Longer ECT Seizure Duration May Improve Odds of Depression Remission

Among patients receiving electroconvulsive therapy (ECT) for major depression, those who experienced longer therapeutic seizures had higher odds of depression remission, according to a study in JAMA Network Open.

Compared with patients whose seizure duration during their first ECT treatment was less than 20 seconds, those who had seizures lasting 30 seconds or more were more than twice as likely to remit by the end of treatment; seizure durations of around a minute seemed to offer the highest odds of remission.

Cecilia Gillving, M.B., of Örebro University in Örebro, Sweden, and colleagues used data from a Swedish ECT registry to examine outcomes of all patients who received unilateral ECT (placing both electrodes on the same side of the head) for major depressive disorder between 2012 and 2019. At each ECT session, the duration of the therapeutic seizure was monitored with electroencephalography (EEG), although the study involved only the patients’ first session.

The study sample included 6,998 individuals (60.4% female) with an average age of 55. Of this group, 39.3% achieved remission of their depression symptoms, usually after six to nine sessions. Patients whose first seizure was less than 20 seconds had the lowest remission rate at 27.2%. The odds of remission then increased for every 10 extra seconds of seizure duration, peaking at 60 to 69 seconds, which was associated with 2.52 times the odds of remission. (Seizure durations of 70 seconds or more were associated with 2.45 times the odds of remission compared with seizures of less than 20 seconds.)

Gillving and colleagues also found that patients who were taking anticonvulsants such as lamotrigine or benzodiazepines had shorter seizure durations on average compared with patients not on these medications, and also had a correspondingly reduced rate of remission.

In an accompanying editorial, James Luccarelli, M.D., D.Phil., of Harvard Medical School, cautioned about extrapolating the findings too broadly. “[E]ven among those with initial seizures of less than 20 seconds the remission rate from depression was 27.2%, which is much greater than that obtained by pharmacotherapy in patients with treatment resistance,” Luccarelli wrote. “As a result, a short seizure at the time of first treatment should not be a reason to discontinue ECT in patients for whom treatment is indicated.”

For related information, see the Psychiatric News article “ECT for Depression May Cut Suicide Risk by Nearly 50%.”

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Bipolar Disorder, Substance Use Disorder Raise Odds of Reincarceration of Youths as Adults

More than half of people incarcerated before the age of 18 go on to be reincarcerated as adults, with bipolar disorder and substance use disorders significantly increasing the odds of recidivism, according to a study issued in the Journal of the American Academy of Psychiatry and the Law.

“Press coverage of the incarceration of children and adolescents comes in the context of long-standing concerns over the personal and societal cost of the threefold increase in U.S. incarceration rates since the 1980s,” wrote Alec Buchanan, M.D., Ph.D., at Yale School of Medicine in New Haven, Conn., and colleagues. “…[T]he further detention of many of these children and adolescents when they become adults raises questions concerning the effectiveness of deterrence and the unwanted effects of incarceration. From a psychiatric perspective, it raises the question also of the extent to which mental ill-health contributes to the risk of subsequent incarceration.”

Buchanan and colleagues analyzed the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-III), a nationally representative, in-person survey of noninstitutionalized adults conducted in 2012 and 2013. Researchers included responses from the 36,293 participants for whom data on childhood incarceration was available and examined their parental history, upbringing, demographics, social factors, and mental illness and substance use to pinpoint ties to recidivism as adults.

Researchers found that 1,543 adults in the NESARC-III sample (4.3%) were in a jail, prison, or juvenile detention center before age 18; when extrapolated to the entire population, this amounts to 10 million current U.S. adults who were incarcerated as children. Almost half had a psychiatric disorder (excluding personality disorders) and nearly two-thirds had substance use disorder during their lifetime.

Among those incarcerated as children, 863 (56%) were subsequently incarcerated as adults. The risk of adult reincarceration increased with length of time spent incarcerated as a child (48% for less than one week versus 63% for longer periods).

In addition to antisocial personality disorder—a risk factor identified in previous criminological research—bipolar disorder and substance use disorder were also independently associated with adult reincarceration. Other reincarceration risk factors that had been previously identified included not graduating college, parental drug use and imprisonment, and childhood and lifetime homelessness.

“The point of release is already known to be a time of vulnerability, particularly with regard to opiate overdose, and these results suggest that coordinating community substance use services when people reenter the community from prison may also have the longer-term benefit of preventing further incarceration,” Buchanan and colleagues wrote.

For related information, see the Psychiatric News article “Incarcerated Individuals With Mental Illness Need More of Psychiatry’s Attention.”

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Medical Debt Linked to Delayed, Foregone Care Among Those With Depression, Anxiety

Individuals with depression and/or anxiety are more than twice as likely to carry medical debt that makes paying bills difficult compared with individuals without those diagnoses, according to a report in JAMA Psychiatry. In addition, those with depression or anxiety who carry medical debt are more likely to delay or forego treatment than diagnosed individuals without medical debt.

Kyle J. Moon, B.S., of Johns Hopkins Bloomberg School of Public Health, and colleagues noted that financial barriers are the most prominent barrier to mental health care among low-income adults in the United States. “When bills are unpaid, the outstanding amount is sent to debt collections, with personal debt limiting access to credit and hindering subsequent use of health care services,” they wrote.

