a safe, natural treatment for nausea, sleep problems, or mood disorders,” they wrote. “Despite guidance from the American Academy of Pediatrics and others to avoid cannabis in pregnancy, many clinicians counsel patients inconsistently and lack knowledge about long-term effects.”

For related information, see the Psychiatric News article “Exposure to Alcohol, Cannabis in Womb Can Have Long-Term Consequences.”

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BIPOC Individuals Much More Likely to Have Cultural Conversations With Therapists

Individuals who identify as Black, Indigenous, or a person of color (BIPOC) are much more likely to discuss their cultural identity with therapists than White individuals are, reports a study appearing today in Psychiatric Services. Overall, two out of three counseling sessions with a BIPOC client included a cultural conversation, the study showed.

“The frequency with which cultural conversations occurred in our study, particularly for BIPOC clients, highlights the need to tailor clinical services to augment opportunities for clinicians to engage in cultural dialogue,” wrote Patty B. Kuo, Ph.D., of the University of Pennsylvania, and colleagues.

Kuo and colleagues examined data from more than 10,000 counseling sessions from 1,997 individuals (39% who identified as BIPOC) seeking therapy at a university counseling center from one of 72 therapists. At the start of each session, the individuals were asked whether any aspect of their cultural background—such as race, nationality, gender, religion, etc.—was discussed in the previous session (the specific cultural identity/identities did not have to be disclosed).

In total, therapy-seeking individuals reported having cultural conversations in 48.4% of sessions, which included 66.2% of sessions with BIPOC individuals and 39.8% of sessions with White individuals. Most BIPOC individuals who had cultural conversations with a therapist did so at every single session.

Kuo and colleagues calculated that BIPOC individuals were 3.56 times as likely as White individuals to have a cultural discussion at some point during counseling.

“Our results may stem from the intertwined nature of racial-ethnic identity and lived experiences,” they wrote. “Therapists may have been more intentional about initiating cultural conversations with BIPOC clients because of the visibility of racial-ethnic identity…. Therapists may have [also] assumed that racial-ethnic identity was not as salient to the lived experiences of White clients, resulting in less engagement in cultural dialogue.”

For related information, see the American Journal of Psychotherapy article “Patients’ Perceptions of Their Therapist: Effects of Race, Culture, and Cultural Competency on the Working Alliance.”

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Misophonia May Be Linked to Emotion Dysregulation

Misophonia—having reduced tolerance for and intense negative emotional reactions to triggering sounds like eating, snoring, gum-snapping, and pen-clicking—may be linked to emotion dysregulation, a study in the Journal of Psychiatric Research suggests.

Laura J. Dixon, Ph.D., of the University of Mississippi, and colleagues analyzed data from 4,005 adults who completed several questionnaires to assess misophonia symptoms, stress, and emotion dysregulation. The questionnaires were based on:

• The Misophonia Questionnaire, to measure sensitivity to certain sounds and emotional and behavioral reactions to misophonia sounds
• The Difficulties in Emotion Regulation Scale, to assess emotion dysregulation, including lack of emotional clarity (Clarity), difficulties engaging in goals (Goals), difficulties controlling emotions when experiencing distress (Impulse), limited access to effective emotion regulation strategies (Strategies), and nonacceptance of emotional responses (Nonacceptance)
• The Work and Social Adjustment Scale, to measure functional impairment due to misophonia across five domains, including ability to work, tasks for the home, social leisure activities, private leisure activities, and relationships with others
• The four-item version of the Perceived Stress Scale, to control for recent stress

Overall, 185 individuals reported clinically significant misophonia symptoms, while another 3,490 reported at least some level of sensitivity to one or more triggering sounds and were classified as having subclinical misophonia.

Two main findings emerged from the questionnaires. First, people with clinical levels of misophonia had significantly greater difficulties in emotion regulation compared with those with subclinical symptoms. Second, emotion dysregulation was significantly associated with sensitivity to misophonia sounds, reactions to misophonia sounds, and misophonia-related impairment, even after controlling for demographic factors and an individual’s current stress.

“[T]he Clarity, Goals, and Nonacceptance subscales were significant, which corresponds to difficulties in knowing and being clear about one’s emotions, focusing on and engaging in goal-directed behaviors, and having a tendency to be less accepting of distress reactions and experiencing secondary negative reactions to the distress (e.g., anger, embarrassment), respectively,” the researchers wrote. “[E]motion dysregulation is central to many disorders, particularly when negative emotions are present, and misophonia is no exception. [F]uture research should conduct comparisons with clinical groups to identify deficits that may be particularly unique to misophonia symptomatology.”

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Semaglutide Linked to Lower Risk of Alzheimer’s Disease in Type 2 Diabetes

Semaglutide, a GLP-1 receptor agonist (GLP-1) approved for treating diabetes and promoting weight loss, may help lower the risk of Alzheimer’s disease in adults with type 2 diabetes compared with other diabetes drugs, a study in Alzheimer’s and Dementia has found.

Rong Xu, Ph.D., of Case Western University, and colleagues analyzed electronic health record data to identify 17,104 new users of semaglutide and 1,077,657 new users of seven other antidiabetic medications, including other GLP-1s, insulin, metformin, dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, sulfonylurea, and thiazolidinedione. The patients received their first prescriptions for these medications between December 2017 and May 2021. Patients had an average age of 58 years, and the researchers followed them for three years.

The researchers found that compared with the other medications, semaglutide was associated with a 40% to 70% lower risk of first-time Alzheimer’s diagnosis, including:

• 69% lower risk than sulfonylureas
• 67% lower risk than insulin
• 62% lower risk than metformin
• 60% lower risk than dipeptidyl peptidase 4 inhibitors
• 57% lower risk than thiazolidinedione
• 41% lower risk than other GLP-1s
• 40% lower risk than sodium-glucose cotransporter 2 inhibitors

The results were similar for older patients, patients with and without obesity, and men compared with women.

