Holidays Bring Anxiety for Some but Continue to Be a Source of Merriment for Many

Holidays can be stressful. This year, nearly a third of Americans (28%) say they anticipate more holiday-related stress than last year, according to the latest APA Healthy Minds Monthly Poll. Yet the holidays also remain a season of joy for many: Nearly two-fifths (38%) of adults say the holidays positively impact them.

“Although there are several different holidays we celebrate in December, many of us share the same anxiety and excitement about preparing for them,” said APA President Ramaswamy Viswanathan, M.D., Dr.Med.Sc. “Holiday stress is normal, and as psychiatrists, we understand that the social determinants of mental health can and do influence the experience of the winter holidays.”

This poll, fielded by Morning Consult on behalf of APA, was conducted Nov. 16-17 among 2,201 adults.

When thinking about this holiday season, adults reported they are worried most about missing someone (47%), affording gifts (46%), affording meals (36%), and challenging family dynamics (35%). Smaller percentages of adults worried about loneliness during the holidays (39%) and discussing politics with loved ones (32%). Younger people and parents were more likely to have these worries.

On the positive side, 41% of adults said that being able to see family and friends was the thing they were most looking forward to this upcoming holiday season, followed by 24% of adults who were looking forward to eating good food.

Apart from the holidays, adults continue to be anxious about the economy (75%), gun violence (64%), and hate speech and hate crimes (60%). Many adults also reported feeling anxious about international conflict (57%), climate change (56%), artificial intelligence (52%), and reproductive rights (50%), but those levels have dropped a few percentage points since August 2024. Anxiety around the 2024 election has also dropped significantly now that it is over: 50% said they are anxious now compared with 72% prior to the election.

For related information, see the Psychiatric News article “Dolce-Amaro December.”

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Low-Resource Patients With OUD Engaged With Collaborative Care Intervention

Patients with co-occurring mental illness and opioid use disorders in a low-resource community engaged with a collaborative care treatment program and stuck with it, according to a study in JAMA Network Open today.

“Opioid use disorders (OUDs) remain undertreated, particularly when co-occurring with mental illness,” wrote Katherine E. Watkins, M.D., M.S.H.S., with the RAND Corporation in Santa Monica, California, and colleagues. “The collaborative care model (CoCM), an evidence-based approach for integrating behavioral health treatment in primary care, offers a potential solution, but the extent to which the CoCM can engage high-risk populations with fidelity in community settings is poorly understood.”

Watkins and colleagues tapped into data from a randomized clinical trial in 14 low-resourced primary care clinics in New Mexico involving adults with probable OUD and co-occurring mental illness who were assigned to a six-month CoCM program between 2021 and 2023. About one-quarter of the adults had used fentanyl or heroin in the 30 days prior to enrollment, and three-quarters were prescribed medications for OUD.

The CoCM deployed addiction-certified psychiatric consultants, primary care clinicians, and community health workers as care managers, supported by a caseload tracking tool. Engagement was defined as participating in an intake interview, while fidelity was defined as having at least two care manager encounters, at least two assessments of OUD and mental health symptom severity, and a treatment plan review by a psychiatric consultant.

Of the 369 adults assigned to the CoCM, 297 participants (81%) engaged with it. Of those who engaged, 206 (69%) stuck with the CoCM, with a median of nine care encounters. Rates varied by substance used: Just 54% of individuals with stimulant co-use participated with fidelity, whereas 81% of those who misused only prescription pain medication did so.

Further work is needed to determine whether fidelity to the CoCM is associated with positive patient outcomes, the authors wrote. Limitations included the study’s use of observational data from one arm of a clinical trial in just one state with high OUD rates.

“Our results indicate that the CoCM may offer a solution to the undertreatment of OUD for patients with complex conditions,” researchers wrote. “When community health workers are used, the CoCM may be an efficient approach to address behavioral health professional shortages.”

For related information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

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Wildfire Smoke Linked to Increased Risk of Dementia

Long-term exposure to particulate matter found in wildfire smoke may raise the risk of dementia, according to a study published today in JAMA Neurology. The findings also suggest that wildfire particulate matter increases the risk more than non-wildfire particulate matter.

Holly Elser, M.D., Ph.D., of the University of Pennsylvania, and colleagues examined data from more than 1.2 million members of Kaiser Permanente Southern California. Patients were at least 60 years old and did not have dementia when they were first included in the study.

The researchers estimated the average daily concentrations of total fine particulate matter in each Southern California census tract from 2006 to 2019 using measurements from the Environmental Protection Agency Air Quality System, and then used additional federal and state meteorological data to subtract the contribution of wildfire-generated fine particulate matter from the total. The researchers then calculated three-year rolling periods of particulate exposure (updated every three months) for each patient.

