Repetitive TMS Shows Promise for Persistent Headache Following Brain Injury

Repetitive transcranial magnetic stimulation (rTMS) may be a promising intervention to treat persistent headache following brain injury, according to findings from a small clinical study published today in the Journal of Neuropsychiatry and Clinical Neurosciences.

As Anika Balse, B.S., of the Kaizen Brain Center in La Jolla, California, and colleagues noted, single-pulse TMS is approved for the management of acute migraines. Because headaches and depression frequently co-occur following traumatic brain injury, finding one treatment that can improve both would be beneficial to clinicians and patients.

The researchers first examined data from 21 adults with a history of mild-to-moderate TBI who received rTMS for depressive symptoms but also had posttraumatic headache (PTH). The patients received an accelerated rTMS protocol that included five days of treatment per week for two to eight weeks. The protocol also involved baseline MRI scans to identify the optimal regions to stimulate.

At the end of treatment, average depression scores (as assessed with the Patient Health Questionnaire-9) dropped from 16.1 to 9.7, while headache severity scores (as assessed with the six-item Headache Impact Test) only dropped from 61 to 59—a 3.3% decline. However, 57% of participants did report meaningful improvements in their headache symptoms. The researchers analyzed MRI data from the participants who responded and identified a potential target site in the brain’s attention network.

Balse and colleagues next performed rTMS on seven additional adults with depression and PTH, all of them receiving stimulation in the identified target location. While these adults reported a similar improvement in depression scores (about a six-point decline) as the first cohort, their headache severity scores decreased by an average of 16%. The researchers noted that headache symptoms improved around two to three weeks after depression improved, suggesting the reduced headache severity was just not a byproduct of better mood.

“The PTH target identified in our study is well within the FDA-approved area [for depression], making it a suitable and clinically translational target for patients with comorbid PTH, depression, and anxiety,” the researchers wrote. “A randomized controlled trial with the same protocol for all participants is needed to address whether the novel target is solely responsible for the reduction in [headache] and to address a possible placebo effect.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review.”

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Air Pollution From Wildfires May Increase Mental Health–Related Emergency Visits

Exposure to fine particulate matter caused by wildfires is associated with a significant increase in mental health–related emergency department (ED) visits, particularly among children, racial and ethnic minority groups, and women, according to a study issued today in JAMA Network Open.

“In 2020, California had the most severe wildfire season on record, with over 70% of the population enduring unhealthy air quality for over 100 days,” wrote Youn Soo Jung, Ph.D., of Stanford University, and colleagues.

The researchers analyzed data on 86,609 ED visits at California hospitals by state residents presenting for mental health conditions between July and December 2020 (average age 38 years, 46% female). Exposure to wildfire-specific fine particulate matter was determined based on patients’ ZIP codes. The mean daily concentration of wildfire-specific fine particulate matter increased from 0.44 to 24.9 micrograms per cubic meter during the peak wildfire period in September.

Each increase of 10 micrograms per cubic meter in wildfire-specific fine particulate matter was associated with an 8% increase in all-cause mental health ED visits, a 15% increase in ED visits related to depression, and a 29% increase in visits for bipolar disorder or manic episode up to seven days after exposure. There was also a 6% increase in anxiety-related ED visits up to four days after exposure.

Additional findings included:

• Women were more likely than men to visit the ED for depression or bipolar disorder/manic episodes after exposure to wildfire smoke.
• The risk of ED visits for all mental health conditions was 35% higher per 10-point increase in wildfire-specific fine particulate matter among children ages 14 and younger than adults.
• Among racial groups, non-Hispanic Black individuals had the highest risk of ED visits for bipolar/manic episodes following exposure, while Hispanic individuals had the highest risk of ED visits for depression.

The authors noted that stress from evacuations and property loss may also contribute to increased ED visits. But in sensitivity analyses, the authors found similar trends in ED visits in areas with and without evacuation orders. “Overall, our subgroup analysis emphasizes the importance of strategies to ensure equal protection from wildfire exposure across demographic groups,” they wrote.

For related information, see the Psychiatric News article “Exploring the Mental Health Toll of the L.A. Wildfires” and the Psychiatric News Alert “Wildfire Smoke Linked to Increased Risk of Dementia.”

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Advocacy Alert: Protect SAMHSA Funding

This week the U.S. Department of Health and Human Services (HHS) announced significant cuts to the Substance Abuse and Mental Health Services Administration (SAMHSA) as part of the Trump Administration’s reorganization of HHS and broader initiative to reduce government spending. These actions will inevitably lead to cutting programs and services that many people with mental health and substance use disorders depend on. Please urge Congress to protect SAMHSA programs within the new reorganization and continue the successful bipartisan collaboration to address mental health, suicide prevention, and substance use care in our country.

Shingles Vaccine May Also Reduce Risk of Dementia, Study Shows

Making use of a Welsh vaccination policy that set strict and defined eligibility criteria for receiving the herpes zoster (shingles) vaccine, researchers have found that shingles vaccination may also significantly reduce the probability of dementia. The findings were published yesterday in Nature.

Previous research has found an association between the shingles vaccine and reduced dementia risk. However, those studies could not determine whether adults who chose to get vaccinated had other fundamental differences in lifestyle or motivation than adults who did not, noted Markus Eyting, Ph.D., of Stanford University, and colleagues.

In 2013, Wales instituted a policy whereby individuals born after September 2, 1933, were progressively eligible for a live-attenuated shingles vaccine; those born before that date were never eligible. Eyting and colleagues noted that this created a “natural experiment” in which they could avoid many confounding variables present in earlier studies.

Drawing on electronic health record registries, the researchers compiled data on 282,541 adults born between September 1, 1925, and September 1, 1942, who were dementia-free prior to the rollout of the vaccine program. These naturally occurring comparison groups did not differ appreciably from each other in ways that might affect the risk for dementia.

During a follow-up period of seven years, a little more than 14,000 adults in the study sample had at least one diagnosis of shingles, while around 35,000 were newly diagnosed with dementia. After adjusting for age differences, the researchers found that adults who were eligible for the shingles vaccine had an 18.8% lower risk of a shingles diagnosis than the ineligible adults, while adults who actually received the vaccine had a 37.2% lower risk of shingles. Similarly, adults eligible for the vaccine had an 8.5% reduced risk of a dementia diagnosis during the follow-up period, while those who took the vaccine had a 20% reduced risk. Differences were seen even between individuals born weeks before or after the eligibility date. This protective effect was stronger among women than men.