“While the underlying mechanisms of the observed association of semaglutide and reduced risk of [Alzheimer’s] are unknown, they could also reflect semaglutide’s improvement of [Alzheimer’s] risk factors such as [type 2 diabetes], obesity, cardiovascular diseases, smoking, alcohol drinking, and depression, among others,” the researchers wrote. “Our findings support further clinical evaluation of semaglutide’s role in mitigating Alzheimer’s initiation and development in patients with [type 2 diabetes]. Future research should explore its effects in mild cognitive impairment, other dementias, and neurodegenerative diseases, as well as investigate other [GLP-1s] like tirzepatide and combination therapies with other antidiabetic medications.”

For related information, see the Psychiatric News article “Blockbuster Weight-Loss Drugs Not Tied to Suicidality, Studies Show.”

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FDA Sends Back PharmaTher’s Ketamine Application

Canada drugmaker PharmaTher received a complete response letter from the Food and Drug Administration (FDA) for its abbreviated new drug application (ANDA) for racemic ketamine, the company announced yesterday.

The company is pursuing approval of its generic ketamine product—Ketarx—to shore up global demand and as part of its research program testing ketamine for mental health and other indications. According to an FDA database, ketamine hydrochloride 50 mg and 100 mg injections have been in short supply in the United States since February 2018, owed to increased demand for psychiatric and acute pain indications.

“As noted by the FDA in the [complete response letter], the resubmission … will be considered to represent a minor amendment, given that the deficiencies have been classified as minor,” PharmaTher wrote. “The FDA requested new and updated information and clarifications related to drug substance, drug product, manufacturing, and microbiology.”

The company noted that the FDA did not express concern about the stability of the ketamine submission batches and no new preclinical and clinical studies were requested; they stated they will work with their third-party manufacturing partner to resolve these deficiencies and respond to the FDA in a timely fashion.

In May 2023, PharmaTher sought fast-track designation from the FDA for Ketarx to treat levodopa-induced dyskinesia in Parkinson’s disease. The company’s clinical trial results showed that ketamine was safe and well-tolerated, and that 100% of subjects treated with ketamine had a reduction in dyskinesias.

ANDAs allow drugmakers to apply to market generic drugs that are comparable to brand-name drugs in terms of safety, effectiveness, and cost. Drugmakers must demonstrate that their generic is bioequivalent to the brand-name drug, meaning it has the same properties and acts in the same way. A complete response letter is not a rejection of an application, but rather a way for the agency to provide drugmakers with guidance on how an application might be improved.

Ketamine was FDA approved in 1970 as a general anesthetic and is still widely used for this indication.

Though used off-label for conditions like depression, the FDA has not approved ketamine for the treatment of any psychiatric disorder. In October 2023, the FDA published an alert warning of the potential risks associated with unapproved compounded ketamine products for psychiatric disorders, specifically from telehealth providers that provide in-home ketamine services.

For related information, see the Psychiatric News feature “Ketamine: Miracle Drug or Double-Edged Sword?”

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Small Minority of Psychiatrists Account for Bulk of Non-Research-Related Industry Payments

Although a majority of psychiatrists received at least one non-research payment from the pharmaceutical and medical device industry between 2015 and 2021, the bulk of these payments went to a tiny fraction of psychiatrists, according to a study published today in Psychiatric Services.

“Of note, psychiatry’s industry payment problem is relatively narrow in scope compared with industry payment patterns in other specialties,” wrote John L. Havlik, M.D., M.B.A., of Stanford University, and colleagues. “Federal-level efforts to target inappropriate physician payments from industry may do well to focus on the psychiatrists who make $10,000 or more from industry each year—a group comprising fewer than a dozen psychiatrists per state—rather than spending valuable resources on less targeted interventions.”

The authors analyzed non-research industry payments—including travel fees, consulting fees, meals, and gifts—to 56,955 psychiatrists between 2015 and 2021 using the Centers for Medicare and Medicaid Services’ Open Payments Database (OPD). The OPD was created in 2010 under the Physician Payments Sunshine Act.

They found that during this study period, psychiatrists received 2,600,264 industry payments totaling $357,971,774. A total of 42,713 psychiatrists (75.0%) received at least one payment between 2015 and 2021. But the distribution was highly unequal: The top 10% of psychiatrists (N=4,271) received a median of $11,459.41, accounting for 93.6% of all industry payments, while the top 1% received a median of $362,631, accounting for 74.7% of all payments.

Havlik and colleagues also found:

• Psychiatrists who were among the top 1% in the amount of industry payments received were significantly more likely to be primarily licensed in Florida, Ohio, Oklahoma, or Texas than elsewhere in the nation.
• Food and beverage accounted for the largest number of payments made to psychiatrists (86.9%), although consulting (5.4% of payments) accounted for the largest dollar amount ($269,027,560), followed by food and beverage ($50,439,781).
• The median psychiatrist received substantially less compensation from industry than did other specialists. In 2019, the median cardiologist received $725 in industry compensation and the median dermatologist received $414, compared with $166.38 for the median psychiatrist.

“Further research is warranted to explore the prescribing behaviors of psychiatrists who receive larger payments compared with the prescribing behaviors of those who receive smaller payments, as well as patterns of prescription by these highly concentrated industry-susceptible psychiatrists,” the authors wrote.

For related information, see the Psychiatric News article “Integrity Is Built Into the Process of Developing DSM-5-TR.”