During follow-up, 6.6% of patients received a diagnosis of dementia, with most of the diagnoses being for nonspecific dementia. The researchers found an 18% increase in the odds of dementia for every 1-µg/m³ increase in three-year average wildfire fine particulate matter. For non-wildfire fine particulate matter, the odds of dementia diagnosis increased by just 1% for every 1-µg/m³ increase in three-year average exposure.

In a secondary analysis, the researchers found that the associations between exposure to wildfire fine particulate matter and dementia were stronger among patients younger than 75 when they were included in the study, patients from racially minoritized subgroups, and patients living in high-poverty census tracts compared with low-poverty census tracts.

“These latter findings underscore the importance of research that considers the effects of air pollution on potentially vulnerable population subgroups and aims to identify potential strategies to mitigate inequities in air pollution exposure effects,” Elser and colleagues wrote—though they cautioned that by relying on EHR data they could not fully account for all socioeconomic or behavioral factors that may raise or mitigate the potentially damaging effects of wildfire smoke.

For related information, see the Psychiatric News Alert “Air Pollution Exposure May Be Linked to Late-Onset Depression.”

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Short-Term Menopausal Hormone Therapy Does Not Affect Long-Term Cognition, Study Finds

Short-term menopausal hormone therapy does not appear to have any long-term cognitive effects, either positive or negative, according to a study published yesterday in PLoS One.

The study findings were part of a long-term follow-up of participants in the Kronos Early Estrogen Prevention Study (KEEPS), in which women in early postmenopause and with good cardiovascular health were randomized to four years of oral estrogen, transdermal estradiol, or placebo. At the end of four years, no cognitive benefit or harm was seen in women who received estrogen compared with those who received placebo.

For the follow-up study, Carey Gleason, Ph.D., M.S., of the University of Wisconsin-Madison, and colleagues brought back 275 KEEPS participants after the original study ended—over a range of eight to 14 years. The women completed the same cognitive tests as years before, including an assessment of global cognitive function along with 11 tasks spanning four cognitive domains: verbal learning and memory; auditory attention and working memory; visual attention and executive function; and speeded language and mental flexibility.

The researchers identified no significant differences in global cognition or any of the four domains between women who had taken either hormone treatment and those who did not—both in the head-to-head performance during follow-up and in the change in cognition from original study to follow-up. A secondary analysis that excluded 40 women who continued to take hormone therapy after KEEPS found similar results.

These findings “may reassure women opting to use hormone therapy in early menopause, to manage menopausal symptoms, that 4 years of therapy started within 3 years of menopause had no long-term deleterious impact on cognition,” Gleason and colleagues wrote. “Our results also indicate that [hormone therapy] does not prevent cognitive decline when initiated around the time of menopause. Therefore, [hormone therapy] should not be recommended as a strategy for improving or preserving cognitive function in recently menopausal women with low cardiovascular risk.”

For related information, see the Psychiatric News Alert “Hormone Therapy May Reduce Relapse Risk for Menopausal Age Women With Schizophrenia.”

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Reaching Age at Which Parent Died by Suicide Increases Suicide Risk Among Offspring

Several studies have shown that individuals with a parent who died by suicide have an increased risk of suicide or self-harm themselves compared with individuals with living parents or a parent who died from other causes. A study issued in Suicide and Life-Threatening Behaviors now finds that this risk may be particularly elevated when the individual reaches the same age at which the parent died by suicide.

“Contemporary models of grief acknowledge that individuals move backwards and forwards between phases or stages of grief rather than in a linear manner,” wrote Yanakan Logeswaran, M.Sc., of the University College of London Division of Psychiatry, and colleagues. “Our findings support the idea of a dynamic process of grief, in so much as the elevated risk of suicidal behavior at [parental] age correspondence might also represent a period of loss orientation and increased distress.”

Logeswaran and colleagues used national data from five Danish registries to identify individuals whose parents died between 1980 and 2016. The data included cause of death as well as hospital records of self-harm or suicide attempt. Individuals were separated into two groups: the 17,806 individuals whose parents died by suicide, and the 452,674 individuals whose parents died due to other causes. The researchers compared the risk of self-harm and suicide during the year before and after individuals reached the age of the deceased parent with the 15 years before and after that period.

Individuals reached the age of their deceased parent a median of 24 years after the loss. The researchers found that individuals whose parents died by suicide had about twice the risk of self-harm or suicide around the time they reached the age of the deceased parent relative to the 15 years before or after. Those whose parents died from other causes did not have an increased risk during this period of age correspondence

“Our findings support the practice of asking suicide-bereaved individuals about age at parental suicide, identifying this as an anticipated period of increased risk and planning increased support,” Logeswaran and colleagues wrote. “This is also an opportunity to reinforce that suicide is not inevitable after the suicide of a parent, with the absolute risk of suicide in offspring of suicide decedents estimated at less than 1%.”

For related information, see the Psychiatric News article “Nature, Nurture Both Contribute to Suicide Risk.”