The researchers replicated these findings in a larger study that combined the populations of Wales and England—which had a similar vaccine rollout initiative—and used a different variable for assessing dementia (death certificates showing death with dementia as a primary cause).

“Our substantial effect sizes, combined with the relatively low cost of the zoster vaccine, imply that, if these findings are truly causal, the zoster vaccine will be both far more effective as well as cost-effective in preventing or delaying dementia than existing pharmaceutical interventions,” Eyting and colleagues concluded.

For related information, see the Psychiatric News article “Dementia Cases Projected to Double: Clinicians, Policymakers Can Help Reduce Risk.”

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Taking Hormonal Contraception Postpartum May Raise Risk of Depression

Starting most hormonal contraceptives in the first year postpartum may raise the risk of depression even among first-time mothers with no recent history of the disorder, according to a study published by JAMA Network Open.

“This study observed that the hormonal contraceptive initiation postpartum was associated with an increased risk of depression across all age groups,” wrote Soren Vinther Larsen, Ph.D., of Copenhagen University Hospital–Rigshospitalet, and colleagues. The risk was increased for all hormonal contraceptives except for progestogen-only “mini-pills,” for which risk was inconclusive.

Using Danish registry data, the researchers examined health records for 610,038 first-time mothers who gave birth between 1997 and 2022, of whom 41% started a hormonal contraceptive within 12 months of delivery. The researchers excluded women who had depression within 24 months before giving birth, multiple births, or stillbirth. Depression was defined as filling a prescription for an antidepressant or receiving a hospital discharge with a diagnosis of depression within 12 months of delivery.

Overall, there were 21 cases of depression per 1,000 person-years among women who started hormonal contraceptives, compared with 14 per 1,000 person-years among those who did not. This amounted to a 49% higher risk of depression among hormonal contraceptive users compared with nonusers, after adjusting for factors like age, history of mental illness, or birth complications. The absolute prevalence of postpartum depression was 1.54% among all women, which the researchers calculated would have been 1.36% had no one taken contraceptives.

The researchers observed this elevated risk of depression for several types of hormonal contraceptives: combined-hormone pills and combined nonoral (patch and vaginal ring) or progestogen-only nonoral (implants, depot injections, and levonorgestrel-releasing IUDs). Progestogen-only mini-pills were an exception, for which an increased risk was evident only after eight months postpartum.

The risk varied by type of hormonal contraceptive: Compared with nonuse, levonorgestrel-releasing IUDs raised risk of depression by 27% during the study period, progestogen-only nonoral contraceptives by 40%, combined-hormone pills by 72%, and combined-hormone patches and vaginal rings by 97%.

“These findings raise the issue of whether the incidence of depression postpartum may be inflated by routine hormonal contraceptive initiation, which is important information to convey at postpartum contraceptive counseling,” Larsen and colleagues wrote.

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

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Eating Disorders Affect More Racially Diverse Population Than Previously Thought

Eating disorders are often thought to primarily affect White people, but a study in the International Journal of Eating Disorders suggests that eating disorders affect college students at largely similar rates across racial and ethnic groups. Furthermore, where differences emerged along racial and ethnic lines, some minoritized groups had a greater probable prevalence and severity of eating disorders than Whites.

Carli P. Howe, a graduate student at the University of Washington in St. Louis, and colleagues analyzed data from 3,929 students from 26 U.S. colleges and universities whose results on a mental health screen suggested the presence of an eating disorder. Participants self-identified as Asian, Black, Hispanic, multiracial, or White. They were also asked about their gender identity and were categorized as men, women, cisgender, or non-cisgender.

The researchers found that:

• Non-cisgender Asian participants had the highest prevalence of probable anorexia nervosa (8.64%), followed by cisgender Asian women (3.61%), non-cisgender multiracial participants (3.28%), and cisgender multiracial women (2.5%).
• Non-cisgender Hispanic participants had the highest prevalence of probable clinical or subclinical bulimia nervosa/binge eating disorder (20.49%), followed by cisgender Hispanic women (18.2%), cisgender multiracial women (17.25%), and cisgender White women (15.54%).
• Non-cisgender Black participants were most likely to be at high risk for eating disorder onset (6.67%), followed by cisgender Hispanic women (5.87%), cisgender White women (4.83%), and cisgender Black women (4.52%).
• Among participants with probable eating disorders, there were no significant differences between racial or ethnic groups across any gender with respect to the frequency of eating disorder behaviors such as binge eating, vomiting, or laxative/diuretic use in the past three months.

“These findings are key for refuting widely held stereotypes that [eating disorders] primarily affect White individuals and also underscore a critical need for solutions aimed to equitably address [eating disorders] in college populations,” the researchers wrote.

They added that universal screening and intervention for eating disorders on college campuses have the potential to significantly reduce the population prevalence of eating disorders in college students: “Such universally delivered programs may include targeted interventions for racially/ethnically minoritized students. These directions represent a critical path to closing the large [eating disorder] treatment gap in this high-risk population.”

For further information, see the Psychiatric Services article “Eating Disorder Treatment Access in the United States: Perceived Inequities Among Treatment Seekers.”

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Therapeutic Chatbot Shows Promise in Randomized Clinical Trial

A therapeutic chatbot guided by generative AI was more effective than a waitlist control at reducing symptoms of depression, anxiety, and disordered eating, according to a report published in NEJM AI.

“Although existing companion Gen-AI chatbots can be highly engaging, they are not trained or evaluated for treating clinical-level mental health symptoms,” wrote Michael V. Heinz, M.D., and colleagues at Dartmouth College. “Gen-AI conversational agents tailored to integrate both evidence-based techniques and important nonspecific factors contributing to psychotherapy outcomes represent a significant opportunity to provide scalable, on-demand, and effective mental health treatment.”

For several years, Heinz and colleagues had been developing such a chatbot, which they called Therabot. This chatbot was trained on therapist–patient dialogues that simulated a cognitive behavioral therapy session and were developed by an expert research team that included a board-certified psychiatrist and a clinical psychologist. As with other chatbots, Therabot analyzes individuals’ text messages and responds with empathetic responses, validation, a targeted intervention, or request for elaboration, as needed.