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Many Patients With Schizophrenia Benefit From Guided Antipsychotic Tapering Program

More than 60% of individuals with schizophrenia who underwent guided antipsychotic tapering at a specialty clinic remained stable for a year while reporting better overall functioning, reports a study in Psychological Medicine. Among individuals who relapsed while tapering medication, most were able to quickly restabilize.

“While [our] sample size is relatively small and the observation period relatively short, we postulate that the gradual reduction of antipsychotics in a safe and supportive environment can mitigate the risk of the severe adverse events normally associated with discontinuation of antipsychotics when done abruptly and/or independently,” wrote Alexander Nøstdal, M.D., and colleagues at the University of Copenhagen.

The researchers examined the outcomes of 88 patients with schizophrenia who were referred to an outpatient clinic in the Copenhagen suburb of Glostrup that specializes in gradual antipsychotic tapering. The clinic’s physicians work with patients to develop a six-month tapering plan that aims for a gradual reduction in antipsychotic dose every four weeks until an optimal balance of functioning and side effects is reached. In addition to monthly physician consultations, the patients maintained weekly contact with clinic staff.

The average starting antipsychotic dose among participants was slightly over 400 mg of chlorpromazine equivalent, which dropped to 250 mg by six months and remained at that level at 12 months; nine patients managed to completely discontinue their antipsychotic.

Overall, 27% of the tapering patients experienced a relapse of their schizophrenia symptoms after six months, while 37% experienced relapse at 12 months. About one-third of the patients who relapsed required hospitalization, but others managed to restabilize, often at a lower antipsychotic dose than where they started. There were also no reports of suicidal or violent behavior in any participants.

Of the 63% of patients who remained stable across 12 months, their overall functioning as rated by the Global Assessment of Functioning (GAF) scale—with a range 1 to 100—rose from 46.6 to 50.9.

“Although the average improvement of 4 points on the GAF scale is relatively small and may perhaps seem insignificant to an observer, it may still be important for the patients,” Nøstdal and colleagues wrote. “Being less socially isolated may for some patients lead to further improvement over time. In addition, these patients experienced a reduction in adverse effects, which for most patients were the main motivational factor for seeking out the tapering clinic.”

For related information, see the Psychiatric Services article by Nøstdal and colleagues “Motivations for and Experiences With Antipsychotic Tapering Among Patients With Schizophrenia Seeking Guided Dose Reduction.”

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Study Finds No Association Between In Utero COVID Exposure and Developmental Delays

Children who were exposed to COVID-19 while in the womb do not appear to have any neurodevelopmental impairments over the first two years compared with those who were not exposed, according to a study in JAMA Network Open.

Eleni G. Jaswa, M.D., M.Sc., M.A.S., of the University of California, San Francisco, and colleagues examined data from 2,003 mothers and their children who participated in a prospective study assessing the safety of pregnancy during the coronavirus pandemic. Among the participating mothers—recruited between May 14, 2020, and August 23, 2021—217 (10.8%) were infected with COVID-19 during pregnancy.

All the mothers completed the Ages & Stages Questionnaires, Third Edition (ASQ-3), when their children were 12, 18, and 24 months of age. The ASQ-3 measures progress in multiple developmental domains: communication, gross motor skills, fine motor skills, problem-solving, and social skills.

At all three time points, the percentage of children with a potential neurodevelopmental delay—defined as scoring below the age-specific cutoff in one or more ASQ-3 domains—was slightly higher in the group exposed to COVID-19 than the non-exposed group. For example, at 12 months, 32.3% of exposed children had abnormal ASQ-3 screens compared with 29.4% of unexposed children.

However, after adjusting for differences in demographics and other variables such as enrollment date to account for evolving viral strains, the researchers identified no association between COVID-19 infection during pregnancy and an increased risk of neurodevelopmental delays at any time point. Follow-up analyses exploring the trimester of infection, presence or absence of fever, or infection occurring before or after vaccination also did not find any differential risk of neurodevelopmental delay.

In an accompanying commentary, Andrea G. Edlow, M.D., M.Sc., of Massachusetts General Hospital cautioned that given this study’s small sample of exposed children and the fact that the ASQ-3 is not 100% accurate, some clinical risk might remain hidden. Edlow co-authored a 2022 study that assessed electronic health record data and found children exposed to COVID-19 in the womb had higher rates of neurodevelopmental diagnoses at 12 months.

“The study by Jaswa and colleagues is an important, carefully conducted and analyzed step toward understanding whether SARS-CoV-2 is like other viruses in contributing risk for adverse neurodevelopmental outcomes, or whether it is somehow different,” Edlow wrote. In the context of other studies with different conclusions, “the most honest answer is the best one: We do not yet know.”

For related information, see the Psychiatric News article “COVID-19’s Impact on Development Remains Unclear.”

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1 in 16 US Adults Has ADHD, Nearly Half With ADHD Use Telemedicine

An estimated 15.5 million adults in the United States—roughly 1 in 16—have been diagnosed with attention deficit/hyperactivity disorder (ADHD), according to a survey analysis in Morbidity and Mortality Weekly Report. The analysis also found that nearly half of adults with ADHD reported using telehealth and that most who take stimulant medications for their ADHD have had problems filling their prescriptions over the past year.

These findings come at a time of ongoing ADHD medication shortages and uncertainty as to whether COVID-19 flexibilities regarding stimulant prescribing via telehealth will remain in effect after December 31.

“As policies are currently developed and evaluated related to ADHD clinical care for adults, access to prescription stimulant medications, and flexibilities related to telehealth, [our] results can guide clinical care and regulatory decision-making,” wrote Brooke S. Staley, Ph.D., of CDC’s National Center on Birth Defects and Developmental Disabilities, and colleagues.