The researchers examined data from 27,651 adults who responded to the 2022 National Health Interview Survey. They looked at associations between medical debt and delayed or foregone care among four subgroups—those with lifetime depression, current depression, lifetime anxiety, current anxiety—and individuals without a history of those diagnoses.

A total of 5,186 adults (18.2%) reported lifetime depression, 1,948 (7.3%) reported current depression, 4,834 (17.7%) reported lifetime anxiety, and 1,689 (6.6%) reported current anxiety.

Medical debt was significantly more common among individuals with a lifetime or current diagnosis of depression or anxiety. Differences were more pronounced for those with a current diagnosis: 27.3% of adults with current depression had medical debt, compared with 9.4% of adults without, while 26.2% of adults with current anxiety had medical debt, compared with 9.6% of adults without.

Among adults with current depression or anxiety, 36.9% and 38.4%, respectively, of those with medical debt delayed getting counseling or therapy from a mental health professional within the past year due to the cost, compared with 17.4% and 16.9%, respectively, of those without medical debt. Likewise, adults with current depression or anxiety and medical debt were more than twice as likely as those without debt to forego needed therapy due to cost.

“Medical debt appears to contribute to the mental health treatment gap, suggesting that aggressive debt collection practices have negative consequences for population mental health,” Moon and colleagues wrote. “Further studies are needed to evaluate policies to inform protections against medical debt at the federal level.”

For related information, see the Psychiatric Services article “Debt Inequity Among Clients of a Community Mental Health Center.”

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Prenatal Cannabis Use Associated With Risk of Adverse Maternal Outcomes

Prenatal cannabis use may increase the risk of pregnancy-related problems such as placental abruption and preeclampsia, according to a study published in JAMA Internal Medicine.

“Whereas many studies have examined how maternal prenatal cannabis use is associated with fetal and neonatal outcomes, less is known about the associations with maternal health during pregnancy” wrote Kelly C. Young-Wolff, Ph.D., M.P.H., at Kaiser Permanente Northern California in Oakland, Calif., and colleagues. “As we continue to learn about the potential harms and benefits of prenatal cannabis use, clinicians must provide coordinated, nonstigmatizing care and education to support pregnant individuals in making informed decisions about cannabis use.”

Young-Wolff and colleagues studied health records for 316,722 pregnancies (from 250,221 individuals) that began during 2011 to 2019; all pregnant individuals were members of Kaiser Permanente Northern California, responded to a self-reported cannabis-use question, and took a THC urine toxicology test. Researchers mined health records for data on various maternal health outcomes and examined potential links to use of cannabis.

Researchers adjusted the results to account for maternal demographics, as well as when prenatal care was initiated, prepregnancy body mass index, other substance use, and psychiatric and other medical comorbidities.

Overall, in 6.3% of pregnancies, the mothers screened positive for prenatal cannabis use, by either self-report and/or positive toxicology testing. Compared with pregnant individuals who did not use cannabis, those who did had significantly greater risk of placental abruption (19% more likely), gestational hypertension (17%), preeclampsia (8%), and gestational weight gain less than or greater than guidelines (5% and 9%, respectively).

However, maternal use of cannabis was associated with an 11% lower risk of gestational diabetes.

“Young-Wolff et al highlight the importance of examining potential maternal outcomes associated with cannabis use in pregnancy,” Jamie O. Lo, M.D., at Oregon Health & Science University, in Portland, and Catherine Y. Spong, M.D., at the University of Texas in Southwestern Medical Center in Dallas, wrote in an invited commentary. They highlighted, however, that the study period was from 2011 to 2019 but did not compare maternal outcomes before and after California legalized recreational cannabis in November 2016.

“Cannabis legalization has been associated with easier access and greater acceptance, including reduced stigma,” Lo and Spong wrote. “Thus, it is important to understand how legalization of cannabis in California was associated with the findings of this study, including disclosure of use, patterns of use, and maternal outcomes during pregnancy.”

For related information, see “Cannabis Use During Pregnancy on the Rise” in Psychiatric News.

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Childhood ICU Stays Linked to Higher Risk of Mental Illness Years Later

Children and adolescents who have been admitted to an intensive care unit (ICU) may have a higher risk of mental illness years later compared with those who have never been to an ICU, a study in the Journal of Affective Disorders has found. Further, the risks for specific mental illnesses varied depending on the condition underlying the ICU admission.

Ping-Chung Wu, M.D., of the Taipei Veterans General Hospital in Taiwan, and colleagues examined data from Taiwan’s National Health Insurance program for 8,704 individuals who were admitted to an ICU as children or adolescents (mean age 10.33) between 1996 and 2013 and survived their ICU stay. The researchers matched these ICU survivors to 87,040 individuals without ICU stays (controls) according to age, sex, family income, and residence. Follow-up ranged from one month to roughly 17 years, with a mean follow-up of about 9.6 years.

Compared with the control group, patients who had been admitted to the ICU had an increased risk of the following mental illnesses during follow-up:

• 4.67 times the risk of posttraumatic stress disorder (PTSD)
• 3.19 times the risk of schizophrenia
• 2.02 times the risk of bipolar disorder
• 1.96 times the risk of obsessive-compulsive disorder (OCD)
• 1.68 times the risk of major depressive disorder

Patients who had an ICU stay of three days or more had a higher risk of these conditions compared with those whose ICU stay was less than three days, except for bipolar disorder.