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FDA Panel Votes 14-1 Against Clozapine REMS

A panel convened by the Food and Drug Administration (FDA) voted overwhelmingly yesterday against key provisions of the Clozapine Risk Evaluation and Mitigation Strategy (REMS) after hearing from clinicians, patients, and caregivers who said access to this effective schizophrenia medication was thwarted by red tape.

The REMS for clozapine is designed to monitor for the relatively rare risk of neutropenia, a potentially deadly reduction in white blood cells.

The panel voted 14-1 against the REMS requirement that prescribers document and pharmacies verify patients’ absolute neutrophil counts (ANC) before dispensing clozapine. The panel also voted 14-1 against the need for educating prescribers and pharmacists on the risk of clozapine-induced severe neutropenia and ANC monitoring.

“I do not believe that the REMS’ approach to documenting and enforcing is serving the health of the patients or the needs of the community,” said panelist Sascha Dublin, M.D., Ph.D., an epidemiologist who studies the health effects of prescription medications for Kaiser Permanente. “I hope we can find better ways to support appropriate monitoring that don’t have a punitive and technocratic approach.”

The FDA is not required to follow the recommendations from this joint meeting of the Drug Safety and Risk Management Advisory Committee and the Psychopharmacologic Drugs Advisory Committee, but it often does.

Kathryn K. Erickson-Ridout, M.D., a member of APA’s Council on Quality Care, testified on behalf of APA. “I have been treating patients with treatment-resistant schizophrenia for 12 years and have seen the life-transforming benefit of this medication—controlling otherwise treatment-resistant psychotic symptoms and providing cognitive clarity.

“The REMS program, while well-intentioned and -designed, does create a barrier to prescribers and patients using clozapine,” said Erickson-Ridout, who is also an inpatient psychiatrist and researcher for Kaiser Permanente. The barriers posed by the REMS can lead to interruptions in access to clozapine, often with disastrous results, she said.

Dozens of patients and their caregivers offered testimonials of rapid decompensation, self-harm, and relapsed psychosis after being denied a refill for their prescribed clozapine—often despite completing required bloodwork—due to missing paperwork or lack of training among pharmacy personnel. Most patients simply could not find a willing clinician, pharmacy, and/or lab to prescribe the drug or complete the required testing.

Tiffany R. Farchione, M.D., director of the FDA’s Division of Psychiatry, testified that 22% to 37% of people with schizophrenia have treatment-resistance illness. Yet only 4% to 5% of patients with schizophrenia receive clozapine, Erickson-Ridout noted in her testimony. She added that surveys have found that since the last change to the Clozapine REMS in November 2021, 66% of prescribers have reported trouble getting the drug for patients.

Read the full story on PN Newswire.

For more information, see the Psychiatric News article “Clozapine Risks Drop Sharply Within Months, May Warrant Less Monitoring.”

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For Coordinated Specialty Care, Fidelity to Program Components Matters

Individuals with first-episode psychosis who received the wide range of services provided in coordinated specialty care (CSC) programs experienced improved symptoms, higher quality of life, and improved functioning, according to a study published today in Psychiatric Services. This was especially true for individuals who were treated in programs that adhered to the core components of CSC.

CSC is a recovery-oriented treatment model for people experiencing first-episode psychosis that provides a range of evidence-based services delivered through a multidisciplinary team. A variety of programs exist, but in 2014, the National Institute of Mental Health (NIMH) outlined the core components of CSC:

• Medication management
• Psychotherapy
• Case management
• Family education and support
• Supported employment
• Supported education.

This study demonstrates that “the six CSC components identified by NIMH may constitute the core essential ingredients that should be made available in all CSC programs, regardless of the specific model, and that fidelity to those components may enhance positive outcomes,” wrote Abram Rosenblatt, Ph.D., of the health care consulting firm Westat, and colleagues.

Rosenblatt and colleagues looked at patient- and clinician-rated measures of psychotic symptom frequency, quality of life, and social and role functioning for 770 individuals receiving CSC services in 36 federally funded programs; patients were assessed at time of entry and every six months for up to 18 months. All programs were also assessed for fidelity to the core components outlined by NIMH. Additional program-level variables assessed during the study included staff turnover rate and time spent on CSC services.

Overall, the average frequency of psychotic symptoms decreased among patients receiving CSC services from baseline to follow-up, while quality of life, social functioning, and role functioning scores all increased. In programs that had higher fidelity to the NIMH model, individuals showed a greater improvement in psychotic symptom frequency and social functioning. After accounting for the other program-level characteristics, the researchers also found that the more time the team leader spent on CSC program services, the greater the patient symptom improvement and social functioning.

Rosenblatt and colleagues said additional research is needed to identify how and whether services specific to existing models yield the most effective CSC programs, including the quality of services offered and received. “…[M]aximizing the value of CSC across a broad range of settings and diverse client populations requires further understanding of and attention to fidelity, implementation, and adaptation,” they wrote.