To test their chatbot, the researchers enrolled 210 adults who self-reported clinically significant symptoms of depression, general anxiety, and/or disordered eating. One-hundred six of the participants received access to Therabot and were prompted to interact with it daily for four weeks; during the subsequent four weeks the participants continued to have access to Therabot but were not prompted to use it. The remaining 104 participants received Therabot after eight weeks.

After four weeks, the adults who received Therabot reported significantly greater decreases across all three symptom categories relative to the waitlist group. For example, depressive symptoms as measured with the Patient Health Questionnaire-9 (range zero to 27) dropped by 6.13 points in the Therabot group and 2.63 points in the waitlist group. All symptom scores remained lower in the Therabot group at the eight-week follow-up.

On average, participants engaged with Therabot for about six hours during the study period and sent 260 messages. Those using Therabot also reported high scores on various measures of user satisfaction (e.g., easy to learn, good interface) as well as their ability to bond with the program.

“Therabot was powered by Gen-AI, allowing for natural, highly personalized, open-ended dialogue,” Heinz and colleagues wrote, adding that within four weeks, participants were able to develop a working alliance comparable to that shown for people attending outpatient psychotherapy.

For related information, see the Psychiatric News article “Popularity of Mental Health Chatbots Grows.”

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Clinicians Often Diagnose Autism Based on Repetitive Behaviors, Not Social Deficits

Clinicians most often diagnose patients with autism when they exhibit repetitive behaviors, special interests, and perception-based behaviors, rather than social deficits, according to a study issued this week in Cell.

“[T]he longstanding experience and expertise of healthcare professionals working alongside people with autism offer a rich resource to unravel the nature of autism,” wrote Jack Stanley, Ph.D., of the Quebec Artificial Intelligence Institute, and colleagues. “In a field that cannot rely upon biological testing methods, breaking down and analyzing subconscious clinical thought and decision-making processes can potentially shed light on opaque facets of the autism phenotype.”

Stanley and colleagues used 4,272 digital health records for 1,080 participants who were assessed for autism at the Autism Spectrum Disorder Assessment Clinic in Montreal (79% male, average age of 7 years, 429 receiving an autism diagnosis). The records included at least one full page of qualitative clinical descriptions, either referral reports and/or assessment reports. The authors built a large language model, a type of artificial intelligence that analyzes human language to identify patterns. Pretrained on hundreds of millions of general language sentences, the model was able to use the digital health records to correctly predict autism diagnoses.

The words that clinicians used most frequently to describe patients they diagnosed with autism involved concepts indicative of repetitive movements and speech, special interests, and sensory-processing and perception-based behavior. For example, the word “flapping” occurred 21 times more often in reports for patients diagnosed with autism compared with reports for children without an autism diagnosis. Additionally, sentences predictive of an autism diagnosis were highly akin to the DSM-5 autism spectrum disorder criteria relating to repetitive behaviors and sensory reactivity. However, there was no overlap between autism-predictive sentences and DSM-5 autism criteria regarding deficits in social communication or social interaction.

“As a consequence of our collective findings, we call into question the heavy focus on social deficits in research and clinical practice, echoed in established diagnostic instruments that are widely used by clinicians,” the authors wrote. “It may in fact be the case that these repetitive, special interest, and perception-based behaviors are much more prototypical of autism than mainstream research and the clinical state-of-the-art suggest.”

For related information, see the Psychiatric News article “More Intensive Early Autism Treatment Not Tied to Better Outcomes.”

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Individuals in U.S. More Likely to Be Referred to Psychiatric EDs by Police Than in Other Countries

Nearly a quarter of referrals to psychiatric emergency departments (PEDs) in the United States are made by police, a rate dramatically higher than the global average, according to a report published today in Psychiatric Services.

Patients referred to PEDs by police tended to be homeless males with a diagnosis of substance use and/or psychotic disorders and were more likely to display aggressive behavior, according to the report.

“Because police-referred patients share many characteristics with incarcerated psychiatric patients, early psychiatric treatment may help reduce the risk for incarceration of police-referred patients,” wrote Thomas Goldschmidt, M.D., of the Frei Universität and Humboldt Universität, Berlin, and colleagues.

The researchers performed a literature search for articles reporting the proportion of adult psychiatric patients brought by police to PEDs in university or general hospitals or comparable settings (such as general medical-surgical hospitals that serve as psychiatric emergency receiving facilities). They included 34 study samples from 28 articles in their analysis, representing 542,143 psychiatric emergency admissions between 1986 and 2021 in 11 countries: the United States, Australia, Belgium, Canada, Croatia, Germany, Israel, Italy, Switzerland, Taiwan, and Turkey. Of the total admissions, 61,647 involved law enforcement.

On average, 13.7% of PED admissions globally were referred by police, compared with 22.8% in the United States. Compared with patients not referred by police, police-referred patients globally were more than four times as likely to show aggressive behavior, 1.84 times as likely to be homeless, and 1.33 times and 1.45 times as likely to have a diagnosis of a substance use or a psychotic disorder, respectively. Police-referred patients were also four times more likely to be involuntarily admitted to a hospital.

Goldschmidt and colleagues said that further research is needed on the effect of early intervention on referrals to PEDS. “Interventions to reduce homelessness among psychiatric patients and other preventive approaches might be especially useful to reduce police referrals,” they concluded.

For related information, see the Psychiatric News article “Stanford Team Examines Intersection of Homelessness, Mental Illness, Police Conduct.”

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Researchers Pinpoint Key Component of Collaborative Care Model for Depression

Manualized psychotherapy and caregiver involvement in the patients’ treatment may be the secret sauce for treating depression with collaborative care, suggests a meta-analysis issued today by JAMA Psychiatry.

“Collaborative care has been shown to be significantly more effective for depression than usual care” in primary care settings, wrote Hannah Schillok, MSc, of Ludwig Maximilian University Hospital in Munich, Germany, and colleagues. “However, its implementation remains rare, primarily due to limited resources and unclear understanding of its components.”