Staley and colleagues used data from roughly 7,000 adults who completed surveys for the National Center for Health Statistics Rapid Surveys System in October and November 2023. Participants were asked whether they had been diagnosed with ADHD by a doctor or other health professional, and, if so, whether they currently had ADHD. Respondents reporting current ADHD received follow-up questions regarding medication use (categorized as stimulant or nonstimulant medications) and/or other treatments, difficulty obtaining prescription medication, and use of telehealth services for their ADHD care.

According to the researchers’ estimates, 6% of U.S. adults had current ADHD diagnosis, of whom slightly more than half received their diagnosis in adulthood. Furthermore:

• 35.2% were prescribed medication and had received counseling or behavioral treatment in the previous 12 months.
• 15.1% were prescribed medication only.
• 13.3% received counseling or behavioral treatment only.
• 36.5% had not received any treatment.

Among adults who reported taking a stimulant medication, 71.5% reported difficulty getting their ADHD prescription filled during the previous 12 months because their medication was not available.

“Patients experiencing these difficulties might seek medication outside the regulated health care system, increasing their risk for overdose because of the prevalence of counterfeit pills in the illegal drug market, which might contain unexpected substances such as fentanyl,” Staley and colleagues wrote.

Regarding telehealth, the researchers found that among adults with ADHD:

• 46% reported ever receiving telehealth services for their condition.
• 8.9% received their diagnosis via telehealth only.
• 9.5% received their diagnosis through a combination of in-person and telehealth visits.
• 30.5% used telehealth to obtain a prescription for ADHD medication, while 30.8% used telehealth to receive counseling or therapy for ADHD since the start of the COVID-19 pandemic in March 2020.

In October 2023, the Drug Enforcement Administration (DEA) and the Department of Health and Human Services extended COVID-19 flexibilities regarding stimulant prescribing via telehealth without an initial in-person medical evaluation through December 31, 2024. Last Thursday, the DEA sent a nonpublic draft proposal for a third temporary extension of these flexibilities to the White House’s Office of Management and Budget (OMB), but the OMB has not yet made a decision.

For related information, see the Psychiatric News articles “Months Later, Stimulant Shortage Persists,” and “Adult Stimulant Initiations Via Telemedicine Found to Rise at Height of Pandemic.”

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Child Problems With Emotional Control May Mediate Relationship Between Maternal, Child Depression

Childhood problems with affective executive function—the brain’s ability to control and regulate emotions—may at least partially explain the relationship between maternal depression during and after pregnancy, and later depression among offspring, according to a report in the Journal of the Academy of Child and Adolescent Psychiatry.

Meredith Han, B.Sc., of the National University of Singapore and Kings College London, and colleagues noted that perinatal depression is an established risk factor for depression among offspring, but the pathway between maternal and later childhood depression has been unknown. This study “identifies executive function as a potential modifiable pathway and leverage point for prevention of depression in at-risk children,” they wrote.

The researchers examined depression and problems with executive function among 739 children of mothers enrolled in Growing Up in Singapore Towards Healthy Outcomes, a prospective longitudinal study exploring the developmental origins of health and human capital.

Mothers reported their depressive symptoms using the Edinburgh Perinatal Depression Scale at 26 to 28 weeks’ gestation, and again three months and 24 months after childbirth. The children’s executive function was assessed at ages 3.5, 4.5, 7, and 8.5 years using validated measurement tools; the researchers assessed “hot” executive function (referring to affective or emotional control and regulation) and “cold” executive function (referring to cognitive skills such as working memory).

Children also self-reported their depressive symptoms at 8.5 and 10 years using the 28-item Child Depression Inventory, Second Edition.

The researchers found that only maternal depressive symptoms before birth were correlated with childhood depression scores; antenatal depression also predicted poorer hot and cold executive function among children. In turn, executive function deficits in children were associated with increased child depressive symptoms. In particular, problems with hot executive function among children accounted for 37.5% of the relationship between antenatal and childhood depression.

The researchers noted that childhood emotional control “strongly associates with greater peer acceptance, more positive friendship quality, and higher academic achievement.” They concluded: “Long-term follow-up of randomized controlled trials of executive function is required to understand whether executive function interventions during childhood directly translate to improvements in emotional functioning.”

For related information, see the Psychiatric News article, “Paid Maternal Leave Improves Health, Mental Health for Both Mothers and Infants.”

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Clonidine May Be Effective Non-Opioid Treatment for Neonatal Opioid Withdrawal Syndrome

Clonidine, a non-opioid approved for the treatment of hypertension, may be an effective alternative to morphine for neonatal opioid withdrawal syndrome (NOWS), according to a report in Pediatrics.

Babies who are exposed to opioids in the womb can develop significant withdrawal symptoms after birth. “Despite the detrimental effects of in utero opioid exposure, the opiate morphine remains a common first-line drug for NOWS treatment, resulting in additional weeks to months of exposing the developing brain to opioids,” wrote Henrietta Bada, M.D., M.P.H., of the University of Kentucky, and colleagues.

Between December 2017 and February 2022, Bada and colleagues randomized 120 infants with NOWS to receive either oral clonidine at 1 µg/kg/dose or morphine at 60 µg/kg/dose, every three hours. Infants with no improvement had their doses increased by 25% every 12 to 24 hours, up to a maximum of 2 μg/kg/dose for clonidine and 120 µg/kg/dose for morphine. Those without improvement by the maximum dose received an adjunct medication such as phenobarbital. Once withdrawal symptoms stabilized, medication doses were weaned by 10% every 24 hours.