For related information, see the Psychiatric News article “Look for Hope and You Will Find It: Outlook for First Episode Psychosis Has Never Been Better.”

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DEA, HHS Issue Third Extension of Pandemic Telehealth Prescribing Flexibilities

On Friday the Drug Enforcement Administration (DEA) in concert with the U.S. Department of Health and Human Services (HHS) issued a third extension of COVID-19 telehealth flexibilities for the prescribing of controlled medications, to be effective through December 31, 2025.

These telemedicine flexibilities, originally granted in March 2020 as part of the COVID-19 Public Health Emergency, authorize qualified health professionals to prescribe Schedule II-V controlled medications via telemedicine, including Schedule III-V narcotic-controlled medications approved by the Food and Drug Administration for the treatment of opioid use disorder via audio-only telemedicine encounters.

“This additional time will allow DEA (and also HHS, for rules that must be issued jointly) to promulgate proposed and final regulations that are consistent with public health and safety, and that also effectively mitigate the risk of possible diversion,” the extension states. “Furthermore, this Third Temporary Rule will allow adequate time for providers to come into compliance with any new standards or safeguards eventually adopted in a final set of regulations.”

Early in 2023, the DEA proposed regulations that would curtail some telemedicine prescribing flexibilities extended to qualified health professionals during the COVID-19 Public Health Emergency—for instance, by requiring an in-person visit for the prescribing of controlled substances. (The proposals appeared as two separate rules in the Federal Register: “Telemedicine Prescribing of Controlled Substances When the Practitioner and the Patient Have Not Had a Prior In-Person Medical Evaluation” and “Expansion of Induction of Buprenorphine Via Telemedicine Encounter.”) APA filed two letters in response to these proposed rules in March 2023, urging that the DEA balance common-sense safeguards for DEA enforcement without decreasing access to lifesaving treatment. In October 2023, the DEA and HHS issued a second temporary extension that continued the telehealth flexibilities until December 31, 2024.

For related information, see the Psychiatric News article “DEA, HHS Extend Telemedicine Flexibilities Through 2024.”

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Pandemic-Fueled Rise in Drinking Persisted Into 2022

Alcohol consumption among adults increased during the early part of the COVID pandemic, and this increase was sustained two years later, according to an analysis published in Annals of Internal Medicine.

“Potential causes of this sustained increase include normalization of and adaptation to increased drinking due to stress from the pandemic and disrupted access to medical services,” wrote Divya Ayyala-Somayajula, M.D., of Thomas Jefferson University in Philadelphia, and colleagues.

The researchers examined data from the 2018, 2020, and 2022 editions of the nationally representative National Health Interview Survey (NHIS), which included responses on drinking behaviors from 24,965 adults 18 or over in 2018, 30,829 in 2020, and 26,806 in 2022.

Between 2018 and 2020, the number of adults who reported any drinking in the past year increased by 2.69% (from 66.34% to 69.03%), with increases seen in both men and women and across racial groups. Likewise, the rate of past-year heavy drinking—defined as 5+ drinks in one day or 15+ drinks per week for males, and 4+ drinks in one day or 8+ drinks per week for females—rose from 5.1% to 6.13% between 2018 and 2020.

In 2022, the rate of any drinking among adults remained elevated overall (69.3%) and across race and gender groups. The overall rate of heavy drinking in 2022 also remained elevated (6.29%), but the researchers noted that among Asian American and American Indian adults, the rate of heavy drinking in 2022 dropped below 2018 levels.

“[O]ur results highlight an alarming public health issue that may require a combination of policy changes,” Ayyala-Somayajula and colleagues wrote. “Increased screening efforts for harmful drinking with systematic integration and rapid linkage to behavioral health treatments by health care professionals, in tandem with community-based interventions for at-risk populations, should be considered to mitigate the public health consequences of the pandemic-related increase in alcohol use.”

For related information, see the Psychiatric News articles “Pandemic May Be Accelerating Problematic Trends in Alcohol Use” and “NIAAA Director Hopeful About Growing Awareness of Risks, Harms of Alcohol.”

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Hallucinogen-Related ED Visits Associated With Schizophrenia Risk

Individuals who require emergency care after using hallucinogenic drugs have an increased risk of developing a schizophrenia spectrum disorder (SSD), according to a report issued yesterday in JAMA Psychiatry.

“Results from randomized clinical trials suggest that psychedelic-assisted psychotherapy may be beneficial for treatment-resistant depression, posttraumatic stress disorder, and alcohol use disorder,” wrote Daniel Myran, M.D., M.P.H., of the University of Ottawa, and colleagues. “However, there are ongoing concerns that hallucinogen use may increase the risk of serious adverse mental health outcomes, including psychosis, particularly when used outside supervised clinical settings and in populations at elevated risk of psychosis, who have historically been excluded from clinical trial.”