Risk among patients admitted to an ICU varied according to the conditions that prompted the ICU stay. For example, the risk of schizophrenia was highest among patients admitted for diseases of the blood and blood-forming organs, the nervous system, and the digestive system. Risk for PTSD was highest in patients admitted for respiratory diseases, while risk of OCD was highest in patients with genitourinary diseases.

“The subanalysis results stratified by type of critical illness can help clinicians to establish optimal MPD [major psychiatric disorder] screening and prevention strategies for high-risk groups; they can also serve as clinical evidence for future research on the etiologies of MPDs,” Wu and colleagues wrote. “Given our study results, the development of appropriate MPD prevention strategies should be emphasized for child and adolescent ICU survivors.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Posttraumatic Stress Symptoms Among COVID-19 Survivors After Hospitalization.”

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Message-Based Psychotherapy Found No Less Effective Than Video-Based Sessions

Delivering psychotherapy for depression via text or voice messages is no less effective than using videoconferencing—and keeps patients more engaged with therapy, according to a report published today in Psychiatric Services in Advance.

Patricia Areán, Ph.D., of the University of Washington, and colleagues recruited 215 adults with depression to receive up to 12 weeks of care from digital mental health care company Talkspace. (This study was funded by the National Institute of Mental Health and not Talkspace.) Half of the adults were assigned to receive psychotherapy via asynchronous text or voice messages, in which the patient could interact with the therapist whenever and how often they wanted. The other half of patients met with a therapist weekly for 30 to 45 minutes over a secure videoconferencing service. 

After six weeks, any patients who did not show significant improvement in their depression—defined as at least a 50% reduction in their Patient Health Questionnaire–9 (PHQ-9) score from baseline—were randomly reassigned to receive six weeks of either weekly videoconferencing sessions plus message-based therapy, or monthly videoconferencing plus message-based therapy.

After six-weeks, 28 patients receiving message-based therapy and 27 receiving videoconferencing therapy showed significant symptom improvements. After factoring in the patients who discontinued or did not return their PHQ-9 assessments, the researchers calculated no statistical difference between the efficacy of these two therapy services; that also held true for participating patients after 12 weeks. The researchers also found that patients in each group showed similar improvements in anxiety symptoms and overall functioning at both six weeks and 12 weeks. 

The adults who received the message-based service remained engaged with treatment longer, communicating with their therapists for an average of 7.8 weeks, compared with 4.9 weeks for adults in the videoconferencing group. 

“The findings are particularly important given the challenges that many people have in accessing traditional psychotherapy,” Areán and colleagues wrote. “The data suggest that psychotherapy delivered via text messages may be a viable alternative to face-to-face or videoconferencing delivery and may allow for more immediate on-demand care.”

For related information, see the Psychiatric News article “Telemental Health Use Remains Robust, but What Does Future Hold?”

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Physician Reluctance to Intervene in SUD Tied to Lack of Institutional Support

The most common reason that physicians are reluctant to intervene when their patients have a substance use disorder (SUD) is a lack of institutional support, according to a study in JAMA Network Open. Other common reasons include a lack of skill and knowledge.

“These data suggest that policy, regulatory, or accreditation changes are needed to systematically address institutional barriers, as well as increases to physician reimbursement and opportunities for clinically relevant training that provides both skill development and knowledge gain,” wrote Melinda Campopiano von Klimo, M.D., of JBS International Inc., and colleagues.

The researchers reviewed 283 studies published between January 1, 1960, and October 5, 2021, assessing or surveying physician reluctance to intervene for SUDs. Intervening was defined as one or more of the following: screening patients, treating patients, offering harm reduction services, or offering recovery support.

Overall, 66,732 physicians participated in the studies. The top four specialties were general practice/primary care, internal medicine, family medicine, and general psychiatry, and the top four countries represented were the United States, United Kingdom, Canada, and Australia.

A lack of institutional support was cited as a reason for physician reluctance 81.2% of the time (173 of 213 studies). Common examples noted under the umbrella of institutional support include the following:

• A lack of trained staff or resources to train staff
• A lack of acceptance of SUD interventions leadership
• A lack of clinician backup
• Regulatory and liability concerns
• Recordkeeping or confidentiality concerns
• Staff time required for prior authorizations
• Cost to the patient or lack of insurance coverage
• Medication unavailability at pharmacies
• An absence of population-specific patient education materials

“Strategies to reduce physician reluctance related to institutional environment include greater commitment by health systems to make essential workflow and staffing changes, the breaking down of barriers between addiction services and both medical and mental health care, and commitment by insurers to provide reimbursement that covers the actual cost of providing addiction interventions,” the researchers wrote.

A lack of skill was cited 73.9% of the time (170 out of 230 studies), a lack of cognitive capacity (i.e., feeling overwhelmed with clinical tasks and the need to prioritize competing patients’ needs) was cited in 73.5% (136 out of 185 studies), and a lack of knowledge was cited in 71.9% (174 out of 242 studies).

“Trainings accessible to physicians (e.g., free or incentivized, hands-on, or delivered in clinical settings) and delivered by specialized trainers and/or mentors would facilitate the growth of a pool of experts to intervene in substance use,” the researchers wrote. “Physicians who expand their knowledge and skills should be eligible for continuing medical education credits and increased compensation.”