All infants also had non-pharmacological interventions including swaddling, low noise and lighting environment, infant massage, and maternal rooming with the infant.

Primary outcomes were length of treatment and neurobehavioral performance as measured by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

Neither length of treatment nor length of hospital stay differed significantly between the two groups. Clonidine treatment lasted between 15 to 19 days while morphine treatment lasted 13 to 17 days; length of stay was between 20 to 24 days for clonidine and 17 to 20 days for morphine. However, 45% of clonidine-treated infants needed adjunct medication compared with just 10% in the morphine group, a concerning finding that the authors said may be related to the dosing schedule for clonidine.

Clonidine-treated infants performed as well on the NNNS as morphine-treated infants. At the initial testing—conducted as soon as withdrawal symptoms stabilized—clonidine-treated babies scored worse on arousal, hypertonicity, and stress abstinence, but at their following treatment, they showed significant improvement with less handling required, reduced excitability and stress abstinence, and improved arousal and regulation.

“We were able to successfully provide an opioid-sparing, medication-assisted treatment regimen to a cohort of infants with significant NOWS,” Bada and colleagues wrote. “Future studies are needed to investigate the optimal dose and frequency of clonidine administration for improved efficacy and the decreased need for adjunctive therapy in NOWS.”

For related information, see the Psychiatric News article “Neonatal Abstinence Syndrome Linked to Unemployment, Mental Health Shortages.”

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Older People With Dementia More Likely to Relocate Than Those With Other Conditions

Older patients who are diagnosed with dementia are more likely to move to another state or county than their peers who are diagnosed with other conditions, a study in JAMA Network Open has found.

“Our findings illuminate the profound impact that a dementia diagnosis can have on an individual’s residential choices, challenging traditional conceptions of aging in place and adding depth to our understanding of the interplay between health and migration,” wrote Momotazur Rahman, Ph.D., of Brown University, and colleagues.

Rahman and colleagues examined data from more than 1.6 million Medicare beneficiaries who received a diagnosis of either dementia, myocardial infarction, chronic obstructive pulmonary disease (COPD), or colon cancer in 2016. The researchers then tracked each patient’s residential history (including nursing home use) from January 1, 2012, to December 31, 2020, with the first four years serving as the prediagnosis period and the last four years serving as the postdiagnosis period.

The researchers found that migration rates to other counties or states were similar among all patient groups in the first three years before diagnosis. In the months immediately before and after diagnosis, migration among people in the dementia group rose substantially and remained higher through the postdiagnosis period.

Within four years of a dementia diagnosis, 22% of individuals moved to a different county, a rate 1.4 times higher than seen for the other conditions. Patients in the dementia group were also more likely to move to another state than those in the other groups, but the difference was not as high. For both intercounty and interstate migrations, individuals with dementia were more likely to move to other community settings versus nursing home settings.

“One possible explanation is that individuals with dementia and their caregivers may choose to move closer to family or informal caregivers, either with independent housing arrangements or entering formal long-term care services,” the researchers wrote. “As the global population ages and dementia prevalence increases, it becomes crucial for policymakers and communities to recognize and address the unique migration patterns and needs of individuals with this life-altering condition.”

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Living Situation of People With ID Does Not Appear to Influence Antipsychotic Prescribing Decisions

Individuals with intellectual disability (ID) who do not live with their family are not more likely to be prescribed antipsychotics to manage challenging behaviors like aggression, reports a study published today in Psychiatric Research and Clinical Practice.

Rather, patient sex and current medication regimen are the dominant influences overseeing prescribing decisions, noted Eion Plenn, B.A., of Penn State School of Medicine in Hershey, and colleagues.

“Previous studies have indicated that residing in group homes or other non-familial residential settings heightens the probability of being prescribed antipsychotic medications,” Plenn and colleagues wrote. However, there has been limited research directly testing the influence of living environment.

The researchers analyzed medical chart data from 112 adults with ID who received care at a regional health system from 2019 to 2021. Of this group, 55% lived with their biological family, 17% lived independently on their own, and the rest were in settings such as group homes, custodial care, or shelters. About 60% of all patients were prescribed antipsychotics, with the highest proportion of prescribing found for adults in group homes or other supported living.

However, when factoring in other demographic and medical variables, living arrangement by itself was not a significant predictor of receiving an antipsychotic. Rather, sex was the strongest predictor, with males having 4.2 times the odds of an antipsychotic prescription compared with females. Medication count was another influence, as each existing prescribed medication raised the odds of being prescribed an antipsychotic by 10%.

Plenn and colleagues also pointed out that about half the individuals with ID who were prescribed antipsychotics did not have any mental illness diagnosis. “[T]hese findings emphasize the ongoing conversations in which physicians and pharmacists bear the responsibility of thoroughly assessing the potential benefits of medication for people with ID, ensuring both its appropriateness before prescription and the realization of anticipated benefits thereafter.”

For related information, see the Psychiatric Services article “Psychotropic Use Among Youths With Intellectual and Developmental Disabilities.”

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Most Americans Align With Family on Politics, but 1 in 5 Reports Estrangement

About 1 in 3 Americans anticipates having a heated political discussion with their family members this election season, and 6% expect family relations will get worse as a result, a new APA survey reveals.

“It is not surprising that some of us will find ourselves having heated conversations and disagreements on sensitive issues, even with the people we are close to,” said APA CEO and Medical Director Marketa M. Wills, M.D., M.B.A. “The most important thing for our collective mental health is to be mindful of how we are feeling during these tense moments, and to carefully consider the impact these interactions might be having on our important relationships.”