Myran and colleagues analyzed medical record data from 9.2 million individuals ages 14 to 65 enrolled in Ontario’s universal health insurance program between January 2008 and December 2021. The researchers identified 5,217 individuals who had an ED visit involving hallucinogen use, which encompassed both dissociative drugs like ketamine and psychedelics like LSD or psilocybin. Those who had an ED visit, hospitalization, or outpatient visit for psychosis in the five years prior to the hallucinogen-related ED visit were excluded.

The primary outcome was the development of an SSD, which was defined as a diagnosis of schizophrenia or schizoaffective disorder.

Individuals who had visited the ED due to hallucinogen use had a 21 times greater risk of developing an SSD within three years compared with the general population. After accounting for sociodemographic characteristics and comorbid mental and substance use disorders, those who had a hallucinogen-related ED visit still had a 3.5 times greater risk of developing an SSD. Additional findings included:

• The most common reasons for ED visits involving hallucinogen use were harmful use (36.6%), intoxication (22.2%) and poisoning from a substance other than LSD (16%).
• Individuals who visited the ED for hallucinogen-induced psychosis (3.5% of all visits) had the greatest risk of developing an SSD.
• Compared with the general population, those who visited the ED for hallucinogen use were younger and more likely to be male and live in low-income neighborhoods.
• The rate of individuals who visited the ED due to hallucinogen use was largely stable from 2008 to 2012, then increased by 86.4% between 2013 and 2021.

The authors noted that the data they studied did not include detailed information on the type of hallucinogens used. They also noted that the study did not establish a causal link between hallucinogen use requiring care in the ED and developing an SSD. “Nonetheless, our findings revealed a group that may have high risk of development of SSD who may benefit from close follow-up and intervention or preventative efforts,” they wrote.

For related information, see the Psychiatric News article “Marijuana, Hallucinogen Use Reach Historic Levels Among Young Adults.”

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‘Institutional Betrayal’ During Psychiatric Hospitalization Leads to Patient Distrust

Individuals who report experiencing negative or harmful effects during psychiatric hospitalization—such as concerns about care being minimized or hearing serious news delivered in an insensitive manner—are less likely to trust mental health providers afterward and less likely to participate in follow-up care or undergo voluntary hospitalization, according to a report in Psychiatric Services.

Such experiences of “institutional betrayal” are also more likely to be reported by patients in for-profit facilities, according to the study.

“Institutional betrayal occurs when an institution creates an environment where harm is likely to occur or when the institution normalizes, minimizes, or fails to respond to reports of harm,” wrote Alicia Lewis, B.S., of Washington University in St. Louis, and colleagues.

Lewis and colleagues surveyed 814 adults who had been treated in any adult psychiatric inpatient unit in the United States between 2016 and 2021, collecting data on patients’ demographics, experiences of institutional betrayal, and the impact of psychiatric hospitalization on their engagement with mental health care post-discharge. The researchers used the Institutional Betrayal Questionnaire to identify various types of institutional betrayal and linked responses to data on facility ownership type.

Among respondents whose inpatient facility could be identified, 27% were admitted to a for-profit hospital, 15% to a government hospital, and 57% to a nonprofit hospital.

More than one-third of the sample (38%, N=307) had not experienced a betrayal, 38% (N=308) had experienced one to five types of betrayal, and 25% (N=199) had experienced more than five types of betrayal. Compared with individuals who had not experienced institutional betrayal, those who did were:

• 25% more likely to report that the hospitalization had reduced their trust in mental health providers.
• 45% more likely to report a reduced willingness to voluntarily undergo hospitalization in the future.
• 30% more likely to report a reduced willingness to disclose future distressing thoughts to a mental health provider.
• 11% less likely to report having a 30-day post discharge follow-up visit.

Compared with participants hospitalized at a nonprofit facility, those who were hospitalized at a for-profit facility were 14% more likely to report having experienced an institutional betrayal.

“…[P]olicy makers and payers need to more closely monitor the impact that profiteering might have on care quality and should identify ways to … better support patients’ well-being and outcomes,” the researchers wrote. “[S]urveying people on the extent to which they felt respected and supported during their inpatient hospitalization and providing these metrics to the public could be an important step in incentivizing a high quality of care.”

For more information, see the Psychiatric News article “Study Identifies Adverse Event Factors Linked to Psychiatric Hospitalization.”

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Brief, Telehealth-Delivered CBT Can Lower Risk of Suicidality Among High-Risk Adults

Brief cognitive behavioral therapy (BCBT) delivered via telehealth can effectively reduce suicide attempts and suicidal thoughts among high-risk adults, according to findings from a randomized clinical trial issued today in JAMA Network Open.

