Hearty Breakfast Associated With Lower Depression Risk in Patients With CVD

Individuals with cardiovascular disease (CVD) who eat more calories at breakfast have a lower risk of depression compared with those who eat fewer calories at breakfast, according to a study issued in BMC Psychiatry.

“[T]here is growing evidence that individuals with [CVD] are more likely to develop depression when compared to the general population—and dietary factors have been shown to play an important role in depression occurrence and development,” wrote Hongquan Xie, of the Harbin Medical University in China, and colleagues.

Xie and colleagues analyzed 2003-2018 data from 31,683 individuals enrolled in the National Health and Nutritional Examination Survey, which collects detailed dietary and nutritional data of adults and children in the United States. A total of 3,490 participants (average age of about 66, about 58% male) had CVD, 554 of whom also had depression according to their responses on the Patient Health Questionnaire-9. Participants reported what they ate during the day, and the food was evaluated for macronutrients and dietary energy (calories).

Overall, participants who ate the most calories at breakfast (791 calories on average) had about a 30% lower risk of depression compared with those who ate the fewest (88 calories). Other macronutrients, including carbohydrates and protein, were not associated with the risk of depression. Additionally, the authors found that substituting 5% of the calories from dinner or lunch with breakfast led to a 5% decrease in depression risk.

The authors wrote that the study’s results emphasize the core principle of chrono-nutrition: “[W]hen you eat is as important as what you eat. Dietary energy consumption time should coordinate with body clock fluctuations to reduce the risk of depression.”

For related information, see the Psychiatric News article “Special Report: Using Nutrition as a Therapeutic Modality.”

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AUD, Depression May Not Dampen Alcohol’s Pleasurable Effects

Individuals with alcohol use disorder (AUD) and comorbid depression still experience high levels of pleasure when drinking, according to a study appearing in the February issue of The American Journal of Psychiatry.

These findings run counter to the allostasis model of addiction, which posits that excessive alcohol use changes brain responses so that people drink more to relieve negative feelings rather than for pleasure or reward.

Yet as Andrea C. King, Ph.D., and colleagues at the University of Chicago, wrote: “Debate remains whether excessive drinking reflects overall acute alcohol tolerance, desire for relief from negative mood states (e.g., depression), or heightened sensitivity to alcohol’s pleasurable effects.”

King and colleagues examined data from 221 adults ages 21 to 35 across the United States who completed a one-week assessment of drinking behavior. This group included 120 adults with AUD (of whom 64 also had a depressive disorder within the past year) and 101 adults without AUD (of whom 45 had past-year depression).

All participants completed daily mood surveys along a detailed survey of a typical drinking session and a typical non-drinking session during the week; for these surveys, participants reported how they felt both while drinking (or not) and the following morning.

As anticipated, individuals with AUD on average drank more during a typical drinking session than those without AUD (8.5 standard drinks versus 3.7 standard drinks, respectively). Individuals with AUD also reported more pleasurable feelings such as stimulation and wanting more than those without, both initially and across the three-hour monitoring period. The researchers identified no significant differences in pleasure levels between individuals with or without depression.

Adults in all groups reported less negative affect during drinking, though the changes were smaller in magnitude and showed no significant difference based on AUD or depression status.

“In the present study’s real-time assessment of naturalistic drinking episodes, we found evidence of sensitivity to alcohol’s desirable subjective effects, rather than tolerance to these effects … in persons with AUD, regardless of depression status,” the researchers wrote. They suggested that the pathway from early drinking to addiction may be better viewed as a coexistence of positive and negative reinforcement, rather than progression from one to the other.

For related information, see the Psychiatric News article “NIAAA Director Hopeful About Growing Awareness of Risks, Harms of Alcohol.”

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Fathers’ Depression May Affect Children’s Behavior

Kindergarten-age children who have fathers with depression are more likely than children not exposed to paternal depression to have behavioral problems and poor social skills several years later, a study in the American Journal of Preventive Medicine has found.

Kristine Schmitz, M.D., of Robert Wood Johnson Medical School, and colleagues examined data from 1,422 children enrolled in the Future of Families and Child Wellbeing study. This ongoing study is following a cohort of individuals born in one of 20 large U.S. cities between 1998 and 2000 as well as their families. More than 75% of mothers in the study were unmarried at the time of their children’s birth. Paternal depression was assessed using the World Health Organization’s Composite International Diagnostic Interview Short Form when the children were 5 years old, at which time 9% of fathers screened positive for depression.

When the children were 9 years old, their teachers reported the children’s behavior via the Conners’ Teacher Rating Scale—Revised Short form and the Social Skills Rating Scale. These assessments measure externalizing behaviors, internalizing behaviors, attention problems, and social problems.

After adjusting for numerous child and family variables, including maternal depression and whether the father lived with the child, the researchers found that paternal depression was associated with a 36% higher oppositional score, 37% higher hyperactive score, and 25% higher attention-deficit/hyperactivity disorder score at age 9. Paternal depression was also associated with an 11% lower positive social skills score and a 25% higher problematic behavior score. There were no associations between paternal depression and cognitive problems/inattention.