For related information, see the Psychiatric News article “Briefing Emphasizes Actions Needed to Address Substance Use Disorder Crisis.”

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Frequent Moving in Childhood Linked to Later Depression

Children of families that move frequently before age 15 may be at increased risk for later depression, according to a report in JAMA Psychiatry.

The study also found that individuals who lived in neighborhoods during childhood that were more income deprived were more likely to develop depression in adulthood, but the experience of moving during childhood—regardless of income—was associated with significantly higher rates of depression compared with those who did not move.

“Rather than solely low neighborhood income deprivation in childhood being associated with onset of depression during adulthood, a settled home environment in childhood may have a protective association,” wrote Clive E. Sabel, Ph.D., of Aarhus University, Denmark, and colleagues.

The researchers used data from the Danish Civil Registration system to examine the association between neighborhood income and relocation frequency during childhood and later depression for 1,096,916 people born in Denmark from January 1, 1982, to December 31, 2003. The system uses a unique personal identification number for each resident, providing data on sex, birthdate, and continuously updated information on vital status and residential address.

Individuals were followed from age 15 until either death, emigration, depression diagnosis, or December 31, 2018. The researchers used a statistical measure of neighborhood income deprivation for each year at a place of residence to calculate a cumulative income deprivation score for everyone over their first 15 years. Individuals who lived in the same neighborhood during their entire childhood were defined as “stayers,” while those who did not were defined as “movers.”

A total of 35,098 individuals received a diagnosis of depression during follow-up. After adjusting for possible confounding factors, the researchers found that each successive increase in the income deprivation index increased one’s risk of depression by 2%. However, those who moved once or more than once as children between the ages of 10 and 15 years—regardless of income—had 1.40 times and 1.61 times greater risk of depression, respectively, than those who did not move.

The researchers suggested that frequent relocation may be an indicator of family instability. “Children of a family that is unstable, perhaps with relationship breakups or loss of employment, are more likely to need to move,” they wrote. “The move itself could sever social ties and contribute to the breakdown of informal and formal social support services, including schooling.”

For related information see the Psychiatric News article “Study Delves Deeper Into Mental Health Effects of Childhood Trauma.”

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New Metric May Better Detect Cardiac Risk in Patients Taking Atypical Antipsychotics

A cardiac measurement known as the index of cardiac electrophysiological balance (iCEB) is more sensitive at predicting cardiac risk in patients taking atypical antipsychotics over the long term than the traditionally used QT interval, according to a study of hospitalized patients issued today by BMC Psychiatry.

The QT interval reflects the time from when the heart’s ventricle starts contracting (depolarization) to when it finishes relaxing (repolarization); it has been considered a reliable marker to identify abnormal heart rhythms that may lead to problems like arrhythmia. “However, if we only evaluate QT intervals, we may abandon some effective treatments and may also overlook some important information,” wrote Qiong Liu, B.A., of the Chaohu Hospital of Anhui Medical University in Hefei, China, and colleagues.

The researchers noted that QT readings can be biased when the ventricular heart rate is elevated, and the QT interval doesn’t always reflect local changes in ventricular muscle. Rather than assessing the total time of a depolarization-repolarization cycle, the iCEB measures the balance between depolarization and repolarization.

Liu and colleagues studied 80 adults with schizophrenia who began taking atypical antipsychotics after hospital admission and were continuously hospitalized for at least four years at Chaohu Hospital between 2017 and 2023. Alcohol, smoking, and caffeine were prohibited on the ward, and participants underwent electrocardiogram (ECG) readings every 2 to 4 weeks. For this study, the authors analyzed ECG data at five time points for each patient: admission, year 1, year 2, year 3, and year 4. They calculated QT interval and iCEB values, both unadjusted and corrected for heart rate (QTc and iCEBc, respectively).

With long-term use of atypical antipsychotics, participants’ ventricular repolarization index gradually increased with time, but no severe arrhythmia was found. In fact, more than 90% of patients did not develop any arrhythmias, researchers reported. Among those who did, the iCEBc changed before the QTc interval, and always had a larger change compared with the patient’s corresponding QTc changes.

These findings suggest “that the iCEBc is more sensitive than the QTc and has greater clinical value in predicting the risk of arrhythmias caused by antipsychotics,” the authors wrote. While the patients in this stable environment had a low overall rate of adverse events, the authors added that “the iCEB grew significantly longer during the 4-year observation period of this study, so we need to be vigilant.”

For more information, see the Psychiatric News article “Document Outlines Key Clinical Considerations About QTc Prolongation and Psychotropics.”

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Altered Eating Patterns in Shift Work Associated With Rates of Depression, Anxiety

Shift workers who have irregular eating patterns may have an increased risk of depression and anxiety, a study in JAMA Network Open has found.

Erliang Zhang, B.S., of Shanghai Jiao Tong University and colleagues examined data from 22,617 airline crew members aged 18-60 from the Civil Aviation Health Cohort of China, an ongoing health survey of pilots, flight attendants, and air security officers employed by major airlines in China. The researchers collected data on when the participants ate breakfast and dinner on workdays and rest days and how much time passed between their meals. Workdays in which participants had a flight takeoff before 9 a.m. were categorized as morning-shift days, while workdays in which a flight landed after 10 p.m. were categorized as night-shift days.