Collaborative care interventions use a multiprofessional approach in which a primary care physician works alongside one or more other health professionals—such as a psychiatrist care manager, a nurse, a psychologist, and/or a social worker—to provide the patient with an evidence-based, structured treatment plan, symptom monitoring, and scheduled follow-ups.

The meta-analysis included data from 35 studies involving 20,046 adults who had depression, mixed anxiety/mood disorder, or symptoms thereof; all were treated in a primary care setting, receiving either a collaborative care approach or usual care. Studies used depression scores from validated inventories as an outcome, from which Schillok and colleagues collected participants’ scores at four to six months.

The researchers then calculated the intensity of each collaborative care model used among four broad components:

• Patient-centered care that respects patient preferences, needs, and values
• Measurement-based care using data-driven decisions for patient management
• Integrated mental health care in the primary setting
• A therapeutic treatment strategy that employs structured treatment strategies such as manual-based psychotherapy, routine follow-ups, and involving friends and family.

Their analysis found that, based on the levels of patient improvement in different models, the most influential component of collaborative care for reducing depression severity was therapeutic treatment strategy, especially the subcomponents of manual-based psychotherapy and involvement of family or friends. The other three components also contributed to a lesser degree.

“Practitioners and policymakers should ensure this key component is consistently included in future intervention designs to optimize effectiveness,” the researchers wrote. “Additionally, these findings offer an initial basis for engaging health insurers to evaluate coverage decisions. Funding critical components may enhance the impact of collaborative care on depression outcomes and support sustainable implementation in routine practice.”

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

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Majority of Hospice Patients With Dementia Continue Cholinesterase Inhibitors, Memantine

More than half of Medicare enrollees with advanced dementia continue to take cholinesterase inhibitors or memantine after being admitted to hospice, even though current guidelines generally recommend discontinuation of these medications in this patient population, according to a research letter in JAMA Internal Medicine.

Lauren J. Hunt, Ph.D., R.N., of the University of California, San Francisco, and colleagues analyzed data from all Medicare claims data from July 2014 through June 2018, when hospice agencies were required to report medications filled for patients to the Centers for Medicare & Medicaid Services (CMS). They examined all hospice enrollees with a terminal diagnosis of dementia who had a 30-day or longer prescription for donepezil, rivastigmine, galantamine, or memantine filled in the three months before admission and who were in hospice care for at least 30 days.

Overall, 138,029 enrollees took cholinesterase inhibitors or memantine at baseline. Of those, 57.3% continued these medications after hospice admission. The researchers defined continued use as any new fill of these medications after admission covered either by the hospice agency or by Medicare Part D. Patients who had Medicaid dual eligibility, lived at an assisted living facility, or lived in the Southeast had increased odds of continuing these medications, as did patients who were enrolled in a large (5,000+ residents) or for-profit hospice agency. More than 80% of fills were covered by Medicare Part D.

“While continued use might be therapeutic and aligned with the goals of some patients, this proportion is much higher than is likely clinically appropriate,” the researchers wrote, adding that many of the predictors of continued use that they identified, such as dual eligibility or hospice ownership, are not known to be related to medical need or benefit. “Study findings reinforce CMS’ concerns that inappropriate cost shifting from the hospice benefit to Medicare Part D may be occurring and point to the need for better enforcement of existing regulations.”

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

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Adding Topiramate to Exposure Therapy Can Boost PTSD Improvements but Doesn’t Affect Drinking

In a clinical trial, veterans taking topiramate alongside prolonged exposure therapy experienced greater improvements in posttraumatic stress disorder (PTSD) symptoms than those receiving exposure therapy alone. However, adding topiramate—used off-label to treat alcohol use disorder (AUD)—did not reduce heavy drinking more than prolonged exposure did by itself.

The trial results were published in the American Journal of Psychiatry.

Sonya Norman, Ph.D., of the University of California, San Diego School of Medicine, and colleagues enrolled 100 veterans (84 male, average age 45) with full or sub-threshold PTSD and co-occurring AUD. The participants were randomized to receive daily topiramate (up to 250 mg) or placebo pills and asked to attend 12 prolonged exposure sessions across 16 weeks. PTSD symptoms were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).

At 16 weeks, veterans in both groups dramatically reduced their number of heavy drinking days and improved their number of days abstinent, though there were no differences between the topiramate and placebo groups. Likewise, there were no differences between groups in secondary outcomes like depression symptoms and quality of life scores.

However, the average CAPS-5 score in the group receiving prolonged exposure and topiramate dropped from 36.72 to 20.83, compared with a drop from 38.60 to 29.87 in the group receiving prolonged exposure and placebo—a significant difference. Overall, 61% of veterans taking topiramate experienced a clinically meaningful change in their symptoms (defined as at least a 12-point improvement in CAPS-5 score), versus 28% of veterans in the placebo group.

At three- and six-month follow-up visits, there was no longer a difference in CAPS-5 scores between the treatment groups, though both groups were still well below baseline.

“While [prolonged exposure] can have lasting effects, with continued recovery up to 10 years following treatment, the actions of topiramate may be such that its efficacy is greatest when patients are actively taking the medication,” Norman and colleagues wrote. “Future studies should examine whether more prolonged topiramate treatment leads to continued greater benefit in PTSD symptoms and perhaps downstream benefits on alcohol use.”

For related information, see the Psychiatric News article “Virtual Exposure Therapy Found Effective for PTSD.”

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Advocacy Alert: Protect SAMHSA Funding

As you are aware, the Substance Abuse and Mental Health Services Administration (SAMHSA) is potentially facing budget cuts as part of the Trump administration’s broader initiative to reduce government spending. The reported cuts could diminish oversight of the grant programs that support patients with severe mental illnesses, hamper efforts to improve 988 awareness, curtail the progress made on reducing overdose deaths, and reduce the ability to bring mental health resources to rural communities. Please urge Congress to protect SAMHSA and continue the successful bipartisan collaboration to address mental health, suicide prevention, and substance use care in our country.

Black Patients Having a Mental Health Crisis More Likely to Be Restrained, Sedated by EMS

Non-Hispanic Black individuals experiencing a mental health crisis are significantly more likely to be restrained or sedated by emergency medical service (EMS) personnel than are non-Hispanic White individuals, according to a report published yesterday in JAMA Open Network.

