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.

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

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

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

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

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

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

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

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

(Image: Getty Images/iStock/MarLei)

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

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

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

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

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

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

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

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

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

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BIPOC Individuals Much More Likely to Have Cultural Conversations With Therapists

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

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

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

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

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

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

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

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Misophonia May Be Linked to Emotion Dysregulation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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FDA Sends Back PharmaTher’s Ketamine Application

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Havlik and colleagues also found:

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

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

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

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Many Patients With Schizophrenia Benefit From Guided Antipsychotic Tapering Program

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

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

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

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

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

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

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

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

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