Overall, 7.8% of participants had symptoms of anxiety as measured by the seven-item Generalized Anxiety Disorder Assessment (GAD-7), and 12.2% had depressive symptoms as measured by the nine-item Patient Health Questionnaire (PHQ-9).

After adjusting for demographics, the researchers found the following:

• Having dinner after 8 p.m. on morning-shift days was associated with increased odds of anxiety (adjusted odds ratio [AOR], 1.78) and depressive symptoms (AOR, 2.01), compared with consuming dinner before 8 p.m. Results were similar on night-shift days and rest days.
• Delayed dinner on morning-shift days (having the meal later than on typical rest days) was associated with increased odds of anxiety (AOR, 1.32) and depressive symptoms (AOR, 1.39). Delayed dinner was also associated with higher odds of anxiety (AOR, 1.22) and depressive symptoms (AOR, 1.21) on night-shift days.
• An eating window of less than 12 hours between breakfast and dinner was associated with reduced odds of anxiety (AOR, 0.84) and depressive symptoms (AOR, 0.81) on morning-shift days compared with an eating window of greater than 12 hours.

“These findings underscore the need for interventions and supportive policies that help mitigate the adverse implications of shiftwork and irregular working hours for mental health,” the researchers wrote. “Such interventions may promote the overall well-being of airline employees and benefit the broader society given that a healthy airline industry workforce is essential to the safety of billions of air travelers worldwide.”

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Short-Term Digital Break Improves Child Behavior, Study Finds

Youth who participated in a two-week family intervention to reduce time spent on smartphones and other screen media showed improved behaviors relative to youth that did not participate, reports a study published today in JAMA Network Open.

While acknowledging that “more research is needed to confirm whether these effects are sustainable in the long term,” the study authors noted that this clinical trial data provides a causal link between a reduction in screen time and improvements in psychological symptoms.

Jesper Schmidt-Persson, Ph.D., of the University of Southern Denmark in Odense, and colleagues examined data from 89 families (181 total children) with moderate to high screen-time use who participated in a family-based intervention study. Forty-five of the families were asked to hand over all smartphones and tablets for two weeks and reduce their leisure use of other screen devices such as televisions to three hours per week or less. These families were given non-smartphones to stay in touch and were allowed 30 minutes of screen time per day for necessary activities like making appointments. The remaining families were asked to maintain and log their normal screen usage.

All parents reported on their children’s behaviors such as conduct, hyperactivity, and sociality using the 25-item Strengths and Difficulties Questionnaire (SDQ)—one week before the trial started and then immediately after (21 days apart).

At the follow-up assessment, the families that were part of the screen-reduction intervention reported significantly greater reductions in their SDQ total difficulties score compared with the non-intervention families (1.67 points lower); the greatest improvements were seen for emotional symptoms and peer-relationship problems. Children who participated in the intervention also showed more prosocial behaviors at the end of the study.

“What is so novel about this intervention is that it does not recommend a lasting reduction of screen time to some arbitrary guideline level, but it examines a radical short-term break,” Henning Tiemeier, M.D., Ph.D., of the Harvard T.H. Chan School of Public Health, wrote in an accompanying commentary. Tiemeier added that the field of developmental health needs more such clinical trials to examine whether short-term “digital detoxification” strategies can be supported by evidence.

For related information, see the Psychiatric News article “Remember Books? Researcher Shows How Reading Is Superior to Screen Time.”

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Combination Physical, Cognitive Rehab May Be Most Helpful for Cognitive Impairment

Interventions that include physical and cognitive training in a single protocol are the most effective nonpharmacological therapy for older people with cognitive impairment, a meta-analysis in the American Journal of Geriatric Psychiatry has found.

Luis Carlos Venegas-Sanabria, Ph.D., of the Universidad de Castilla-La Mancha in Spain and colleagues analyzed data from 121 studies with a combined 9,361 participants. Overall, 53.7% of the studies included only participants with mild cognitive impairment (MCI), 39.7% included only patients with dementia, and 6.6% included a mixed population. The mean age of study participants was 74.6 years.

The nonpharmacological interventions assessed were aerobic exercise, strength exercise, multicomponent physical exercise, other physical exercises, tai chi, other mind-body exercises, traditional cognitive rehabilitation, computer-based cognitive rehabilitation, occupational therapy, music therapy, physical-cognitive rehabilitation, and reminiscence therapy. The most frequent intervention was conventional cognitive training, followed by aerobic exercise, multicomponent physical exercise, computerized cognitive training, and physical-cognitive exercise.

Among individuals with any cognitive impairment (dementia or MCI), physical-cognitive exercise was the most effective nonpharmacological intervention for improving, followed by computerized cognitive training in a distant second. Regular cognitive intervention and multicomponent physical exercise also showed positive, albeit minor, effects. Physical-cognitive exercise was also the most effective intervention for individuals diagnosed with dementia, followed again by computerized cognitive training.

For people with MCI, however, occupational therapy was the most effective intervention, followed by multicomponent physical exercise and physical-cognitive exercise. In this case, the difference between the interventions was less profound. The researchers noted that the occupational therapy performed in the studies they assessed was a dual-task intervention that targeted both motor skills and cognitive functioning.