Diana Bongiorno, M.D., M.P.H., of Harvard Medical School, and colleagues noted that caring for patients with acute agitation is particularly challenging in the prehospital setting because EMS clinicians must consider safety on scene and within the enclosed space of an ambulance, often with limited resources. But, the researchers added, “Although restraints and/or sedation are needed in certain situations, there are notable risks associated with these interventions, including respiratory depression, hypoxia, physical trauma, and, rarely, cardiac arrest.”

The researchers used data from the 2021 ESO Data Collaborative—a database on EMS services—to analyze EMS encounters among patients ages 16 to 90 years having a behavioral health emergency from January 1 to December 31, 2021. The primary outcome was administration of any physical restraint and/or chemical sedation (defined as any antipsychotic medication, benzodiazepine, or ketamine).

The dataset included 661,307 encounters, of which 9.9% were with Hispanic patients, 20.2% non-Hispanic Black patients, 59.5% non-Hispanic White patients, 1.9% non-Hispanic other patients, and 8.6% patients of unknown race and ethnicity. Restraint and/or sedation was used in 7% (46,042) of the encounters.

After adjusting for demographic and community variables, non-Hispanic Black patients were 1.17 times more likely to experience any kind of restraint or sedation compared with non-Hispanic White patients; Black patients were also 1.31 times more likely to experience both restraint and sedation during an EMS encounter. Hispanic patients were 1.04 times as likely to experience physical restraint as non-Hispanic White patients but had no increased odds of chemical sedation or both restraint and sedation.

Bongiorno and colleagues said that future work should include investigation of EMS agency protocols for restraint or sedation use. “Our results also suggest a need for increased EMS training on behavioral health emergencies, and potentially consideration of expanded national prehospital education standards … that include de-escalation training,” they wrote.

For related information, see the Psychiatric News article “APA Resource Document Outlines Principles on Use of Seclusion, Restraint.”

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Advocacy Alert: Protect SAMHSA Funding

The Substance Abuse and Mental Health Services Administration (SAMHSA) is potentially facing budget cuts as part of the Trump administration’s broader initiative to reduce government spending. The reported cuts could diminish oversight of the grant programs that support patients with severe mental illnesses, hamper efforts to improve 988 awareness, curtail the progress made on reducing overdose deaths, and reduce the ability to bring mental health resources to rural communities. Please urge Congress to protect SAMHSA and continue the successful bipartisan collaboration to address mental health, suicide prevention, and substance use care in our country.

TikTok ADHD Content Receives Millions of Views but Is Accurate Less Than Half the Time

Fewer than half the claims about attention-deficit/hyperactivity disorder (ADHD) in the most popular TikTok videos on the topic were clinically accurate, according to a study published yesterday in PLOS One. Yet young adults, particularly those who diagnosed themselves with ADHD, reported that they were likely to recommend these videos to others as ADHD psychoeducation.

Vasileia Karasavva, M.A., of the University of British Columbia, and colleagues identified the 100 most popular TikTok videos on a single day that included the hashtag #ADHD. In total, these videos amassed more than half a billion views. Two clinical psychologists with expertise in ADHD assessed whether the claims made in the videos aligned with the DSM-5. They also rated each video on whether they would recommend it to others as an example of ADHD psychoeducation on a scale of one to five.

Overall, there was 84.8% agreement between the two psychologists about the videos, and only 48.7% of the claims made in the videos were considered accurate by at least one of them. The most common mischaracterization was to suggest that reasonably normal human behavior (e.g., occasional lapses in concentration) was a symptom of ADHD.

The researchers then showed the top five videos the psychologists would recommend and the bottom five they would not recommend to 843 participants between the ages of 18 and 25 (79% female). Among the participants, 224 had no ADHD diagnosis, 198 had received a formal diagnosis from a mental health professional, and 421 were self-diagnosed with ADHD. The participants rated each video on whether they would recommend it to others as an example of ADHD psychoeducation on the same one-to-five scale.

Participants with a self-diagnosis perceived TikToks about ADHD more favorably than those without ADHD. Additionally, those who reported watching ADHD-related TikToks more frequently were more likely to favorably evaluate the top- and bottom-rated TikToks.

Compared with the psychologists, participants had a more favorable view of the bottom five videos and a less favorable view of the top five videos. Yet overall, their ratings of the top five videos (2.82) were higher than their ratings of the bottom five videos (2.32). “Taken together, this suggests that young adults do critically evaluate #ADHD TikTok videos, albeit not always in a pattern that converges with psychologist judgments,” the researchers wrote.

“On a positive note, this [study] underscores the importance of TikTok for democratizing mental health information, and for promoting understanding and destigmatization of the challenges faced by those with ADHD,” Karasavva and colleagues concluded. “At the same time, TikTok’s anecdotal content could lead some viewers to misattribute normal behaviors or those better explained by other conditions to be signs of ADHD, complicating an already challenging differential diagnosis and treatment process.”

For related information, see the Psychiatric Services article “The Need to Adapt the Psychiatric Clinical Assessment to the Digital Age: A Practical Approach.”

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Experts at AAGP Annual Meeting Offer Tips for Addressing Ageist Microaggressions

Ageism and ageist microaggressions can damage the rapport between psychiatrists and their older patients and affect the quality of care. However, there are multiple ways of addressing these microaggressions, said speakers at the American Association for Geriatric Psychiatry (AAGP) 2025 Annual Meeting in Phoenix.

Wayles Haynes, M.D., M.F.A., an assistant professor of geriatric psychiatry at the University of New Mexico, described age-related microaggressions as commonplace verbal or behavioral indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative ageist slights or insults. “[They convey that] you’re invisible, you don’t belong, you’re not normal, you’re a burden,” she said. Examples include speaking to older adults in an infantilizing manner, refusing to hire someone because of age, or even making a perceived positive comment such as “you look good for your age.” 

“Whether ageist microaggressions are targeted toward oneself or others or exist within institutions, think about what they are doing,” Haynes said. “What are the consequences? “What makes things harder … for our patients?” 