“BCBT directly targets suicidal behavior by teaching patients to effectively regulate their emotions and cognitively reappraise when presented with stressors,” wrote Justin C. Baker, Ph.D., assistant professor of psychiatry and behavioral health and clinical director of the Suicide and Trauma Reduction Initiative for Veterans at Ohio State University, and colleagues. “However, no studies have investigated the safety and effectiveness of BCBT delivered via telehealth.”

The researchers recruited 96 adults from an outpatient clinic between April 2021 and September 2023, all of whom scored a 5 or higher on the Scale for Suicide Ideation and/or had a suicide attempt within the past month. They were randomly assigned to receive either BCBT or present-centered therapy via telehealth for 12 weeks. The latter focused on identifying adaptive responses to stressors. All participants attended one in-person intake session to meet their therapist, discuss guidelines, and complete a diagnostic interview. Participants completed follow-up assessments at three, six, nine, and 12 months.

Prior to beginning telehealth treatment, clinicians looked up the address of patients’ closest emergency room and helped patients complete either a safety plan or crisis response plan, Baker told Psychiatric News. Clinicians also obtained the name of a nearby emergency contact who could check in on the patient if needed. At the outset of each telehealth visit, clinicians obtained the address of the patients’ current location in case they needed to summon help.

After 12 months, participants who received BCBT reported significantly fewer suicide attempts on average than participants randomized to patient-centered therapy (0.70 vs 1.40 per participant). After adjusting for differences between groups and patient dropout, this resulted in a 41% reduced risk for suicide attempts among adults receiving BCBT. Reductions in suicidal ideation occurred in both treatments, with no significant differences between groups.

The researchers noted that while additional research is needed to distinguish the therapeutic targets associated with improvements in suicidal behaviors vs. ideation, one implication of their findings is that suicidal ideation levels may have limited clinical utility as an indicator of treatment response and risk for suicidal behavior.

“We’ve known that telehealth treatment is effective for some time. What we’ve shown with this trial is that it can also be safe and effective for individuals at high risk of suicide, who have typically been excluded from this type of care,” Baker said.

One issue is the lack of mental health clinicians with the training to provide this specialized form of BCBT. “A lot of therapists just do what they know best. So, these evidence-based psychotherapies are found only in academic centers,” said Baker, who is currently in year one of a four-year grant to develop an online training platform for BCBT that will allow any licensed mental health clinician with internet access to log in and learn to provide this treatment.

For related information, see the Psychiatric News article “To Lower Suicide Risk, Treat Troubled Sleep.”

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Endarterectomies and Pain Surgeries Pose Elevated Delirium Risks, Study Finds

Among a range of common surgeries for older adults, an endarterectomy—opening blood vessels blocked by plaques—may pose the highest risk of postoperative delirium, reports a study in Journal of the American Geriatrics Society. Endarterectomy patients are more likely to have delirium risk factors such as frailty and a history of stroke and/or depression, the study researchers noted.

Patients undergoing other surgeries such as hernia repair or knee/hip replacement also had elevated delirium risk, but for different underlying risk factors.

“By identifying and targeting specific risk factors within each surgical phenotype, healthcare providers may be more efficiently able to enhance postoperative care and outcomes for this vulnerable population,” wrote Hyundeok Joo, M.D., M.A.S., and colleagues at the University of San Francisco.

Joo and colleagues used data from the Health and Retirement Study—a nationwide cohort of older adults in the U.S.—to assess preoperative health characteristics of 7,424 adults ages 65 or older who underwent one or more of 10 noncardiac surgeries from 2000 to 2018. The surgeries were: total knee arthroplasty (TKA), total hip arthroplasty (THA), spine surgery, cholecystectomy, colorectal surgery, hernia repair, endarterectomy, prostatectomy, transurethral resection of the prostate (TURP), and hysterectomy.

The researchers identified distinct patterns of delirium risk:

• Endarterectomy patients presented with the highest burden of medical and cognitive risk factors, including advanced age, high rates of stroke (22%), depression (30%), frailty (42%), and high school or less education (73%).
• Patients receiving a general surgery—cholecystectomy, colorectal surgery, or hernia repair also had elevated delirium risk due to higher rates of frailty (29-32%) and depression (24-26%), with moderate rates of other comorbidities.
• Patients receiving a pain-related surgery—THA, TKA, or spine surgery—had elevated delirium risk due to higher rates of pain (47-53%) and more reported impairment of daily activities, despite low rates of other medical comorbidities.
• Patients in the remaining surgical groups—hysterectomy, prostatectomy, and TURP—generally had a lower risk for delirium.

“The observed variation in delirium risk profiles across different surgical types…suggests that different surgical populations may benefit from different types of delirium prevention strategies,” Joo and colleagues wrote. For example, they noted endarterectomy patients might benefit from resource-intensive interventions such as preoperative cognitive training, prehabilitation to build physical and psychological health, and enhanced perioperative monitoring. Patients receiving one of the pain-related surgeries, meanwhile, would not necessarily need significant prehabilitation, but rather multimodal pain management protocols and early mobilization strategies after surgery.