The survey was conducted among 2,201 adults from September 20-22 by Morning Consult. Results include:

• 67% of respondents said they align with close family members on political issues.
• 22% of adults said that conversations around controversial topics made them anxious, but slightly more (27%) said they enjoyed hearing different points of view.
• 41% of respondents reported that they had argued with a family member about a controversial issue.
• About 1 in 5 Americans reported each of the following: becoming estranged from a family member, blocking a family member on social media, or skipping a family event due to disagreements on controversial topics.

Earlier this year, the APA Council on Communications compiled tips on “How to Discuss Controversial Issues With Your Mental Health in Mind.” Among their recommendations:

• Decide carefully when it’s time to engage. If someone says something you disagree with, take a few minutes to think about the speaker’s personality traits and whether they are likely to engage thoughtfully with you, the outcome you would want to reach, and what you might want to say.
• Be ready to listen and consider whether you are ready to be open to someone else’s viewpoints.
• Set some ground rules, such as agreeing to let the other person talk before you start to speak or having a true willingness to learn from the other person.

“If a conversation feels like it may be turning in a direction that will adversely impact your mental health, consider politely excusing yourself from the conversation,” Wills said. “Or consider gently steering the conversation to less intense topics where you’ll be able to find more common ground.”

For related information, see APA’s “How to Discuss Controversial Issues With Your Mental Health in Mind.”

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Genetic PTSD Risk Linked With Lipid Disorders, Women’s Health Issues, and More

In a large and thorough genomic analysis, researchers have found that having a genetic risk for posttraumatic stress disorder (PTSD) may also raise the risk of developing lipid-related health problems like hypercholesteremia or having an oophorectomy. Their findings were published today in the American Journal of Psychiatry.

Gita A. Pathak, Ph.D., of Yale University School of Medicine, and colleagues made use of data from the Psychiatric Genomic Consortium, which includes DNA samples from over 1 million individuals, and the UK Biobank, which in addition to genetic data includes comprehensive lifestyle and health information on more than 400,000 participants. They tested 710 lifestyle and health traits that have been linked with PTSD to see if any of these PTSD comorbidities might be due to genetic causes.

The researchers identified eight traits that are linked with genetic PTSD risk. Four of these traits were lipid-related disorders such as elevated cholesterol, elevated triglycerides, and other problems with lipid metabolism. The other four health outcomes associated with PTSD were:

• Receiving a prescription for a malaria medication
• Receiving a bilateral oophorectomy
• Having a cardiac or vascular implant
• Undergoing menopausal hormone replacement therapy

A further analysis suggested that most of these outcomes might be caused by genetic PTSD risk variants, whereas hormone replacement therapy might contribute to PTSD—although the researchers could not confirm the latter finding when running a second type of genetic analysis.

“However, a prospective study in the Nurses’ Health Study II reported that trauma and … PTSD symptoms are associated with initiating menopausal hormone therapy use in a dose-response manner,” Pathak and colleagues wrote. “The possible implication of hormone replacement therapy in PTSD pathogenesis is also supported by the effect of estrogens on fear extinction.”

The researchers also noted that some prior research in veterans suggested a connection between certain antimalarial drugs and mental health; these new findings suggest that connection may have been influenced by genetic PTSD risk.

For related information, see the American Journal of Psychiatry article “Leveraging Large-Scale Genetics of PTSD and Cardiovascular Disease to Demonstrate Robust Shared Risk and Improve Risk Prediction Accuracy," and the accompanying editorial, “From Soldier’s Heart to Shared Genetic Risk: PTSD and Cardiovascular Disease.”

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Stopping SSRIs/SNRIs During Pregnancy Not Tied to Adverse Outcomes in Women With Milder Symptoms

Women with mild to moderate depression or anxiety and no other mental illnesses who discontinue antidepressants during pregnancy do not appear to experience adverse psychiatric outcomes postpartum, according to a study issued today by JAMA Network Open.

“(E)vidence suggests that the severity of the maternal psychiatric burden rather than the discontinuation of antidepressants per se is associated with the risk of adverse psychiatric events,” wrote Carolyn E. Cesta, Ph.D., of the Karolinska Institutet in Stockholm, Sweden, and colleagues. Their study aimed to investigate that possibility.

Cesta and colleagues analyzed health records of 27,773 individuals in Sweden with singleton pregnancies between 2006 and 2019 who had taken at least one selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) within 90 days of their pregnancy. Individuals with any recorded psychiatric diagnosis from a specialist in the year before pregnancy—beyond outpatient diagnoses of mild or moderate unipolar depression and anxiety—or any prescription fill in the 90 days prior for other antidepressants, antipsychotics, or antiepileptics were excluded.

Overall, 47.5% of the individuals discontinued their SSRIs/SNRIs during pregnancy while 52.5% continued taking them. The researchers assessed psychiatric-related hospitalizations as well as outpatient visits, self-harm and suicide, and any cause mortality at 90 days and 1.5 years after childbirth in both groups; they also examined sick leave usage in the 1.5 years after childbirth.

The researchers found no association between antidepressant discontinuation and adverse psychiatric-related outcomes, including outpatient visits, hospitalizations, or suicidal behavior during the 90 days or 1.5 years after childbirth. Individuals who discontinued their antidepressants during pregnancy also used fewer days of sick leave 1.5 years after childbirth compared with those in the continued use group (45 days vs. 53 days).

“Reasons for discontinuing SSRIs or SNRIs during pregnancy can include wishing to avoid fetal exposure, resolution of symptoms of depression or anxiety, or worsening of symptoms, resulting in a possible switch to other psychotropic medications,” the researchers noted. “Notably, 69.9% of individuals taking SSRIs or SNRIs before pregnancy were included in the study cohort, highlighting that this is an important patient group for which evidence on risks and benefits of SSRI or SNRI use or discontinuation in pregnancy is needed.”

