Monday, April 22, 2024

Overactive Bladder Linked to Depressive Symptoms

People who have been diagnosed with overactive bladder are nearly three times as likely to have depression than those without overactive bladder, a study in the Journal of Affective Disorders has found.

Xiansheng Zhang, M.D., Ph.D., of Anhui Medical University in Hefei, China, and colleagues examined responses from adults who participated in the National Health and Nutrition Examination Survey from 2005 to 2018 and who had complete data related to depression and urinary function. The researchers excluded adults who had conditions that could affect their urination, such as pregnancy, benign prostate issues, certain cancers, or stroke.

The final sample included 6,612 participants, among whom 1,005 had a diagnosis of overactive bladder. Overactive bladder was defined as a measurement of at least three on the Overactive Bladder Symptom Score, which includes questions about urinary incontinence and nocturia (waking up at night to urinate). Symptoms of depression were defined as a score of at least 10 on the nine-item Patient Health Questionnaire.

After adjusting for sociodemographic factors, behavioral factors (BMI, smoking status, alcohol use), and chronic diseases, the researchers found that participants with overactive bladder were 2.89 times more likely to have depressive symptoms than those without overactive bladder.

“[U]rinary incontinence symptoms…can affect social functioning and an individual's quality of life, such as decreased participation in social activities and loneliness, which can then lead to depression,” Zhang and colleagues wrote.

The researchers noted that the relationship between overactive bladder and depressive symptoms can go in both directions. First, the more severe overactive bladder symptoms were, the more likely participants were to have depression. Second, depressive symptoms may make overactive bladder symptoms worse.

“For psychiatrists, this underscores the importance of proactively assessing urinary system symptoms in patients with depression to improve treatment adherence and effectiveness, offering a more holistic approach to patient care,” they wrote.

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Friday, April 19, 2024

One in Four People With Schizophrenia or Bipolar Have Multiple Physical Health Problems

A study in Lancet Psychiatry reports that adults with schizophrenia or bipolar disorder are more than twice as likely as those without these disorders to have multiple physical health problems like heart disease or diabetes. Further, the presence of multiple physical problems was more common in adults with schizophrenia or bipolar disorder than the presence of multiple psychiatric disorders.

“While health services and treatment guidelines often operate on the assumption that individuals have a single principal diagnosis, these results attest to the clinical complexity many people with severe mental illness face in relation to burden of chronic disease,” wrote Sean Halstead, M.D., of the University of Queensland in Brisbane, Australia, and colleagues.

Halstead and colleagues collected data from 82 observational studies of adults with schizophrenia spectrum disorder or bipolar disorder that assessed the prevalence of co-occurring physical or psychiatric conditions (though only a few studies examined both). The combined data included more than 1.6 million adults with one of these disorders and over 13 million adults with neither disorder (controls).

Overall, 25% of adults with schizophrenia or bipolar disorder had two or more physical health problems, while 13% had three or more physical health problems. In comparison, 14% of these adults had two or more psychiatric problems (on top of their index diagnosis). The prevalence of multiple physical health problems was roughly the same for schizophrenia and bipolar.

After analyzing data from 11 studies of physical problems that included controls, the researchers calculated that compared with controls, adults with schizophrenia or bipolar disorder had 2.4 times the odds of having two or more physical health problems. The burden was even higher in adults 40 or younger, who had 4 times the odds of multiple physical health problems.

Halstead and colleagues suggested that “a nuanced combination” of multiple factors likely contributes to the poor physical health of young adults with schizophrenia or bipolar disorder, including genetics, prenatal exposures, lifestyle choices, and psychotropic medication side effects. This greater lifetime exposure to poor physical health may explain the high rates of premature mortality seen in people with these two disorders.

For related information, see the Psychiatric News article, “Award Winner Describes Efforts to Improve Cognition in People With Bipolar Disorder.”

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Thursday, April 18, 2024

Most People Experiencing Homelessness Have Mental Health Disorders, Study Finds

Sixty-seven percent of people experiencing homelessness worldwide have a mental health disorder, according to a report published yesterday in JAMA Psychiatry. Additionally, the prevalence of mental health disorders among this population appears to be on the rise.

“The relationship between mental health disorders and homelessness is complex and bidirectional,” wrote Rebecca Barry, Ph.D., of the University of Calgary and colleagues. “[M]ental health disorders may lead to situations that result in homelessness, or homelessness may be a stressor contributing to the development or worsening of mental health disorder symptoms.”

Barry and colleagues combined data from 85 studies that investigated the current and/or lifetime prevalence of mental health disorders among adults aged 18 and older experiencing homelessness. The combined sample included 48,414 adults (77% male) from 19 countries—though about half the studies were from the U.S. or Canada.

The current prevalence of mental health disorders among people experiencing homelessness was 67%, while the lifetime prevalence was 77%. Additional findings included the following:

  • Males experiencing homelessness had a significantly higher lifetime prevalence of mental health disorders (86%) compared with females (69%).
  • Substance use disorders (including alcohol) were by far the most prevalent disorder identified, with a current prevalence of 44% and a lifetime prevalence of 56%.
  • Antisocial personality disorder was the second most common disorder, with a current prevalence of 26%, followed by major depression (19%), general mood disorders (18%), anxiety disorders (14%), psychotic disorders (14%), posttraumatic stress disorder (11%), bipolar disorder (8%), and schizophrenia (7%).
  • North America had the highest prevalence of mental disorders among people experiencing homelessness at 77% compared with Australia (47%), Asia (59%), and Europe (60%).

The authors also found that the prevalence of mental health disorders among people experiencing homelessness was higher in studies published after 2010 compared with those published earlier (76% vs 48%). They called this an important finding and posited that people with mental health disorders may be at increased risk of experiencing homelessness due to factors like housing affordability, limited access to care, low income, and problems reintegrating after receiving inpatient treatment.

“Conversely, the increase in prevalence could be the result of people experiencing homelessness being more likely to develop a mental health disorder due to stressors related to being unhoused, given the bidirectional relationship,” the authors continued. “Regardless, our finding that there is increasing prevalence of mental health disorders among people experiencing homelessness is concerning and effective strategies are needed to address the significant mental health needs of this population.”