Using roleplay and case vignettes, Haynes and other panelists in the session demonstrated strategies for responding to ageist microaggressions. These strategies are based on the 6D model of responding to racism, discrimination, and microaggressions: 

• Direct, where the person addresses the microaggression in a verbal or behavioral way in the moment
  
  
• Distract, where the person changes the topic
  
  
• Delegate, where the person turns to someone else in the hierarchy to respond to it (i.e., an attending physician addressing a microaggression overheard by a resident)
  
  
• Defer, where the person chooses a later time to discuss the microaggression with the individual who committed it
  
  
• Display discomfort, where the person pauses a conversation after hearing a microaggression and nonverbally and subtly indicates that what was said did not “sound right,” and then continues the discussion, without directly confronting the microaggression
  
  
• Debrief, where the person discusses the microaggression with a peer or mentor to help process the experience.
  
  

Haynes noted that which strategy a witness or recipient of a microaggression chooses to use depends on several factors, such as whether the person belongs to a privileged demographic, whether the person is in a position of power, and the person’s own comfort level. 

“All of these strategies are appropriate,” Haynes said. “You get to decide when you act and what you do. It’s a very individualized choice.”

For related information, see the Focus article “Check Your Ageism at the Door: Implicit Bias in the Care of Older Patients.”

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More Than a Quarter of American Adults Gamble Online Daily, APA Poll Finds

As millions of Americans prepare to track their college basketball pools throughout March Madness, new poll data from APA reports that more than one-quarter of American adults report a daily habit of online gambling.

The poll shows that among U.S. adults, 28% have a daily habit of gambling online, with men being more likely than women to gamble online for at least a few minutes a day (36% compared with 20%, respectively). More than half of adults (58%) who gamble online daily said that they have intentionally taken a break or limited the amount of time they spend gambling, with men more likely to report doing so than women.

However, 9% of adults reported gambling online for more than four hours daily, with 2% of individuals indicating they regularly gamble for more than 10 hours a day.

Maladaptive gambling behavior is diagnosed as gambling disorder when it is persistent and recurrent and disrupts personal, family, and/or vocational pursuits. While previously categorized as an impulse control disorder, gambling disorder is now recognized in the DSM as a behavioral addiction.

Gambling disorder is marked by behaviors such as preoccupation with gambling, increasing amounts gambled, unsuccessful control attempts, restlessness or irritability when attempting to stop, and “chasing losses.” As noted in a Psychiatric News Special Report, however, most people with this disorder do not show any clear physiological signs of intoxication or withdrawal that may suggest a problem.

One-third (35%) of respondents who said they gamble online daily said they began doing so between the ages of 18 and 25, suggesting that late adolescence and early adulthood is a crucial period for shaping attitudes toward online gambling. For each age ascending range following 18-25, respondents were less likely to report having begun gambling during that time.

For related information, see the Psychiatric News “Viewpoints” article “The Real Madness of March: Why Every Psychiatrist Should Be Screening for Gambling Disorder.”

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APA Expresses Concern Over Reported Cuts to SAMHSA

In a statement released today, APA voiced its disapproval of the possible personnel cuts to the Substance Abuse and Mental Health Services Administration (SAMHSA) that have been reported in multiple news outlets. According to reports, SAMHSA has already seen a reduction in about 10% of its workforce, with additional reductions of up to 70% being considered.

“SAMHSA’s programs have contributed to the advances our nation has made in fighting the mental health and addiction crises. Its impact across the nation is widespread and crucial,” the APA statement reads, noting the numerous vital services provided by SAMHSA, particularly the national 988 Suicide & Crisis Lifeline, which took in more than 14.5 million calls, texts, and chats in its first two years.

SAMHSA also oversees the Certified Community Behavioral Health Clinic program, which provides mental health and substance use care across the United States, including in many rural communities. New data from the CDC has shown a 24% decline in drug overdose deaths in the United States for the 12 months ending in September 2024, compared with the previous year. This would be the fewest overdose deaths in any 12-month period since June 2020.

“Before taking any executive actions that will affect our nation’s mental health, the APA calls on the Administration and Congressional leadership to work with us and our partner organizations to thoughtfully pursue the best path forward to ensure people with mental health and substance use disorder do not lose services they desperately need,” the statement concludes.

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Stigma, Unfamiliarity Identified as Patient Barriers to Medications for AUD

Patients cite stigma, lack of knowledge, and concerns over side effects as the biggest barriers to taking medications for alcohol use disorder (AUD), according a study issued this week in Alcohol: Clinical and Experimental Research.

Although medications for AUD have been approved by the U.S. Food and Drug Administration (FDA) for decades and are effective, they remain underutilized. “In 2022, among adults with past-year AUD, only 2.2% received [medications for AUD],” wrote Devin Tomlinson, Ph.D., of the University of Michigan, and colleagues. “To place this in context, although there are important differences, about 22.3% of people with opioid use disorder receive medication treatment.”

Tomlinson and colleagues conducted a scoping review of 14 studies that examined the perspectives of adult patients with AUD on naltrexone, disulfiram, and acamprosate, all of which are FDA-approved for AUD. The authors identified several common themes:

• Many patients reported a lack of awareness of existing treatments for AUD, including medications.
• Patients who had no experience with medications for AUD reported a lack of understanding of their therapeutic effects. These patients also cited side effects as a reason why they were unwilling to try medications in the future.
• The studies identified substantial stigma around medications for AUD. Patients referred to medications as a “last resort,” and some shared feelings of shame, failure, and negative judgments associated with AUD treatment in general and medications specifically.
• For some patients, medications did not align with their treatment goals because they wanted to reduce their alcohol use rather than eliminate it completely.
• However, patients were willing to try medications for AUD when they were adequately informed.

The authors emphasized the importance of educating patients to help alleviate the gap in understanding about medications for AUD: “These recommendations are consistent with results indicating that increasing a patient’s knowledge of [medications on AUD], the intended therapeutic effects, and the potential for unfavorable side effects (including those related to drug interactions) would facilitate the adoption of MAUD.”

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

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Strong Sense of Ethnic Identity Among Black, Latinx Teens Linked to Feelings of Belonging

Black and Latinx adolescents with a stronger sense of ethnic identity are less likely to experience “thwarted belongingness,” a feeling of disconnectedness to others and not belonging to a larger group, according to a report today in Psychiatric Research and Clinical Practice. Thwarted belongingness, along with perceived burdensomeness, has been shown to be significantly associated with suicide risk.