For related information, see the Psychiatric News article “Neurodevelopmental Problems Not Linked to Antidepressant Exposure In Utero.”

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Masked Taper, Targeted CBT May Help Older Patients With Insomnia Discontinue Benzodiazepines

Implementing a masked taper along with targeted cognitive behavioral therapy (CBT) designed to address the placebo effect may help older patients discontinue benzodiazepine use for insomnia better than CBT and standard tapering alone, according to a study published today in JAMA Internal Medicine.

Constance H. Fung, M.D., M.S.H.S., of the VA Greater Los Angeles Healthcare System, and colleagues enrolled 188 adults ages 55 years or older who had used benzodiazepines and/or zolpidem for insomnia at doses of less than 8 mg diazepam equivalent two or more nights per week for at least three months. One group, the supervised taper group, received a paper schedule for tapering their medication over nine weeks along with a pill cutter. They also received eight sessions of standard CBT for insomnia during the nine-week taper and had periodic withdrawal check-ins.

The other group, the masked taper group, also received eight sessions of CBT for insomnia along with withdrawal check-ins. However, their CBT included additional exercises aimed at disrupting pathways thought to result in placebo effects. In essence, the exercises challenged any preconceived notions the participants may have had about whether benzodiazepines—which some studies have shown to have at least a moderate placebo effect for treating insomnia—actually helped them sleep and whether they would experience renewed insomnia or other discomfort upon discontinuing their medication.

Further, this group received their medication capsules in seven-day blister packs that, unbeknownst to the participants, contained progressively larger amounts of inert filler over nine weeks. The participants in this group were instructed to take one pill per night, with no pill cutting.

There were 179 participants at one-week posttreatment follow-up. Of those, 88.4% in the masked taper group had stopped taking their benzodiazepine, compared with 67.4% in the supervised taper group. There were 176 patients at six-month follow-up, and 73.4% in the masked taper group had stopped taking their benzodiazepine, compared with 58.6% in the supervised taper group.

“Although the 14.8% difference between groups [at six months] fell short of the 20% threshold used for power calculations, the sustained and high percentage of discontinuation, which is statistically significant and not without merit, may be attributed to our novel approach,” Fung and colleagues wrote. “The results are most applicable to individuals who use (not misuse) benzodiazepine receptor agonists for chronic insomnia disorder, can attend weekly therapy sessions and engage in prescribed homework, and are not at high risk for complicated withdrawal.”

For related information, see the Psychiatric News article “To Improve Safety in Older Patients, Consider Deprescribing.”

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Study Finds Neighborhood Diversity May Lessen Symptoms in Youth At Risk of Psychosis

Minority youth at high risk of psychosis who live in more diverse neighborhoods tend to have less severe positive symptoms—such as unusual thoughts or grandiose ideas—than those surrounded by less diversity, reports a study in Psychiatry Research.

The researchers found that part of this association was because youth in diverse neighborhoods experience less perceived discrimination and less peer victimization such as bullying.

“Numerous studies have suggested that membership in a minoritized ethnoracial group itself does not confer risk for greater psychotic symptoms, but rather exposures to unequal social environmental conditions, which disproportionately affect underrepresented youth,” wrote Benson S. Ku, M.D., of Emory University School of Medicine, and colleagues. “Our study contributes to the social determinant model of psychosis risk … shedding light on how marginalized youth might be influenced by various interlinking neighborhood and individual factors.”

Ku and colleagues used data from the North American Prodrome Longitudinal Study Phase 2, a large cohort study aimed at improving the prediction of which high-risk individuals may develop psychosis. Their analysis included 492 at-risk youth and 136 low-risk youth, with an average participant age of 18; 45% of the youth identified as an ethnoracial minority.

The researchers found that among ethnoracial minority youth at high risk of psychosis, average positive symptom severity decreased as neighborhood diversity increased—independent of neighborhood socioeconomic status. Diversity was assessed with the Simpson’s Diversity Index, which measures the probability that two people in a community chosen at random will be from different racial and ethnic groups. The association between diversity and positive symptoms was not found for at-risk White youth.

In exploring potential explanations, Ku and colleagues identified peer victimization and perceived ethnoracial discrimination as factors that mediated about 15% of the association between neighborhood diversity and positive symptom severity.

“Perhaps chronically feeling ‘different’ or being ‘othered’ in less diverse neighborhoods, along with experiencing greater victimization life events, may shape individuals’ maladaptive coping mechanisms and core beliefs and affect their social interactions with others,” the researchers wrote. “This … may lead to maladaptive social behaviors (social isolation and self-defeated attitudes) and, in turn, contribute to worsening distress and psychotic symptoms.”

For related content, see the Psychiatric News article “Review Examines How Racism May Increase Psychosis Risk.”

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Bright Light Therapy May Boost Odds of Remission of Nonseasonal Depression

Participants who received add-on bright light therapy for nonseasonal depression, either unipolar or bipolar, were more likely to respond and reach remission than those who did not receive it, according to a systematic review and meta-analysis issued by JAMA Psychiatry.

“Bright light therapy has been studied as a potential adjunctive treatment for major depressive disorder, as light exposure is well understood to affect human mood and cognitive function,” wrote Artur Menegaz de Almeida, M.S., of the Federal University of Mato Grosso in Sinop, Brazil, and colleagues. However, they noted the efficacy of bright light therapy is only established for seasonal depression.