For related information, see the Psychiatric News article “M.D.s Call for Community Resources Amid Plans to Force Homeless Into Care.”

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Wednesday, April 17, 2024

Access to In-Network Mental Health Care Still Lags Far Behind Other Medical Care

Patients are far more likely to go out of network to obtain health care from mental health professionals than from medical or surgical professionals, a report by RTI International has found.

In research that was partially funded by APA, Tami L. Mark, Ph.D., M.B.A., and William J. Parish, Ph.D., M.A., analyzed enrollment data and claims from more than 22 million individuals captured annually from 2019 through 2021 to evaluate out-of-network use and reimbursement rates across all 50 states.

The researchers found that patients went out of network 3.5 times more often to see a behavioral health professional (physician or nonphysician) than to see a medical or surgical professional. Patients went out of network 8.9 times more often to see a psychiatrist than another specialty physician, and 6.9 times more often to see a psychiatrist than a primary care physician.

The researchers also found that reimbursement for an in-network office visit was 22% higher for medical and surgical professionals than office visits with behavioral health professionals. Notably, physician assistants were reimbursed for office visits an average of 19% higher than psychiatrists, while nurse practitioners were reimbursed about 8% higher than psychiatrists.

Mark and colleagues concluded that shortages of behavioral health professionals do not explain the disparities in out-of-network use and reimbursement. “The finding of large disparities for out-of-network use and reimbursement rates highlights that health plans are not using the same measures to improve the adequacy of their behavioral health provider networks as they do for medical networks,” Mark said in a statement.

“The report’s findings make it clear that health insurers must be held accountable for not complying with the Mental Health Parity and Addiction Equity Act and provide appropriate payment for the care offered by psychiatrists and other mental health professionals,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “Enforcing parity will increase participation in insurance plans among mental health professionals and therefore increase access to mental health care by making those services more affordable for patients.”

The researchers recommended that federal and state agencies develop standardized templates to identify and remedy parity violations. They outlined several methods for developing these templates, including the following:

  • Comparing behavioral health and medical/surgical reimbursement rates using Medicare benchmarks to allow valid and accurate comparisons across the array of services.
  • Evaluating reimbursement disparities by specific provider type.
  • Using all procedure billing codes when evaluating out-of-network use and reimbursement disparities, and not just a few selected codes.

For related information, see the Psychiatric Services article “Patients’ Reasons for Using Out-of-Network Mental and General Medical Health Providers.”

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Tuesday, April 16, 2024

Generic Drug Combination Cuts Drinking in Adults With Severe Alcohol Use Disorder

Adults with severe alcohol use disorder (AUD) who took a combination of a generic antihypertensive and antihistamine reduced their daily alcohol consumption by about 24 grams—nearly the amount in two standard drinks—over those taking a placebo, according to a report in Addiction.

“Considering the small number of approved medications and current limited use of pharmacotherapy for AUD, all with limited-to-moderate efficacy, patients with AUD as well as their physicians [need] additional treatments,” wrote lead author Henri-Jean Aubin of the Université Paris-Saclay in Villejuif, France, and colleagues.

Aubin and colleagues suggested that cyproheptadine, an anti-allergic medication, and prazosin, which treats hypertension and urinary urgency, might work well together. The former targets receptors involved in impulsive behaviors, and the latter targets receptors related to cravings.

The researchers recruited 154 adults who met DSM-5 criteria for severe AUD and had a high-risk drinking level, defined as consumption of more than 60 grams of alcohol a day for men or 40 grams for women; a standard drink such as a bottle of beer, glass of wine, or shot of liquor contains 14 grams of alcohol.

Participants received 12 weeks of either a high dose medication regimen (10 mg prazosin plus 12 mg cyproheptadine daily), low dose regimen (5 mg prazosin plus 8 mg cyproheptadine daily), or placebo. All participants received brief, simple psychosocial support focused on treatment adherence and reduction of alcohol consumption. The researchers used alcohol consumption as the primary outcome because they noted that people with AUD are increasingly interested in drinking reduction goals rather than achieving abstinence.

After 12 weeks, participants taking the high or low dose regimen reduced their alcohol consumption by 23.6 grams and 18.4 grams more than the placebo group, respectively. A separate analysis of adults with a very high-risk drinking level (more than 100 grams of alcohol a day for men and 60 grams a day for women) showed that they experienced an even larger response to the high-dose treatment: These adults reduced their drinking by 29.8 grams a day on average over placebo.

Both dosing regimens were well tolerated; a review of all significant adverse events study-wide deemed them unlikely to be related to the study drugs.

“The promising efficacy of the combination of prazosin and cyproheptadine warrants prolonging this work with phase 3 trials,” the researchers concluded.

For related information, see the Psychiatric News article “Special Report: Psychiatrists Critical in Screening, Treatment of Alcohol Use Disorder.”

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Let APA Know of Buprenorphine Access Issues

APA is in discussions with our partner medical societies about the challenges patients are facing in accessing buprenorphine due to the opioid settlements. If you are hearing about challenges, please reach out to us at practicemanagement@psych.org to share your stories. We will continue to advocate for access and reduced burdens of helping our patients receive the treatment they deserve.



Monday, April 15, 2024

Adult ADHD Linked to Later Lewy Body Disease, Cognitive Impairment

Adults with attention-deficit/hyperactivity disorder (ADHD) may be at increased risk of dementia and cognitive impairment compared with those without ADHD, according to a report in the American Journal of Geriatric Psychiatry. Adults with ADHD seem particularly susceptible to dementia associated with Lewy body disease, a disorder characterized by abnormal deposits of proteins called Lewy bodies in the brain that results in various forms of cognitive impairment, delirium-like symptoms, Parkinson’s-like movement problems, and hallucinations.

“Determining whether there is an association between ADHD and subsequent conversion to a specific type of dementia is important,” wrote lead author Ángel Golimstok, M.D., of Hospital Italiano, Buenos Aires, and colleagues. “This information could generate opportunities for prevention and early treatment.”