“Strengthening these adolescents’ sense of ethnic identity to reduce TB may be a plausible suicide prevention strategy to reduce suicide ideation,” wrote Carolina Vélez-Grau, Ph.D., L.C.S.W., of Boston College of Social Work, and colleagues.

The researchers recruited 61 Black and Latinx teenagers, ages 13 to 17, from community‐based organizations in New York City between 2021 and 2022. Most participants were male (72.1%) and self‐identified as Latinx (75.4%).

The teenagers answered The Multigroup Ethnic Identity Measure (MEIM), rating how much they agreed with 12 statements such as “I have a clear sense of my ethnic background and what it means to me” on a four-point scale (strongly disagree to strongly agree). Higher scores indicate a stronger, more secure ethnic identity.

The researchers also completed the Interpersonal Needs Questionnaire, which measured participants’ beliefs about the extent to which they feel like a burden to others (for instance, “These days, the people in my life would be better off if I were not here”) or about how much they feel connected to others (for instance, “These days, I feel like I belong”).

Individuals with higher total MEIM scores reported significantly lower levels of thwarted belongingness, even after controlling for sociodemographic factors such as gender, age, ethnicity, country of origin, income, and language. The researchers did not find an association between ethnic identity and perceived burdensomeness.

The results also showed an association between speaking Spanish as a preferred language and lower perceived burdensomeness among Latinx adolescents, suggesting the importance of maintaining a strong ethnic identity through language. Additionally, higher income was associated with higher scores of thwarted belongingness. The authors speculated that Black and Latinx teenagers with high income “might live, play, and learn in environments where non‐Latinx White adolescents are the majority, which may lead to feelings of being an outsider.”

Vélez-Grau and colleagues suggested that programs such as the Ethnic Identity Project may help reduce suicide risk among Black and Latinx teenagers.

“Incorporating ethnic identity in the psychiatric assessment and prevention of suicide ideation and as a universal upstream approach to suicide may be valuable and relevant to ethnoracially minoritized adolescents,” they wrote.

For related information see the Psychiatric News Alert “BIPOC Individuals Much More Likely to Have Cultural Conversations With Therapists.”

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Clozapine Linked to Lower Mortality in Older Patients With Schizophrenia

Older patients with schizophrenia who take clozapine may have a lower risk of death than those who take several other atypical antipsychotics, a study in the American Journal of Geriatric Psychiatry suggests. However, the study also found that there was no significant difference between clozapine and ziprasidone with respect to mortality.

Júlio César Menezes Vieira, M.Sc., of the Federal University of Minas Gerais in Brazil, and colleagues analyzed data from 83,284 Brazilian patients ages 60 years and older who were diagnosed with schizophrenia and received their first atypical antipsychotic from the Brazilian National Health System between 2000 and 2014. The antipsychotics prescribed included clozapine, risperidone, quetiapine, olanzapine, and ziprasidone. Patients were followed until December 31, 2015.

Overall, the 15-year (180-month) survival rate among these older patients was 18.4%, with a median survival time of 31 months. When compared with all non-clozapine antipsychotics as a group, clozapine was associated with a higher median survival time (38 months versus 31 months), higher 100-month survival rate (55.6% versus 39.4%), and higher 180-month survival rate (32.5% versus 18.1%). Among all individual antipsychotics, ziprasidone had the highest median survival time of 44 months, while quetiapine had the lowest at 26 months.

Patients who took quetiapine, risperidone, and olanzapine had an 80%, 69%, and 12% greater risk of dying, respectively, during the complete 16-year follow-up than those who took clozapine. There was no statistically significant difference in the risk of dying between those who took clozapine and those who took ziprasidone.

The researchers noted that clozapine is not the first antipsychotic of choice for older patients with psychosis because of its adverse effects and tolerability: Older patients have four times the risk of clozapine-induced neutropenia/agranulocytosis compared with younger patients, and clozapine has been linked to increased cardiovascular and metabolic risks.

“To ensure safe clozapine management in older patients, comorbidities must be medically assessed before introducing the antipsychotic, in addition to monitoring side effects and conducting regular complementary tests during treatment,” the researchers wrote. “Greater clozapine tolerability can be achieved in older adults through lower doses and slow titration.”

For related information, see the Psychiatric News article “FDA Has Ended the Clozapine REMS. What Happens Now?”

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Out-of-Network Care More Common in Substance Use, Mental Disorder Treatment

Patients with private insurance who saw behavioral health professionals went out-of-network for their care more often than their peers who received care from medical or surgical health professionals, according to a study published today in Psychiatric Services.

Tami L. Mark, Ph.D., of RTI International, and colleagues analyzed deidentified health insurance claims data from 22.8 million individuals in the Merative MarketScan Commercial Database who had private insurance in 2021. They compared the percentage of out-of-network claims for behavioral health providers with the percentage of out-of-network claims for medical and surgical providers across four settings: inpatient facilities, subacute inpatient facilities, outpatient facilities, and office visits to independent practitioners.

Across all settings, patients with substance use disorder (SUD) were most likely to go out-of-network for care, followed by those with a mental disorder and those who received medical or surgical care. For example, the percentages of out-of-network encounters in acute inpatient facilities such as hospitals were 18.1% for SUD, 4.3% for mental disorders, and 1.5% for medical or surgical treatments. The percentages of out-of-network encounters in subacute inpatient facilities such as residential settings were 35.9% for SUD, 31.7% for mental disorders, and 1.7% for medical or surgical treatments.

“Our finding of greater use of out-of-network behavioral health providers versus medical or surgical providers is consistent with findings from other studies in which researchers used different methodologies (e.g., secret shopper calls, employer surveys, consumer surveys, and provider network analyses) that showed that consumers have limited access to in-network behavioral health providers,” the researchers wrote. “Health plans have strategies to increase providers’ network participation, such as increasing reimbursement rates, reducing the administrative inconveniences of joining a health plan, and reducing the administrative burden of being paid by a health plan.”

For related information, see the Psychiatric News article “Access to In-Network Mental Health Care Still Lags Far Behind Other Medical Care.”

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Sensory Sensitivity in People With Autism May Be Due to Emotional Blindness

Alexithymia—a condition associated with difficulty in identifying and describing one’s own emotions—may be a strong influence in how much sensory sensitivity people with autism spectrum disorder experience, reports a study in Translational Psychiatry.