For related information, see the Psychiatric Research & Clinical Practice article “Simple and Objective Evaluation Items for the Prognosis and Mortality of Delirium in Real‐World Clinical Practice: A Preliminary Retrospective Study.”

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ADHD Associated With Lower Weight at Birth, but Obesity in Childhood

Children with attention-deficit/hyperactivity disorder (ADHD) weighed less at birth but were significantly more likely to have obesity after age five compared with those without ADHD, according to a study issued by the Journal of the American Academy of Child & Adolescent Psychiatry. However, elevated ADHD symptoms were not predictive of increased obesity risk until age 7 in females and age 11 in males.

“The relationship between ADHD and body weight, despite being largely investigated, is still unclear,” wrote Claire Reed, M.Sc., of the University of Southampton, and colleagues. “Children with increased ADHD symptoms are typically lighter at birth than their peers but are later more likely to have obesity. Research into the ‘when and why’ regarding this turning point is scarce.”

Reed and colleagues used data from the Millennium Cohort Study, which included 7,908 children born between 2000 and 2002. Families provided data when children were 9 months old and again at ages 3, 5, 7, 11, 14, and 17. The 442 children with ADHD were identified either when they received a diagnosis or by the results of the Strengths and Difficulties Questionnaire (SDQ) hyperactivity/inattention subscale. Parents completed the SDQ during each data collection wave between the ages of 3 and 17. Children who scored high or very high on the subscale during at least five of the six waves were considered to have ADHD. The control group included 5,398 children without an ADHD diagnosis who never scored high on the hyperactivity/inattention subscale.

All children were weighed during each wave of data collection, and parents reported birth weights at the first wave.

Though children in the ADHD group weighed less on average at birth compared with the control group, the difference in weight between the two groups was not significant at 9 months or 3 years. However, those in the ADHD group were significantly more likely to have obesity from age 5 onwards, after excluding children taking stimulants. Further, higher ADHD symptoms as measured on the SDQ scale at ages 7, 11, and 14 were significantly associated with higher body mass index (BMI) scores at the next data wave among girls. This association was only seen in boys at ages 11 and 14.

The findings suggest that there may be a sensitive period between the ages of 3 and 5 during which higher ADHD symptoms become associated with obesity, the authors wrote. Additionally, the later association between higher ADHD symptoms and higher BMI scores may relate to increasing independence regarding food choices as children age, the authors posited. “Those with higher levels of impulsivity may be less likely to make healthier choices,” they wrote.

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Excessive Screen Time in Toddlers Linked to Autism Diagnosis in Early Adolescence

Toddlers who have more than 14 hours per week of screen time have nearly twice the odds of having a diagnosis of autism spectrum disorder when they are 12 years old, a research letter in JAMA Psychiatry has found.

Ping-I. Lin, M.D., Ph.D., of St. Louis University, and colleagues examined data amassed from parents of 5,107 children in the Longitudinal Study of Australian Children, a study examining how children's social, economic, and cultural environments affect their wellbeing over the life course. The researchers defined early childhood screen time as the weekly number of hours of exposure to television, videos, or other internet-based programs at 2 years of age.

A total of 145 children had a parent-reported diagnosis of autism spectrum disorder at 12 years. Children who had more than 14 hours of weekly screen time when they were two years old had 1.79 times the odds of having a diagnosis of autism spectrum disorder when they were 12 years old than those who had less than 14 hours of weekly screen time. Children were more likely to have more than 14 hours of screen time when they were 2 years old if they were boys, their mothers had less than 13 years of education or less, or they lived in households with a family income of $60,000 or less.

“Although our findings suggest that the association between screen time and ASD risk is not causal, there are still important clinical and policy implications,” the researchers wrote. “Screen time can be a useful marker for identifying families needing additional support. Interventions should address underlying socioeconomic factors, providing resources to reduce adverse health impacts of screen time.”

For related information, see the Psychiatric News Alert “Early Childhood Tablet Use Linked to Angry Outbursts.”

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Cognitive Remediation Plus Transcranial Stimulation May Slow Cognitive Decline in At-Risk Patients

Treating older adults with cognitive remediation (CR) plus transcranial direct current stimulation (tDCS) was effective in slowing cognitive decline in older adults with remitted major depressive disorder, according to a study issued by JAMA Psychiatry.

“Older adults with mild cognitive impairment (MCI) or a major depressive disorder (MDD) constitute two overlapping groups that are at high risk for cognitive decline and dementia,” wrote Tarek K. Rajji, M.D., at the Centre for Addiction and Mental Health in Toronto, and colleagues. “There is also a substantial body of evidence supporting that a depression occurring in early or mid-life, even if it has been in remission for years or even decades, can double or triple the risk of dementia in late life. Thus, interventions that could reduce this risk are needed.”