The researchers followed 161 patients with ADHD and 109 without ADHD aged 45 to 70 for an average of 12 years to determine the rates of dementia and cognitive impairment. Both groups presented at a neurology service between February 2, 2007, and December 31, 2012, because of cognitive complaints or a family history of cognitive impairment or ADHD. Patients in either group taking psychoactive drugs including ADHD medications were excluded, except for those taking a single benzodiazepine or hypnotic for insomnia.

At the end of the follow-up, 27 patients with ADHD developed dementia (16.8%) compared with just four patients in the non-ADHD group (3.7%). Of the 27 ADHD patients with dementia, 19 also had Lewy body disease. The incidence of non-amnestic mild cognitive impairment (MCI) was also higher in the ADHD group (108 patients) compared with the non-ADHD group (19 patients); many of these ADHD patients with MCI also had Lewy body disease, and the authors noted that Lewy body-related cognitive problems usually do not affect memory.

In fact, all the core symptoms of Lewy body disease were more prevalent in the ADHD group than the non-ADHD group: REM sleep behavior disorder, Parkinsonism, delusions and hallucinations, cognitive fluctuations, decreased sense of smell, and syncope (fainting).

“Future studies should determine if ADHD represents a prodromal phase of the disease or if it is a risk factor. The connection between ADHD and dementias, in general, seems to be related more to comorbidity with depression than to shared pathophysiological mechanisms,” the authors wrote.

For related information see the Psychiatric News article “Symptoms, Impaired Function of ADHD Often Persist Beyond Childhood.”

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Friday, April 12, 2024

Psychedelic Use in Psychiatry Requires Complex Informed Consent, Experts Say

While psychedelics are moving toward possible approval for clinical use for the treatment of mental disorders, the medical standards for integrating these substances into health care have lagged, according to a special report issued in JAMA Psychiatry.

Of particular concern is the establishment of norms for informed consent, an ethical and legal cornerstone of medicine, according to a special communication written by Mason Marks, M.D., J.D., of Florida State University; Rebecca W. Brendel, M.D., J.D., of Harvard Medical School; and colleagues.

“Psychedelics have unique properties that complicate the informed consent process. They often produce intense subjective experiences that are difficult to explain, predict, or comprehend, especially for psychedelic-naive individuals,” the authors wrote. “These effects can include profound perceptual changes or hallucinations, mood disturbances, paranoia, and an altered sense of self and reality.”

The authors proposed several essential components of informed consent that professionals need to address before administering psychedelics in clinical settings. These include the following:

  • Advising patients about the potential for specific adverse events, such as acute and chronic perceptual changes, personality changes, and altered metaphysical beliefs.
  • Establishing safeguards in advance of treatment around the potential use of limited physical touch in treatment, such as a reassuring touch of the shoulder.
  • Advising about the increased risk of abuse, exploitation, or coercion during treatment and in the weeks or months after.
  • Conveying the heightened social, legal, and professional risks associated with information that may be disclosed during a psychedelic state.
  • Disclosing potential conflicts of interest or other relevant practitioner information.
  • Creating more interactive education and consent processes to improve comprehension, such as consent quizzes to test knowledge or virtual reality content to simulate the experience.

An accompanying editorial by Paul S. Appelbaum, M.D., of the New York State Psychiatric Institute at Columbia University, points out that the proposed elements focus solely on the nature and risks of psychedelic treatment. “Although it would be difficult to quarrel with any of these suggestions, it is important to recognize that these elements are only part of a complete informed consent process.”

Applebaum pointed out that treatment questions pertaining to the optimal number of psychedelic episodes, the duration of response to psychedelic therapy, and the likelihood of response to psychedelic administration in the event of a relapse are all unknown. “At present, all that can—and should—be shared with patients is the profession’s uncertainty about these important issues,” he wrote.

Another source of uncertainty stems from the narrowly selected participant samples for most psychedelic research studies. Frequently excluded are people with personal or family histories of psychotic disorders, prior suicide attempts requiring hospitalization, manic episodes, or borderline personality disorders.

“Right now, there are essentially no data that can be enlisted to help such patients understand the unique risks, if any, that they may face,” Appelbaum wrote.

For related information, see the Psychiatric News article “Psychedelic Therapy Requires Enhanced Consent Discussions.”

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Let APA Know of Buprenorphine Access Issues
APA is in discussions with its partner medical societies about the challenges patients are facing in accessing buprenorphine due to the opioid settlements. If you are experiencing or hearing about challenges, please email the details to APA. APA will continue to advocate for access and reduced burdens of helping patients receive the treatment they deserve.



Thursday, April 11, 2024

Nonemergency ED Use Higher Among Infants of Mothers With Perinatal Depression, Study Finds

Compared with infants of mothers with no perinatal depression symptoms, those born to mothers with mild or moderate/severe symptoms were significantly more likely to have emergency department (ED) visits for nonemergency reasons, according to a study published in Health Affairs.

“Perinatal mental health conditions affect 20% of birthing people and are associated with a range of adverse child outcomes, including increased ED use,” wrote Slawa Rokicki, Ph.D., M.S., of Rutgers University. “This may be a result of increased illness or injury due to biological effects of depression on infant health or inadequate infant care practices associated with parental depression. Alternatively, increased ED use may be due to overuse resulting from a lack of social support at home or low health literacy.”

Rokicki used data from the hospital records of 207,428 mothers who gave birth to non-twins in New Jersey between 2016 and 2018; New Jersey implemented universal depression screening for new mothers before hospital discharge in 2006. Most hospitals screened with the Edinburgh Postnatal Depression Scale. Rokicki categorized perinatal depression symptom severity as none (scores of zero to six), mild (scores of seven to 13), and moderate/severe (scores of 14 or greater).

She linked these data with infants’ ED discharge records during the first year of life. Infants’ primary diagnosis codes when discharged from the ED were used to determine if the visits were nonemergent or emergent.

A little over 10% of infants were born to mothers who had mild depressive symptoms at delivery, and just under 1% were born to mothers with moderate/severe depressive symptoms. Additional findings included the following:

  • In total, 68.4% of ED visits among infants were classified as nonemergent.
  • Infants born to mothers with moderate/severe depressive symptoms had an average of 1.05 ED visits, both emergent and nonemergent, during the first year, compared with 0.82 among those born to mothers with mild symptoms and 0.70 among those born to mothers with no symptoms.
  • Similarly, infants born to mothers with moderate/severe depressive symptoms had an average of 0.6 nonemergent ED visits during their first year, compared with 0.48 among those born to mothers with mild symptoms and 0.41 among those born to mothers with no symptoms.
  • Infants whose deliveries were paid for by Medicaid had an average of 1.24 ED visits in the first year compared with 0.41 visits among those with commercial insurance.