Venegas-Sanabria and colleagues noted that physical exercise has been reported to change the hippocampal volume in healthy human brains, improve learning ability, and modulate inflammation associated with cognitive decline. They added that cognitive training has been shown to affect neuroplasticity and neural networks in aging and neurodegenerative disease.

“The combination of these interventions seems to enhance their effects, and cognitive training could increase the number of surviving new neurons generated in response to physical exercise,” the researchers wrote. “Additionally, the combination of physical and cognitive training could cooperate to induce neuroplasticity and increase neurogenesis and synaptogenesis.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article, “Mid- and Late-Life Physical Activity and Neuropsychiatric Symptoms in Dementia-Free Older Adults: Mayo Clinic Study of Aging.”

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Intrauterine Hormonal Contraceptives May Raise Depression Risk, Study Finds

Women who use hormonal intrauterine contraceptives may be at increased risk for depression, according to a report in AJP. Although the absolute risk is low, the risk increases with higher hormone doses.

Levonorgestrel-releasing intrauterine systems (LNG-IUS) release the female hormone levonorgestrel in the uterus where it works to prevent pregnancy. Søren Vinther Larsen, Ph.D., of Copenhagen University Hospital and colleagues note that the systems are available in over 120 countries worldwide, and they are used by about 14% of women of reproductive age in Denmark, where the study was conducted.

The study “highlights the importance of educating women to be aware of potential mental health side effects and of clinical evaluation of mood symptoms at follow-up visits after LNG-IUS insertion,” they wrote.

Larsen and colleagues analyzed data from the Danish national birth registry on 149,200 women, ages 15-44, who were first time users of LNG-IUS between 2000 and 2022. They looked at the relative risk of depression associated with three different initial hormone-release dosages:

• low-dose 14 μg/day (22,029 users)
• medium-dose 17.5 μg/day (47,712 users)
• high-dose 21 μg/day (79,459 users)

Depression was determined by prescription of an antidepressant medication or diagnosis of depression at an inpatient or outpatient psychiatric department within one year of initiating the hormone-releasing system.

Within 12 months after initiating low-dose LNG-IUS use, 279 women had an incident of depression, compared with 633 among medium-dose users and 1,346 among high-dose users. The risk of developing depression for high dose users was 1.52 greater than the risk for low-dose users and 1.26 greater than the risk for medium dose users.

The authors emphasize that the findings do not indicate a causal link between hormonal contraception and depression. Moreover, they note that the absolute risk of depression for all three doses was low (between 1.2% and 1.8%) and that increasing dosages were associated with only a small proportion of women developing depression to a degree that resulted in medical attention.

The results “should be weighed against potential benefits as well as other side effects of LNG-IUS use when providing personalized contraceptive counseling,” the authors wrote.

For related information, see the Psychiatric News article, “Depression After Hormonal Contraception Linked to PPD.”

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Long-Acting Buprenorphine May Help Patients Initiate Treatment Without Withdrawal

Most patients with opioid use disorder (OUD) and mild withdrawal symptoms can initiate buprenorphine using a 7-day injection without precipitating withdrawal symptoms, according to a study issued in JAMA Network Open.

“To date, there is little evidence for rapid strategies to initiate buprenorphine without the prerequisite withdrawal,” wrote lead author Gail D’Onofrio, M.D., at Yale School of Medicine and colleagues. “Thus, patients are often instructed to initiate buprenorphine on their own after a brief education or are discharged without medication treatment, leaving them at risk for overdose.”

D’Onofrio and colleagues recruited 100 patients at emergency departments (ED) who had screened positive for moderate to severe OUD; all were experiencing minimal to mild withdrawal as measured on the Clinical Opioid Withdrawal Scale (COWS), with 38 scoring 0-3 and 62 scoring 4-7. All received a 7-day injectable 24 mg formulation of extended-release buprenorphine, CAM2038, which is equivalent to 16 mg of buprenorphine daily.

Participants were monitored in the ED for four hours and referred to community-based programs or clinicians for ongoing OUD treatment upon discharge. Over the following week, they provided daily phone and text assessments on their opioid use, cravings, injection pain or other side effects, and engagement with treatment.

Each day, between 33% and 43% of patients reported no cravings, and between 78% and 85% reported no use of opioids. Overall, 60% of participants did not use opioids in the week after buprenorphine administration, and there were also no reported incidences of overdoses. In addition, 73% of patients engaged in OUD treatment within seven days of the injection. Participants rated the improved privacy and not requiring daily medication as extremely important advantages of the long-acting formulation.

Within four hours of receiving the injection, just 10 of the 100 patients experienced a 5-point or greater increase in COWS scores and of those, seven participants transitioned to moderate or greater withdrawal (COWS score of 13 or higher). Participants who had baseline COWS scores of 0 to 3 were more likely to experience significantly increasing withdrawal, so researchers said further study is needed to assess the criteria for using rapid buprenorphine initiation in this subgroup.

“The opportunity to initiate buprenorphine in patients without having to first experience prolonged withdrawal has many clear benefits and could substantially increase the number of patients with OUD able to initiate buprenorphine upon ED presentation,” researchers wrote. “This finding may have a significant public health impact in light of the continued increase in opioid deaths in 2023 driven primarily from fentanyl and the heightened risk of overdose death without medication treatment.”