Menegaz de Almeida and colleagues combined data from 11 randomized trials involving 858 participants who had nonseasonal major depressive disorder or bipolar depression and used bright light therapy as adjunctive treatment to their medication. Bright light therapy was defined as using a fluorescent light box that produces white light for at least 30 minutes, with the commonly used range of 10,000 lux; the treatment length ranged from one to six weeks. All studies compared outcomes to a control group who received either an air ionizer or dim red light. Studies were published between 2000 and March 25, 2024.

In total, 60.4% of participants receiving bright light therapy responded to treatment (typically defined as a 50% or greater reduction in depressive symptoms), compared with just 38.6% of those in the control groups. Participants treated with bright light therapy also had a significantly higher remission rate than the control group (40.7% versus 23.5%, respectively). Menegaz de Almeida and colleagues also found that bright light therapy increased the likelihood that individuals could achieve a response or remission within four weeks or less.

“The primary supportive argument in favor of using bright light as an adjunctive treatment is the cost,” the authors wrote. “Even though outpatient treatment costs with antidepressants are widely variable, exposure to external light generally involves no costs or limitations, which reinforces the need to firm [bright light therapy] as an efficient adjunctive treatment for nonseasonal depressive disorders.”

For related information, see the Psychiatric Research and Clinical Practice article "Commercially Available Phototherapy Devices for Treatment of Depression: Physical Characteristics of Emitted Light."

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Hearing Loss Linked to Cognitive Decline; Hearing Aids Do Not Appear to Change Risk

Mild or disabling hearing loss (HL) among adults ages 45 to 69 may be associated with cognitive impairment, according to a report in JAMA Open Network. Further, wearing a hearing aid does not appear to significantly change the risk for cognitive impairment.

Baptiste Grenier, M.D., of the Universite Paris Cite, and colleagues noted that the prevalence of cognitive impairment is increasing, with up to 150 million individuals worldwide expected to be living with dementia by 2050. “Given the major burden of cognitive decline and the absence of curative treatment, identifying modifiable risk factors is of importance,” they wrote.

Grenier and colleagues analyzed data on 62,072 older participants (average age 57.4 years; 52% female) in the French CONSTANCES cohort, a population-based epidemiological cohort that recruited more than 200,000 randomly selected adults ages 18 to 69 from the French National Insurance Fund between January 1, 2012, and December 31, 2020.

Overall, 49% of participants (n = 30,624) had normal hearing, 38% (n= 23,768) had mild HL, 10% (n = 6,012) had disabling HL without use of a hearing aid, and 3% (n = 1,668) used a hearing aid; hearing status was objectively assessed with audiometric testing.

Upon enrollment, all participants ages 45 and older also underwent an extensive cognitive evaluation from trained neuropsychologists. The researchers computed a global cognitive score for the participants based on three of the tests:

• Digit Symbol Substitution Test of attention, psychomotor speed, and reasoning
• Free and Cued Selective Reminding Test of episodic verbal memory
• Trail Making Test of shifting abilities and executive function

Across all ages, 27% of individuals with mild HL and 37% of those with disabling HL had global cognitive scores indicative of impairment, compared with 16% among those with normal hearing. The authors found no statistical difference in cognitive impairment risk between all individuals with disabling HL who used a hearing aid and those who did not. A secondary analysis suggested that hearing aids may reduce the risk of cognitive impairment in individuals with disabling hearing loss and depression.

The authors said that HL may cause cognitive decline because of social isolation, prolonged deprivation of auditory input, and/or shared neurodegenerative processes in the brain associated with hearing loss and cognitive deterioration. HL is also associated with loss of brain volume in critical sections of the brain.

Prescription of hearing aids for patients with disabling HL “should be guided by their established benefits on quality of life and social isolation, but not to mitigate cognitive decline for which further research is needed,” the authors wrote.

For related information, see the Psychiatric News article “Late Life Anxiety Linked to Cognitive Decline.”

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APA Honors and Celebrates Contributions of Hispanic, Latino Membership

Today, on National Latino Physician Day, APA is celebrating the contributions—past and present—of its Hispanic and Latino membership to the field of psychiatry.

“We applaud our bilingual, bicultural members for their commitment to educating patients and families as well as other physicians with culturally relevant resources,” said APA President Ramaswamy Viswanathan, M.D., Dr.Med.Sc. “And it is equally important to acknowledge the disparity in mental health care for Hispanics and Latinos, so that we can continue to increase access to quality care.”

Among adults with mental illness, just 40% of Latinos received mental health treatment in 2022, compared with 56% of whites, according to the Substance Abuse and Mental Health Services Administration. Factors include structural inequalities, lack of insurance, language barriers, and historical mistrust of the medical system.

APA Foundation’s Melvin Sabshin, M.D., Library and Archives recently launched “Líderes Audaces: Hispanic Pioneers in American Psychiatry,” an exhibit that highlights Hispanic leadership who have advocated for and advanced the mental health needs of the Latino community. Among other events “Líderes Audaces showcases the origins of the 1970 Task Force on Mental Health of Spanish-Speaking People in the United States, the Committee of Hispanic Psychiatrists, and the establishment of the Simón Bolívar Award in 1975 to raise awareness of the mental health goals and challenges of Hispanic and Latino individuals.

APA has also expanded its evidence-based Spanish resource website, LaSaludMental.org, which now offers information on 17 mental health conditions, including recently added sections on anxiety disorders, the connection between climate change and mental health, and Alzheimer’s disease and dementia. In the last two years, the site has been viewed hundreds of thousands of times, reaching Hispanic and Latino communities as well as the mental health professionals who serve them. The updated resource now also features a Spanish-language version of the “What Is Psychiatry?” informational page, “¿Qué es la psiquiatría?”

For related information, see the Psychiatric News article “Disparities Remain Obstacles for SUD Treatment in Hispanic/Latinx Communities.”

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