After adjusting for demographic, economic, and birthing (for example, preterm birth or need for a C-section) differences among the groups, there remained a significant association between perinatal depressive symptoms and increased nonemergent infant ED visits, but not emergent visits.

“Medicaid is the primary payer for more than 60 percent of pediatric ED visits, and this proportion has been steadily rising,” Rokicki concluded. “Implementing policies that interrupt the relationship between perinatal depression and nonemergent ED use is therefore an important priority with potential for cost savings.”

For related information, see the Psychiatric News article “In Addressing Maternal Mortality, Mental Health Often Left Out.”

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Wednesday, April 10, 2024

Suppressing Emotions, Feeling Like a Burden Linked to Suicidal Behavior in Preteens

Preteen children who have more trouble expressing their feelings and who perceive themselves as a greater burden to others may be on the cusp of having suicidal thoughts and behaviors (STB), according to a report in the Journal of the American Academy of Child and Adolescent Psychiatry.

Increases in caregiver criticism and conflict are also risk factors for impending STBs, according to the study. Preteen girls with these traits are at especially high risk.

“Preadolescent STBs are dramatically increasing, and it is critical to identify risk factors that can be clinically assessed and modified with treatment,” wrote Renee Thompson, Ph.D., of Washington University, St. Louis, and colleagues.

The researchers analyzed the association between a host of psychosocial factors and suicidal thoughts and behaviors in 192 children aged 7 to 12; most of the children had participated in a clinical study of preadolescent depression, though some children who did not have depression were added as controls.

The participants completed a series of surveys that assessed suicidality and the following psychosocial risk factors:

  • Depressive symptoms
  • Positive and negative affect
  • The ability to understand what one is feeling
  • The sense of being disconnected from people and not belonging anywhere
  • The perception that one is burdensome to others
  • Criticism from and conflict with caregivers
  • The ability or willingness to manage and/or express one’s feelings

The surveys were conducted weekly with children whose caregivers reported any incidents of suicidal thoughts or self-harm at baseline, or monthly otherwise, for 12 months. Participants were on average 10.13 years old and 63% male. Thirty percent met criteria for major depression, and 37.7% met criteria for another internalizing disorder. During the one-year time frame, 70 children screened positive for STBs.

Overall, girls were four times more likely than boys to report STBs, and boys and girls with severe depressive symptoms were 10 times more likely to have STBs than children with mild or moderate symptoms.

Thompson and colleagues then looked closer at the week-to-week responses of high-risk children—those with a history of STBs when entering the study. They found that at any given week, children who reported expressive suppression, perceived burdensomeness, and caregiver criticism and conflict above their historical average levels were more likely to have a positive STB report in the following week.

“The risks identified in the present study … may be useful to clinicians and important for future research to consider as potential targets for prevention and treatment aimed at decreasing STB risk,” the authors concluded.

For related information see the Psychiatric News article “Suicidal Thoughts Begin Early for Some Youth.”

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Tuesday, April 9, 2024

Study Finds No Link Between Acetaminophen Use During Pregnancy And Autism, ADHD Risk

Children exposed to acetaminophen in the womb do not appear to have an increased risk of autism or attention-deficit/hyperactivity disorder (ADHD), according to a study published today in JAMA. While a broad analysis of Swedish families found a slightly increased rate of these disorders in children exposed to acetaminophen in the womb, the researchers found no evidence acetaminophen was responsible when factoring in genetic or family influence.

“Results of this study indicate that the association between acetaminophen use during pregnancy and neurodevelopmental disorders is a noncausal association.,” wrote Viktor H. Ahlqvist, Ph.D., of the Karolinska Institutet and colleagues. “Results suggested that there was not one single ‘smoking gun’ confounder, but rather that multiple … health and sociodemographic characteristics each explained at least part of the apparent association.”

Ahlqvist and colleagues first examined developmental outcomes of nearly 2.5 million non-twin children born in Sweden between July 1, 1995, and December 31, 2019. The researchers followed the children until the end of 2021 and identified all diagnoses of autism, ADHD, and intellectual disability. Overall, 7.62% of these children were diagnosed with at least one of these neurodevelopmental disorders. The researchers found that children whose mothers used acetaminophen at some point during pregnancy had a 5% increased risk of an autism or intellectual disability diagnosis and a 7% increased risk of an ADHD diagnosis.

However, mothers who used acetaminophen were more likely to have lower education and/or income levels, have a higher body mass index during early pregnancy, smoke during pregnancy, and have a psychiatric diagnosis. The researchers tried to account for these variables and many others (like the use of other pain medications) in their analysis but noted there might be some genetic or family factors they couldn’t account for.

So, as a further step, Ahlqvist and colleagues conducted a sibling control analysis in which they examined families with siblings in which some children were exposed to acetaminophen while others were not. In this model, they found no association between acetaminophen use during pregnancy and risk of a neurodevelopmental disorder. (In an unexpected result, they did find that the use of aspirin was associated with a reduced risk of neurodevelopmental disorders in children; the researchers hypothesized this association reflected individuals who took low-dose aspirin to reduce birthing problems like preeclampsia.)

For related information, see the Psychiatric News stories “Exposure to Valproate in Utero May Increase Risk of Autism, ADHD” and “Most Antipsychotics During Pregnancy Do Not Increase Neurodevelopmental Risks.”

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Monday, April 8, 2024

APA Opposes Efforts to Ban Diversity Initiatives in Medical Education

On Friday APA issued a statement opposing efforts to ban diversity, equity, and inclusion (DEI) programs and initiatives in medical education.

“In today’s medical schools and academic psychiatry departments, the principles of diversity, equity, and inclusion are critical to ensure that the next generation of physicians can serve the needs of evolving, diverse, underrepresented, and underserved patient populations,” the statement said.