Rajji and colleagues recruited 375 participants from five academic hospitals in Toronto, who had remitted MDD, MCI, or both. Some were randomized to receive CR plus tDCS targeting the prefrontal cortex for eight weeks, five days a week, followed by twice-a-year five-day booster sessions of tDCS plus CR; participants were also asked to do at-home CR exercises daily. For the CR, a therapist trained participants on completing computerized exercises and provided them with ways to apply these skills to everyday difficulties. Other participants received sham tDCS and sham CR. Researchers conducted assessments at baseline, two months, and then yearly for three to seven years (median follow-up time was four years).

The primary outcome was the participants’ change in global composite cognitive score; secondary outcomes included change in short-term cognition and delayed progression to MCI or dementia.

The study showed that CR and tDCS did slow cognitive decline—particularly executive function and verbal memory—in participants over five years, though the effect was stronger in adults with remitted MDD (with or without MCI) than those with just MCI. The researchers found CR plus tDCS did not have any short-term effects on cognition relative to sham treatment, nor did it delay the progression from MCI to dementia.

“Our study was not designed to determine whether the observed benefits are due to CR plus tDCS or one of them alone,” Rajji and colleagues wrote. “Still, given the small and nonsignificant effects of CR on global cognition in [other] long-term studies, including in patients with mood disorders, our findings suggest that adding tDCS to CR augmented its procognitive effects.”

For more information see the Psychiatric News article, “New Medication, Staging Criteria Signal a Potential Shift in Alzheimer’s Care.”

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Poll Finds Many Americans Experience Changes in Mood as Winter Approaches

As autumn renders the daylight hours shorter and winter creeps closer, a significant percentage of Americans will experience changes in mood, according to the latest APA Healthy Minds poll.

Two-fifths of Americans (41%) said their mood declines during the winter months. This is especially true in the Midwest and Northeast, where 52% and 46% of respondents, respectively, said they experience a decline in mood.

The poll was conducted on behalf of APA by Morning Consult from October 18-20, 2024, among a sample of 2,201 adults.

While the “winter blues” are usually mild, a small percentage of people may experience a form of depression, known as seasonal affective disorder (SAD). The symptoms—including sadness, loss of interest in pleasurable activities, and changes in appetite and sleep—usually occur during the fall and winter months when there is less sunlight and then improve with the arrival of spring. While it is much less common, some people may experience SAD in the summer.

SAD can be effectively treated in several ways, including light therapy, antidepressant medications, and/or psychotherapy.

“The winter months have less light, the time change can feel abrupt, and the holidays for some are overwhelming,” said APA President Ramaswamy Viswanathan, M.D., Dr.Med.Sc. “It’s helpful to keep tabs on your mood…. If you’re feeling very poorly, consider talking to a mental health clinician, and also know that spring is only a few months away.”

When asked about what behaviors and feelings they noticed during winter, Americans reported sleeping more (41%), feeling fatigued (28%), feeling depressed (27%), and losing interest in things they like (20%). When asked which activities helped them cope with winter weather, Americans were most likely to select talking with friends and family (46%), sleeping more (35%), and going outside (35%).

Some other findings from the poll:

• More women (45%) than men (37%) said their mood declined in winter.
• The time change also had a greater impact on women—33% of women said it was bad for their mental health versus 26% of men.
• Urbanites were less likely to report a winter decline in mood (36%) compared with people in rural areas (46%).
• The time change was also more likely to affect the mental health of people in rural areas (31%) than their counterparts in cities (24%).

For related information, see the Psychiatric News article “This Winter Pandemic May Intensify Seasonal Depression.”

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APA Announces Candidates for 2025 Election

The APA Nominating Committee, chaired by Immediate Past President Petros Levounis, M.D., M.A., reports the following slate of candidates for APA’s 2025 election. This slate has been approved by the Board of Trustees and is considered official.

President-Elect
Rahn Bailey, M.D.
Mark Rapaport, M.D.
Harsh Trivedi, M.D., M.B.A.

Secretary
Gabrielle Shapiro, M.D.
Eric Williams, M.D.

Minority/Underrepresented Representative Trustee
Mansoor Malik, M.D.
Kamalika Roy, M.D., M.C.R.

Area 3 Trustee
Kenneth Certa, M.D.
Mandar Jadhav, M.D.

Area 6 Trustee
Lawrence Malak, M.D.
Adam Nelson, M.D.

Resident-Fellow Member Trustee-Elect
Craig Perry, M.D.
Tariq Salem, M.D.

The deadline for petition candidates is November 13, 2024. APA voting members may cast their ballots from January 2, 2025, to January 31, 2025.

For more details on the candidates and election process, please visit the “Election” section of APA’s website. Also look for more information on APA’s 2025 election in the December issue of Psychiatric News.

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