For more information, see the Psychiatric News article, “OUD Overdose, Suicide Risk in Veterans Four Times Higher Without Buprenorphine.”

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Adults Who Play Sports Say It Helps Their Mental Health

The forthcoming 2024 Olympics in Paris will likely inspire more than a few armchair sports enthusiasts and their kids to participate in sports themselves—which may lift their emotional well-being. According to APA’s latest Healthy Minds poll, an overwhelming majority of Americans who participate in sports either competitively or recreationally say that it benefits their mental health.

The poll, conducted online June 18 and 19 by Morning Consult on behalf of APA, asked 2,203 adults for their thoughts on sports and mental health and found the following:

• 67% of men and 48% of women (57% overall) said they participated in sports, with swimming, basketball, and running the most popular activities.
• 67% of Black adults, 70% of Hispanic adults, and 50% of non-Hispanic White adults said they participated in sports.
• 84% of those who participate in sports said it benefits their mental health.

In addition, 73% of respondents said that team sports are very or somewhat beneficial for children and teenagers’ mental health. These participants said that team sports offer important benefits besides staying active, such as increased confidence camaraderie, and a sense of structure.

“You don’t have to be an Olympic athlete to reap the mental health benefits of exercise and sports,” said APA President Ramaswamy Viswanathan, M.D., Dr.Med.Sc., in a news release. “Getting together with a group of friends, working out, having a hobby, all these aspects of sports can be good for positive mental health.”

Studies have shown that exercise may help reduce symptoms of depression and maintain well-being both as a primary treatment and in conjunction with medication or therapy. There is also evidence that exercise benefits people with posttraumatic stress disorder, anxiety, and attention-deficit/hyperactivity disorder.

Among all respondents, 85% agreed that mental health should be prioritized as much as physical health in professional athletes.

“In recent years we’ve heard Olympic and professional athletes share stories about their own mental health challenges,” said APA CEO and Medical Director Marketa M. Wills, M.D., M.B.A. “Their courage and openness helps others understand that it’s okay to take a break or ask for help when needed.”

For related information, see the Psychiatric News article “Exercise May Offset Genetic Risk of Depression.”

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FDA Approves Donanemab Infusions for Treatment of Early Alzheimer’s Disease

The Food and Drug Administration (FDA) approved this week the third amyloid-targeting drug treatment for Alzheimer’s Disease: donanemab-azbt, an intravenous antibody infusion being marketed by Eli Lilly as Kisunla.

FDA’s decision is in line with the agency’s independent advisory committee, who voted unanimously last month that the clinical trial data demonstrated the treatment's efficacy.

In a pivotal clinical trial involving 1,736 participants, Alzheimer’s disease progressed 22% more slowly in those given donanemab compared with those given a placebo. Participants earlier in the disease course with low or medium levels of another brain protein called tau had a greater response: their disease progressed 35% more slowly compared to placebo.

Donanemab is intended for patients with mild cognitive impairment or the mild dementia stage of disease who have confirmed amyloid pathology, which is assessed via lumbar punctures or PET scans. Donanemab is a monoclonal antibody that reduces the accumulation of amyloid beta plaques in the brain, which are associated with the disease. Donanemab joins Eisai and Biogens’ lecanemab (Leqembi) on the market, which was approved in January 2023. The first-approved antibody treatment, aducanumab, was taken off the market due to concerns over efficacy and safety.

Donanemab is the first treatment with evidence supporting its discontinuation after patients’ brains are clear of amyloid plaques. Clinical trial data showed that 47% of participants taking donanemab had visually negative amyloid PET scans at 12 months, and 69% had negative scans at 18 months. Furthermore, its intravenous infusions are given every four weeks (as opposed to every two weeks with lecanemab).

“These medications have given us hope and they’ve given our families hope,” Elizabeth J. Santos, M.D., M.P.H., president-elect of the American Association for Geriatric Psychiatry told Psychiatric News Alert. Santos, who is also the clinical chief of the Division of Geriatric Mental Health and Memory Care at the University of Rochester, was not involved in the development of Kisunla.

Santos added, however, the FDA guidance leaves open the question about how to obtain the needed amyloid-confirming PET scans to determine when to discontinue donanemab. Amyloid-assessing PET scans are largely unavailable in non-research settings and scarcely ever covered by insurance.

As with lecanemab, the drug carries a boxed warning on the risk of amyloid-related imaging abnormalities (ARIA), which may in rare cases cause serious and life-threatening intracerebral hemorrhages or focal neurologic deficits that can mimic ischemic stroke.

The approval came just days after the Alzheimer’s Association Workgroup issued revised criteria for the diagnosis and staging of Alzheimer’s disease that calls for the use of biomarkers and a revised disease staging system.

“Defining diseases biologically, rather than based on syndromic presentation, has long been standard in many areas of medicine — including cancer, heart disease and diabetes — and is becoming a unifying concept common to all neurodegenerative diseases,” said lead author Clifford Jack, Jr., M.D., a professor of radiology at the Mayo Clinic in Rochester, Minn., in a news release. “An unchanging principle is that effective treatment will always rely on the ability to diagnose and stage the biology driving the disease process.”