“Recently, there have been efforts to ban these principles in colleges and universities. This presents a chilling and undesirable development that restricts the ability of medical students and residents studying psychiatry to explore the various factors that impact mental health and wellness,” the statement continued.

According to a DEI legislation tracker by the Chronicle of Higher Education, 82 anti-DEI bills have been introduced in the states and Congress since 2023. Of these, 12 have become law; 12 have final legislative approval; and 35 have been tabled, failed to pass, or vetoed. The actions contained in the legislation include the following:

  • Prohibiting colleges from having diversity, equity, and inclusion offices or staff.
  • Banning mandatory diversity training.
  • Forbidding institutions to use diversity statements in hiring and promotion policies.
  • Barring colleges from considering race, sex, ethnicity, or national origin in admissions or employment.

Last summer, in a decision rendered in Students for Fair Admissions v. President and Fellows of Harvard College and Students for Fair Admissions v. University of North Carolina, the U.S. Supreme Court ruled 6-3 that the admissions programs at Harvard and the University of North Carolina that relied in part on racial considerations violate the Constitution’s guarantee of equal protection under the 14th Amendment. At the time, APA issued a statement against the decision, noting that race-conscious admissions policies are designed to address racial discrimination by recognizing and responding to the structural barriers that hinder access to higher education for underrepresented students.

In its current statement, APA said, “The abilities to discuss, to learn about, and to research topics such as diversity, equity, and inclusion, not limited to but certainly including protected classes such as race, ethnicity, gender, gender identity, gender expression, and sexual orientation, are essential to foster and ensure a culturally competent psychiatric workforce that can provide high quality care for all patient populations.”

For related information, see the Psychiatric News article “APA Speaks Out Against Supreme Court Ruling on Affirmative Action in Higher Education.”

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Friday, April 5, 2024

High Blood Glucose, Triglycerides Linked to Long-Term Risk of Mental Disorders

Individuals with elevated blood levels of glucose and triglycerides have an increased risk of depression, anxiety, and stress-related disorders, as do individuals with low blood levels of HDL cholesterol (“good cholesterol”), a study in JAMA Network Open has found. Further, elevated levels of glucose or triglycerides were present in individuals who developed one of these disorders as far back as 20 years prior to diagnosis.

Charilaos Chourpiliadis, M.D., of the Karolinska Institutet in Stockholm and colleagues analyzed data from 211,200 participants in the Apolipoprotein-Related Mortality Risk cohort who underwent occupational health screening between January 1, 1985, and December 31, 1996. As part of the screening, blood tests were done to measure glucose, total cholesterol, HDL cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides and other markers of metabolic and cardiovascular risk. The researchers determined clinical cutoffs for these blood markers based on previous research and/or cardiovascular disease guidelines.

Study participants had a mean age of 42.1 years at their first screening and were followed for a mean of 21 years. The researchers examined the individuals’ diagnoses in the Swedish Patient Register to look for a first diagnosis of depression, anxiety, or stress-related disorders. They defined stress-related disorders as acute stress reaction, posttraumatic stress disorder, adjustment disorders, other reactions to severe stress, and unspecified reaction to severe stress.

Over the follow-up period, 16,256 individuals were diagnosed with depression, anxiety, or stress-related disorders, with a mean age at diagnosis of 60.5 years. The researchers found the following:

  • Individuals with blood glucose levels of 110 mg/deciliter or higher had a 30% higher risk of depression, anxiety, and stress-related disorders compared to those with lower levels.
  • Individuals with triglyceride levels of 150 mg/deciliter or higher had a 15% higher risk of these mental illnesses compared to those with lower levels.
  • Individuals with HDL cholesterol levels of 40 mg/deciliter or higher had a 12% lower risk of these mental illnesses compared to those with lower levels.

“These results add further evidence of the association between cardiometabolic health and psychiatric disorders and potentially advocate for a closer follow-up of individuals with metabolic dysregulations for prevention and early diagnosis of psychiatric disorders,” the researchers wrote. “Additional studies are needed to explore whether rigorous or earlier interventions for cardiometabolic diseases could counteract such an association.”

For related information, see the American Journal of Psychiatry article “Genetic and Environmental Contribution to the Co-Occurrence of Endocrine-Metabolic Disorders and Depression: A Nationwide Swedish Study of Siblings.”

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Thursday, April 4, 2024

Family History of Treatment-Resistant Depression May Be Risk Factor for Antidepressant Resistance

Individuals with a family history of treatment-resistant depression (TRD) have an increased risk of experiencing antidepressant resistance themselves, a study published yesterday in JAMA Psychiatry found. Further, individuals with a family history of TRD have a greater risk of other psychiatric illnesses and dying by suicide.

“In recent years, an increasing number of genetic studies have attempted to understand the genetic architecture of antidepressant response or TRD phenotype,” wrote Chih-Ming Cheng, M.D., of the Taipei Veterans General Hospital in Taiwan and colleagues. “Although the efforts to understand the genetic mechanism behind antidepressant response are promising, these positive results require more replication and must overcome methodological concerns, such as relatively small sample size and diverse definitions of TRD.”

Cheng and colleagues used data from the Taiwan National Health Insurance program, which covers nearly the entire population of Taiwan and includes diagnoses of psychiatric disorders. The authors used all medical records from 2003 to 2017, which were linked to records from the Database of National Mortality Registry to determine date and cause of death. Patients who were diagnosed with major depressive disorder and received at least three adequate antidepressant trials (exceeding 56 daily doses in an eight-week period) within two years were defined as having TRD. In total, 21,046 individuals met these criteria. The authors then identified 34,467 first-degree relatives of those with TRD and matched them by birth year, sex, and kinship with 137,868 first-degree relatives of individuals without TRD.

Relatives of those with TRD had nine times the risk of developing TRD compared with those in the control group. They were also significantly more likely to develop other psychiatric illnesses, including schizophrenia, bipolar disorder, attention-deficit/hyperactivity disorder, major depressive disorder, autism spectrum disorder, anxiety, and obsessive-compulsive disorder. These findings persisted even after controlling for factors such as birth year, sex, income, and comorbid conditions. Relatives of those with TRD also had a higher risk of all-cause and suicide mortality, and this risk remained even after excluding relatives who developed TRD from the analysis.