“Reported across almost all sensory domains (e.g., taste, touch, audition, smell, vision and interoception), atypical sensory experience is now considered a diagnostic feature of autism … and ranks as one of the top concerns reported by autistic individuals,” wrote Isabel Yorke, Ph.D., of King’s College London, and colleagues. “Given the impact of sensory sensitivity on the wellbeing of autistic individuals, understanding the aetiological factors that contribute towards atypical sensory experience is an urgent research goal.”

Yorke and colleagues made use of the Twins Early Development Study, an ongoing cohort study that recruited more than 16,000 pairs of twins born in England or Wales between 1994 and 1996. They included data from 127 twin pairs who had received comprehensive diagnostic assessments and in which at least one twin had autism. The researchers then added in 80 families in which neither twin had autism. The final sample included 55 identical twins and 152 fraternal twins.

The researchers conducted a series of modeling analyses to examine the interaction between the severity of alexithymia, sensory issues, and/or autism in the twins. The co-occurrences of these conditions in identical versus fraternal twins was also compared to explore the role of genetics versus environment.

Overall, the analysis found a strong correlation between autism and sensory symptoms; however, after controlling for alexithymia, the association between autism and sensory symptoms was no longer significant. In contrast, the correlation between alexithymia and sensory symptoms was significant, even after factoring in the influence of autism.

“This suggests that alexithymia and sensory processing share genetic factors, independent of those that increase the likelihood of autism,” Yorke and colleagues wrote. “As such, although alexithymia and sensory symptoms commonly co-occur with autism (potentially due to a degree of shared genetic liability), they are also independent from autism.”

Given that sensory symptoms are now included in the diagnostic criteria for autism spectrum disorder, “these results suggest a need to consider the influence of alexithymia both when diagnosing autism and providing support,” they concluded.

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Frontotemporal Dementia: A Window to Alexithymia.”

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Childhood Trauma, Early Puberty Associated With Internalizing Symptoms in Girls

Girls who experience childhood trauma are at a higher risk of developing internalizing symptoms like depression and anxiety by ages 12 to 14, an association that is partially explained by starting puberty ahead of their peers, according to a study issued this week in The Journal of Child Psychology and Psychiatry.

Niamh MacSweeney, Ph.D., of the University of Oslo, Norway, and colleagues used data from 4,225 girls enrolled in the Adolescent Brain Cognitive Development Study. Each participant, who enrolled at age nine or 10, was assessed annually over four years, with their parents reporting their exposure to trauma at baseline and their pubertal development at each assessment. When participants were between the ages of 12 and 14, they self-reported their internalizing symptoms.

Participants followed three distinct patterns of pubertal development:

• Typical developers (76% of participants) were in the early stages of puberty when the study began and had the most rapid pace of development over time, such that they were in the later stages by ages 12 to 14.
• Slow developers (15%) were just entering the early stages of puberty by ages 12 to 14.
• Early starters (9%) were already midway through puberty by ages nine to 10 (these participants, however, showed a protracted pace of development and had about the same degree of pubertal maturation on average as typical developers by ages 12 to 14).

Early starters had significantly higher exposure to trauma at baseline compared with slow or typical developers, while slow developers had lower trauma exposure compared with typical developers. Slow developers also had significantly lower internalizing symptoms compared with early starters and typical developers. In examining the trajectories of the girls’ development, the researchers found that greater childhood trauma was linked with greater internalizing symptoms at ages 12 to 14, and this association was mediated by early puberty onset. Among early developers, having a slower pace of puberty development after age nine partially reduced this risk of internalizing symptoms.

“It has been proposed that the association between early pubertal timing and internalizing symptoms is underpinned by an asynchrony between a young person’s physical, cognitive and social development,” the authors wrote. “Additionally, the type of trauma experienced (e.g., threat vs. neglect) and the trajectory of internalizing difficulties across adolescence (e.g., limited to early adolescence, persistent across adolescence, or only emerging in later adolescence) will be crucial to consider in future longitudinal research to better characterize at-risk and resilient youth and inform prevention strategies.”

For related information, see the Psychiatric News article “Group School Intervention Helps Girls Cope With Internalized Trauma.”

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Condensed, High Intensity TMS Found Effective in Patients With Treatment-Resistant Depression

Patients with treatment-resistant depression receiving three weeks of accelerated theta burst stimulation (aTBS)—a form of transcranial magnetic stimulation (TMS) using short, targeted bursts—experienced greater reduction in depression scores than did those who received a sham procedure, according to a report in JAMA Psychiatry.

“Our study introduced a pragmatic aTBS approach for clinical practice,” wrote Matheus Rossi F. Ramos, M.D., of the University of Sao Paulo Medical School, and colleagues. “The 78-minute daily treatment duration can likely fit into most outpatient participants’ routines, allowing them to maintain daily functionality.” Further, their protocol does not require neuroimaging equipment to identify where the TMS bursts should be directed.

From July 2022 to June 2024, 89 outpatients with treatment-resistant depression (average age of 41.7) were randomized to receive either 45 sessions of active aTBS over 15 weekdays or a sham procedure. All participants had scores of greater than 16 on the Hamilton Depression Rating Scale (HDRS), were considered at low risk of suicide, and had not responded to more than one antidepressant trial. The active aTBS involved three magnetic pulse sessions (each for six minutes and 18 seconds) interspersed with two 30-minute breaks. The magnetic pulses were directed to the brain's left dorsolateral prefrontal cortex.

Those patients receiving the active procedure experienced an average reduction in HDRS scores of 9.68 (a 55% decrease from baseline) compared with 5.57 in the sham group, indicating a medium-to-large effect size. A total of 17 patients (34%) in the active treatment arm experienced remission—defined as an HDRS score of eight or less—compared with eight participants (16%) receiving the sham procedure. The treatment was well tolerated, although those receiving active aTBS experienced scalp pain.

“Further research offers promising directions for future advancements in this field, including clinical trials comparing new aTBS protocols with standard ones and studies exploring the optimal parameters for these protocols,” the researchers concluded.

For related information, see the Psychiatric News article “FDA Clears Accelerated TMS Protocol for Depression.”

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