For more information, see the Psychiatric News article “Donanemab May Slow Alzheimer’s Progression”

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

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

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

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

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

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

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

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

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

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Bupropion Linked to Lowest Weight Gain Among Common Antidepressants

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

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

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

The results at six months were as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Quetiapine, Clozapine, and Olanzapine Associated With Increased Pneumonia Risk

Individuals with schizophrenia who take high-dose olanzapine, quetiapine, or clozapine may face an increased risk of pneumonia, according to an analysis in JAMA Psychiatry. Broadly speaking, the findings of this population study also showed that the anticholinergic burden of an antipsychotic —not how strongly it blocks dopamine receptors—may drive pneumonia risk.

“[P]neumonia constitutes the fourth leading cause of death in [patients with] schizophrenia,” wrote Jurjen J. Luykx, M.D., Ph.D., of Amsterdam University Medical Center and colleagues. They pointed out that many schizophrenia practice guidelines provide no guidance on how to manage pneumonia or mitigate pneumonia risk. “Identification of antipsychotic drugs that are associated with pneumonia risk may better inform prevention programs [like vaccinations],” they wrote.

The researchers examined the incidence of pneumonia in 61,889 individuals aged 16 or older in Finland who received inpatient care due to schizophrenia or schizoaffective disorder between 1972 and 2014. The patients were followed for an average of 22 years, and their antipsychotic medications and doses during this time were carefully tracked.

Overall, Luykx and colleagues found a modest 15% increase in pneumonia risk among individuals taking one antipsychotic medication (monotherapy) compared with individuals taking no antipsychotics; interestingly, there was no increased pneumonia risk among individuals taking multiple antipsychotics. The pneumonia risk associated with antipsychotic monotherapy was mainly limited to individuals taking high doses of medication (at least 1.1 times the World Health Organization’s defined daily dose for a particular medication).

Specifically, high-dose quetiapine was associated with a 78% increased risk of pneumonia compared with no antipsychotic use, while high-dose olanzapine was associated with a 29% increased risk. Clozapine was associated with pneumonia risk at both high doses (44% increased risk) and standard doses (43% increased risk).

All three of these antipsychotics are anticholinergic, which means they can inhibit receptors that control involuntary functions like swallowing and saliva production (saliva has antimicrobial properties).

Luykx and colleagues said these findings highlight the value of promoting healthy eating habits in schizophrenia patients taking high-dose antipsychotics, especially older individuals. “Other prevention strategies targeting at-risk groups of patients with schizophrenia include pneumococcal pneumonia, influenza, or SARS-CoV-2 vaccination programs,” they said.

For related information, see the Psychiatric News article “Study Finds Higher-Dose Antipsychotic Polypharmacy Does Not Increase Hospitalization.”

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Surgeon General Lays Out Approach to Stem Growing Crisis of Gun Violence

The U.S. Surgeon General issued a landmark advisory Tuesday spelling out the crisis of firearm violence and calling for a commitment from the nation—from firearm owners to clinicians to community leaders—to tackle the growing and urgent threat using a public health approach.

The report calls for implementing community violence prevention programs and firearm risk reduction strategies; expanding research funding; and improving access to mental health care and support for those exposed to or at risk for firearm violence including trauma-informed care.

More than half of adults (54%) report that they or a family member have experienced a firearm-related incident, leading to ripples of harm across society, Vice Adm. Vivek Murthy, M.D., M.B.A., said in a video briefing. “The collective trauma and fear that Americans are experiencing is contributing to the mental health challenges that we are facing today. Nearly 6 in 10 U.S. adults say they worry about a loved one being a victim of firearm violence.

“Our children should not have to live in fear that they are going to get shot if they go to school. None of us should have to worry that going to the mall or a concert or a house of worship means putting our lives at risk, or that we'll get a call that a loved one in a moment of crisis has taken their own life with a firearm,” Murthy said.

The report noted that the rate of firearm deaths has reached a nearly three-decade high. More than 48,000 people died from firearm-related injuries in 2022, an increase of more than 16,000 lives since 2010. The majority of such deaths were from suicide (56%), and 40% were from homicide. Firearm injuries became the leading cause of death of U.S. children and adolescents starting in 2020, surpassing motor vehicle crashes, cancer, and drug overdose and poisoning.

The report also calls for building a strong foundation of gun violence prevention research, as well as launching community risk reduction strategies to support populations at increased risk of firearm violence involvement. Organizations can help address the issue with early intervention strategies like behavioral threat assessment and management teams (BTAM) in schools or having health systems educate patients on safe and secure firearm storage.

In addition, the report discusses the importance of “building distance in terms of time and space” between firearms and people who are at risk of harming themselves and others. To that end, it recommends various gun control measures and temporary firearm removal policies such as Extreme Risk Protection Orders and Domestic Violence Protection Orders, the latter of which have been implemented in some capacity in all 50 states.

“The members of the American Psychiatric Association have become all too familiar with suicides and homicides involving gun violence and the additional impacts on people’s mental and physical health,” said Marketa Wills, M.D., M.B.A., APA CEO and medical director in response to the report. “The Surgeon General’s Advisory on Firearm Violence elevates this crisis in our national attention and emphasizes the damage gun violence has caused to families across the United States. It affirms that people with mental illness are especially vulnerable and includes prevention strategies that could help save lives.”

For more information, see the Psychiatric News article “Psychiatrists Have Tools to Prevent Gun Violence.”

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