“Family history of TRD is a clinical risk factor due to its association with increased suicide mortality and resistance to antidepressant treatment; therefore, more intensive depression treatments, such as add-on pharmacotherapy or nonpharmacotherapy might be considered earlier, as opposed to antidepressants alone, for treating the symptoms of individuals with TRD,” the authors concluded.

For related information, see the Psychiatric News article “To Address Treatment-Resistant Depression, First You Have to Define It.”

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Wednesday, April 3, 2024

Clozapine, LAIs Found Effective in Patients With First-Episode Psychosis and Cannabis Use Disorder

Individuals with first-episode psychosis (FEP) and cannabis use disorder who were prescribed any antipsychotic were significantly less likely to be hospitalized for psychosis than similar patients who did not receive an antipsychotic, according to a report in Schizophrenia Bulletin.

Clozapine and long-acting injectable (LAI) formulations of risperidone, aripiprazole, and paliperidone were the most effective medications at preventing relapse and hospitalization due to psychosis. Clozapine was also most effective at preventing hospitalization due to substance use.

Alexander Denissoff, M.D., of the University of Turku, Finland, and colleagues noted that cannabis use is common among FEP patients. Further, continued cannabis use after a first episode of psychosis has been associated with more severe symptoms, nonadherence to antipsychotic treatment, and an increased frequency of relapse.

For that reason, “improving outcomes of FEP patients with dual disorders is of paramount importance as relapse after the index psychotic episode is associated with adverse clinical outcomes,” they wrote.

Denissoff and colleagues used Swedish national registries to track the outcomes of 1,820 individuals diagnosed with FEP and co-occurring cannabis use disorder between 2006 and 2021. The main outcome was hospitalization due to relapse of psychosis, though the researchers also looked for hospitalizations due to any substance use disorder.

A total of 1,111 of the 1,820 patients were hospitalized due to psychotic relapse. The researchers found that patients who received any antipsychotic were 33% less likely to be hospitalized due to a relapse of psychosis compared with patients who did not receive an antipsychotic. Regarding individual medications, LAI risperidone was associated with the most significant reduction in hospitalization risk (60%), followed by LAI aripiprazole (58%), oral clozapine (57%), and LAI paliperidone (54%). In contrast, LAI olanzapine, oral quetiapine, and oral risperidone were not found to prevent hospitalization due to relapse.

In the cohort, 1,143 of 1,820 patients were hospitalized due to substance use disorder. Clozapine was associated with the greatest decreased risk of subsequent hospitalization due to any substance use (86%) followed by LAI formulations of risperidone (67%) and paliperidone (63%).

“These findings encourage the early use of second-generation long-acting injectables as an important secondary pre­vention strategy to reduce rates of hospitalization in first-episode patients with comorbid cannabis use disorders,” the researchers concluded.

For related information, see the Psychiatric News article “Strategies for Reducing Cannabis Use By Patients With FEP.”

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Tuesday, April 2, 2024

Social Media Found to Be More Helpful to Children Today Than in 2022

While U.S. adults remain divided on the mental health impacts of social media, more parents view social media as helpful to their children’s mental health than they did two years ago. These are some of the findings from APA’s latest Healthy Minds Monthly Poll released today.

For example, 31% of parents in 2024 said they believe that social media has helped their child’s mental health, up from 24% in 2022; 31% of parents today also believe social media has helped their child’s self-esteem, up from 23% in 2022. These changes reflect fewer parents viewing social media as a neutral influence, as the number of parents who said social media hurts their child’s mental health has remained steady at 20% between 2022 and 2024.

This new poll also found changing perceptions of social media’s impact on society at large, with fewer respondents in 2024 saying that social media is hurting political or civil discourse compared with 2022.

“Social media is a ubiquitous technology, and our understanding of the harm it can cause is shifting,” said APA President Petros Levounis, M.D., M.A., in a news release. “Ultimately our personal use of social media is similar to the interaction we have with any technology, which is to say that we have to be mindful of its impact on our mood, thoughts, and feelings. Helping children and adolescents learn and practice mindfulness can give them skills to manage their journeys in social media.”

This year’s poll also showed that many respondents use social media to search for and/or share information on mental health. Younger adults were especially likely to use social media for such purposes; for example, 77% of 18- to 34-year-olds had used social media to find mental health information, compared with only 23% of adults ages 65 or older.

“It is no surprise that particularly younger Americans are listening and joining the social media conversation on mental health,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in the release. “In many ways, that is a very healthy sign. However, those of us in the mental health and medical fields must work to ensure that accurate information is available and that people can reach a doctor or other mental health clinician if they aren’t feeling well.”

This year’s poll was fielded by Morning Consult on behalf of APA between March 11 and 14 and included responses from 2,204 adults. The 2022 poll was fielded January 19 and 20, 2022, among a sample of 2,210 adults.

To read more on the impacts of social media, see the latest Psychiatric News special report,“Is Social Media Misuse a Bad Habit or Harmful Addiction?

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Monday, April 1, 2024

Sports Gamblers More Likely to Binge Drink, Study Shows

People who gamble on sports are disproportionately more likely to engage in binge drinking, a research letter in JAMA Network Open reports.

Joshua B. Grubbs, Ph.D., of the University of New Mexico and colleagues analyzed data from 4,363 adults about their gambling and drinking habits. The researchers assessed sports betting status by asking participants whether they had placed bets on sporting events or esports or participated in daily fantasy sports over the past 12 months. Sports gamblers were then separated into four groups according to how many times they bet on sports in the past year: those who bet once or twice, those who bet monthly, those who bet weekly, and those who bet daily or almost daily. The researchers then used the National Institute on Drug Abuse Quick Screen, version 1.0, to ask participants how often they consumed an excess of alcohol at a single time over the past year.

Among participants, 1,326 were nongamblers, 1,225 were non-sports gamblers, and 1,812 were sports gamblers. Overall, 74.9% reported past year alcohol use. The sample was almost evenly divided between men and women.

Women who bet on sports once or twice over the past year had 2.4 times the odds of reporting binge drinking compared with women who did not gamble at all. Those who bet on sports monthly, weekly, or daily/almost daily had 3.8, 5.9, and 14.4 times the odds of reporting binge drinking, 4respectively.

Men who bet on sports once or twice over the past year had 1.9 times the odds of reporting binge drinking compared with women who did not gamble at all. Those who bet on sports monthly, weekly, or daily/almost daily had 2.9, 4.7, and 8.9 times the odds of reporting binge drinking, respectively.

After adjusting for age, race, and ethnicity, the researchers found that risky drinking episodes were not associated with demographic differences.

“Given the rapid spread of sports wagering in the U.S. over recent years, this finding highlights an immense need for ongoing research, particularly to examine how novel gambling technologies influence the prevalence, presentation, and prevention of alcohol use disorders and related harms,” Grubbs and colleagues wrote.

For related information, see the Psychiatric News special report “Gambling Disorder Not Uncommon but Often Goes Undiagnosed.”

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Friday, March 29, 2024

More Patients Take OUD Medications When Treatment Centers Offer Them Onsite

Individuals with opioid use disorder (OUD) are much more likely to take buprenorphine or methadone if their treatment center offers these medications onsite, according to an analysis appearing in Psychiatric Services in Advance.

“In July 2018, Philadelphia became the first U.S. municipality to mandate the availability of medications for opioid use disorder (MOUD) in publicly funded substance use disorder treatment agencies,” wrote Rebecca E. Stewart, Ph.D. of the University of Pennsylvania Perelman School of Medicine, and colleagues. However, treatment agencies could either provide medications onsite or have a documented plan to refer patients to external MOUD providers.

The researchers reached out to the leaders of all 53 public OUD treatment agencies in Philadelphia between March and July 2020 to ask whether their site provides medications onsite or coordinates with external providers. Forty-five leaders responded, of whom 34 reported providing methadone and/or buprenorphine onsite. Stewart and colleagues then used Medicaid data to calculate how many patients of these 45 sites received methadone or buprenorphine.

Overall, 43% of the patients who went to an onsite provider received an MOUD, compared to 28% of patients at referral agencies. The researchers noted that only two of the 11 referral agencies contacted said they provided naltrexone (an OUD medication that works differently on opioid receptors than methadone or buprenorphine), so the lower prescription rate at these centers was not because they were offering an alternative.

“Agencies that coordinate with external MOUD providers may be creating barriers that impede uptake, or the clients of these agencies may be less motivated to engage with MOUD treatment,” Stewart and colleagues concluded. “Regardless, these findings highlight the need for MOUD mandates specifying how care is provided at substance use disorder treatment agencies, as well as for efforts to build the capacity of these agencies to provide MOUD onsite.”

To read more about this topic, see the Psychiatric News article “Rutgers Grad Students RIOT for Opioid Education.”

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Were You Impacted by Recent Cybersecurity Attack?

In the wake of the Change Healthcare cybersecurity attack and resulting system outages, the AMA would like to assess the level of workflow disruptions and financial impact on practices through an informal, 11-question survey. The AMA will use the information to inform its advocacy efforts on this issue. The deadline to respond is noon CT on Wednesday, April 3.

Thursday, March 28, 2024

Telehealth Treatment for Alcohol Use Disorder Associated With Patient Retention

Patients with alcohol use disorder (AUD) who receive treatment via telehealth are more likely to engage in more psychotherapy visits and have a longer duration of medication treatment compared with those who have only in-person visits, according to a study published this week in Alcohol, Clinical and Experimental Research.

“Evidence-based treatment for AUD differs from other substance use disorders in that it includes multiple psychotherapy and medication options,” wrote Ponni V. Perumalswami, M.D., of the VA Ann Arbor Healthcare System and colleagues. “Evaluating telehealth delivery of treatment to vulnerable patients, including those with AUD, is particularly important in the current context as the United States debates whether to sustain or revoke pandemic-era policies that decreased barriers to telehealth.”

Perumalswami and colleagues analyzed electronic health record data from the Veterans Health Administration (VHA) during the year following the start of the COVID-19 pandemic (between March 1, 2020, and February 28, 2021). They included 138,619 patients aged 18 or older who were diagnosed with AUD in the year prior to or during the study period and who had at least one AUD treatment visit. AUD treatment included an individual or group psychotherapy visit and/or AUD medication coverage (defined as the number of days covered by a filled prescription for AUD). The authors used VHA codes to determine whether patients received their treatments via video, telephone, or in person.

During the study period, 52.8% of participants had at least one video visit, 38.1% had at least one telephone visit but no video visits, and 9.1% had only in-person visits. Telehealth was associated with a greater number of psychotherapy visits and medication coverage days compared with in-person visits for both patients initiating and continuing treatment during the study period. Further, among those who received any treatment via telehealth, those who had video visits had a significantly greater number of psychotherapy visits compared with those who only had telephone visits.

Participants who had only in-person visits were more likely to be initiating AUD treatment and were older, male, Black, rural, homeless; they were also more likely to have an opioid and/or stimulant use disorder. Additionally, among participants who received any treatment via telehealth, those who were 45 years or older, Black, and diagnosed with a cannabis or stimulant use disorder or serious mental illness were less likely to receive video compared with telephone visits. The authors noted that this finding highlights “important disparities in AUD telehealth use.”

“Additional efforts to increase the engagement of certain VHA patient groups in telehealth use should be made, given its association with receiving more AUD treatment,” the authors concluded. “This study offers insights into patient characteristics associated with AUD treatment in an era of expanded telehealth and suggests that future policy changes in telehealth should be carefully considered given the potential to widen disparities in care.”

For related information, see the Psychiatric News article “Federal Telehealth Policy Changes After COVID-19 Public Health Emergency.”

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Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

Wednesday, March 27, 2024

Safety Planning for Suicidal Patients in ED Linked to Lower Readmissions

Patients with suicidal behavior who received a safety plan—a set of suicide-prevention strategies—during an emergency department (ED) visit were less likely to be readmitted to the ED or the hospital for suicidal behavior or other mental health problems within 30 days of discharge than those who went to a hospital without routine safety planning. The finding appeared in a study published today in Psychiatric Services.

“Our findings support the notion of making safety planning universally available in EDs for patients with suicidal behavior and as a standard component of outpatient mental health care,” wrote Sara Wiesel Cullen, Ph.D., M.S.W., of the School of Social Policy and Practice at the University of Pennsylvania and colleagues.

Between May 2017 and January 2018, Cullen and colleagues mailed and emailed a survey about management of self-harm to a random selection of 665 hospitals that had recorded five or more ED episodes related to self-harm in the previous year. The contacted hospitals were linked with a patient population derived from a database of deidentified information on millions of individuals privately insured through UnitedHealthcare. The final sample included the 130 hospitals that had returned a completed survey and 2,328 patients who had continuous insurance eligibility 30 days before and after their ED visit.

The hospital survey included questions on how frequently EDs implemented the components of safety planning:

  • Helping patients recognize the warning signs of an impending suicidal crisis.
  • Providing strategies and identifying social activities to take patients’ mind off of their problems.
  • Identifying family members or friends whom patients could ask for help.
  • Providing a list of professionals or agencies to contact in a crisis.
  • Developing an individualized plan to restrict access to lethal means at home.

Possible responses were “never or rarely,” “sometimes,” “usually but not routinely,” and “on a routine basis.”

Of the 130 hospitals in the analysis, 55% routinely conducted safety planning. Of the patient sample, 62% visited EDs that routinely conducted safety planning.

Among patients who visited an ED that regularly provided a safety plan, 18% were readmitted to the ED and 12% were readmitted to the hospital within 30 days versus 22% and 15%, respectively, of patients who visited an ED that did not regularly provide safety planning. Among patients who had not received any mental health care in the 30 days prior to their ED visit, just 8% of those who went to an ED that routinely conducted safety planning were readmitted versus 14% of patients who were treated in an ED that did not routinely conduct safety planning.

“Safety planning may be more strongly associated with beneficial effects among individuals experiencing a new mental health crisis managed in the ED, perhaps by providing a clear roadmap of what to do when a crisis recurs and by teaching coping skills or strategies to help thwart subsequent crises,” the authors wrote.

For related information, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in at-Risk Patients.”

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Tuesday, March 26, 2024

Combining SSRIs With Oral Anticoagulants Found to Increase Risk of Major Bleeding

People who take serotonin reuptake inhibitors (SSRIs) and oral anticoagulants have an increased risk of multiple types of major bleeding compared with people who take only oral anticoagulants, a study in JAMA Network Open has found. The study findings also showed that bleeding risk differs depending on the type of anticoagulant.

Christel Renoux, M.D., Ph.D., of Jewish General Hospital in Montreal and colleagues examined data from 331,305 patients in the United Kingdom aged 60 years or older who had atrial fibrillation and began taking oral anticoagulants between January 2, 1998, and March 29, 2021. The researchers included anticoagulants that directly target blood-clotting proteins (apixaban, dabigatran, edoxaban, and rivaroxaban), as well as warfarin, which indirectly reduces clotting by inhibiting vitamin K. They also identified if these patients were being prescribed SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline) at the same time.

Patients were followed until a first major bleeding event, death, end of registration with the patient’s internal medicine practice, or end of the study period, whichever came first.

The researchers identified 42,190 patients who experienced a major bleeding event and matched each one with up to 30 similar adults taking an oral coagulant who did not experience bleeding (a total of 1,156,641 controls, though this included duplicates).

Compared with patients who took only oral anticoagulants, patients who took oral anticoagulants and an SSRI had a 33% increased risk of any major bleeding. Among subtypes of events, there was a 38% increased risk of gastrointestinal bleeding, a 56% increased risk of intracranial hemorrhage, and a 23% increased risk of other types of major bleeding. Overall, the risk of major bleeding was strongest in the first 30 days of taking both types of medications.

The researchers also found that the increased risk of major bleeding was higher in patients who took warfarin and an SSRI (36%) compared with those taking a direct oral anticoagulant and SSRI (25%). However, the risk of major bleeding was not higher in patients taking more potent SSRIs like fluoxetine, paroxetine, or sertraline compared with other SSRIs.

“In light of these findings, the risk of major bleeding may be a pertinent safety consideration for patients using SSRIs and [oral anticoagulants] concomitantly,” Renoux and colleagues wrote. “To minimize the risk of bleeding, individual modifiable risk factors should be controlled, and patients should be closely monitored, particularly during the first few months of concomitant use.”

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Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

Monday, March 25, 2024

CMS Offers Extensions in Wake of Cybersecurity Attack on Change Healthcare

Last month, Change Healthcare, a subsidiary of United Healthcare, experienced a massive cybersecurity attack that continues to impact insurance payments to hospitals and health practices. While Change Healthcare works to restore key systems to enable claim processing, the Centers for Medicare & Medicaid Services (CMS) has taken steps to assist impacted physicians.

  • Physicians impacted by the cyberattack may request advance Medicare payments to help with cash flow disruptions. More details of the program, terms, and the steps needed to apply can be found in the CMS Fact Sheet and FAQ.
  • CMS has also extended the 2023 MIPS (Merit-based Incentive Payment System) submission deadline until April 15. In addition, CMS has reopened the 2023 MIPS Extreme and Uncontrollable Circumstances hardship application, which likewise has a deadline of April 15 (the hardship exemption is not automatic). Physicians can make their submission by logging on to the CMS portal.

UnitedHealth Group/UnitedHealthcare is providing the latest updates and resources related to the cyberattack and how it’s managing the impacts on its website.

In addition, the Department of Health and Human Services has posted resources to assist providers with the aftermath of the cybersecurity attacks. The resource document includes a national contact person for each plan, though HHS urges providers to contact their health insurer’s regional contact first. If these contacts do not respond, contact HHScyber@hhs.gov.




Help APA Address Parity Issues

APA needs member input to assist us in discussions with federal agencies that work to enforce the Mental Health Parity and Addiction Equity Act. This will help APA counteract misinformation coming from health insurance plans. Please take a few minutes to answer this short survey here. The deadline is Monday, April 1.

Disclaimer

The content of Psychiatric News does not necessarily reflect the views of APA or the editors. Unless so stated, neither Psychiatric News nor APA guarantees, warrants, or endorses information or advertising in this newspaper. Clinical opinions are not peer reviewed and thus should be independently verified.