“Several potential mechanisms could underlie the findings,” the researchers wrote. “Depression can lead to suboptimal parenting and less emotional support for the child. Paternal depression has been associated with fewer positive and more negative parenting behaviors, including harsher parenting and physical punishment.”

The researchers added that the findings support the need to identify fathers at risk for depression beyond the perinatal period and link them to interventions to support their children’s well-being.

“[The findings] also suggest the need for interventions supporting school-aged children exposed to paternal depression,” the researchers wrote. “Pediatricians, with their frequent contact with families, are well-positioned to address these important needs.”

For related information, see the Psychiatric News article “One-Third of Teens Have Parent With Anxiety or Depression.”

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Antidepressant Use Drops During Pregnancy, but Often Not Replaced With Psychotherapy

Many women stop taking antidepressants during pregnancy but don’t substitute their depression management with psychotherapy, reports a study in JAMA Network Open.

“Choosing whether to continue taking antidepressants during pregnancy can be complicated,” wrote Claire Boone, Ph.D., of McGill University, and colleagues. “Although evidence is limited, there are safety concerns regarding in utero exposure to some antidepressant medications. However, untreated maternal depression can have severe long-term consequences for mother and child.”

The researchers used the Merative MarketScan Research Databases, which contain private insurance claims data, to analyze prescription trends in 385,731 women who gave birth between 2011 and 2017.

Overall, 4.3% of women in the sample filled an antidepressant prescription in the year before pregnancy while 2.2% filled a prescription during pregnancy. Within one month of childbirth, antidepressant prescriptions returned to pre-pregnancy trends. In addition, there was a slight decrease in psychotherapy claims among pregnant women compared with pre-pregnancy trends, with such claims also jumping back up after childbirth.

The researchers did not find similar drops in antidepressant use among the spouses of these women during pregnancy, suggesting that the medication change was not associated with other, co-occurring changes in the couple’s life.

These findings show that many women value treatment “but were choosing to avoid antidepressant use during pregnancy. However, given the time delay for antidepressant medication to function, restarting medication after pregnancy may leave many women effectively untreated during the high-risk postnatal period,” Boone and colleagues wrote.

For related information, see the Psychiatric News article “Mood Symptoms in Pregnant Women May Not Be Fully Resolved by SSRIs.”

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Stimulant Dispensing for Young ADHD Patients Remains Below Pre-Pandemic Levels

Stimulant dispensing to U.S. children being treated for attention-deficit/hyperactivity disorder (ADHD) dropped significantly from the start of the COVID-19 pandemic through 2023, with adolescent boys bearing most of the brunt of the drop, according to a study in Pediatrics.

The shortage of immediate-release mixed amphetamine salts (Adderall) that began in fall 2022 was not a significant contributor to the drop because it was largely offset by increased dispensing of other stimulants, according to Sijia He, M.S., from the University of Michigan Medical School, and colleagues.

The findings stand in contrast to prior research that found that the number of new stimulant prescriptions for patients of all ages was well above pre-pandemic levels by the end of March 2022, He and colleagues noted. “The discrepant findings may derive from our inclusion of all stimulant prescriptions, not just incident prescriptions, as well as the fact that trends in stimulant dispensing to adults and children have diverged, with large increases among the former and much smaller changes in the latter,” they wrote.

The researchers analyzed stimulant dispensing data for youth ages 5 to 17 from IQVIA, a database that captures 92% of U.S. prescriptions from retail pharmacies, from 2017 through 2023. Their analysis revealed three main findings:

• The overall stimulant-dispensing rate to youth as of December 2023 was 6.6% lower than pre-pandemic levels in January 2017 because this rate never fully recovered after the large decline that began with the pandemic in March 2020.
• The impact was different by sex and age, with adolescent boys particularly impacted. By December 2023, the monthly stimulant-dispensing rate was close to pre-pandemic levels among boys ages 5 to 11 and 9% higher than predicted among girls. Among adolescents ages 12 to 17, the stimulant-dispensing rate dipped only slightly for girls but fell 19% below the pre-pandemic level for boys.
• There was a 13% decrease in dispensing rates of immediate-release mixed amphetamine salts starting in October 2022, but counterbalancing increases in the dispensing of extended-release mixed amphetamine salts and dexmethylphenidate.

“Decreases in dispensing of stimulants and antidepressants to adolescent boys are unlikely to reflect improved mental health, given evidence that the mental health of adolescent boys worsened during the pandemic,” the researchers wrote. “A more plausible explanation is that adolescent boys were less likely to seek care for mental health symptoms during the pandemic, potentially increasing their risk of adverse events…. This possibility should be urgently explored.”

In an accompanying commentary, Sarah Weas, M.S.N., M.P.H., with Boston Children’s Hospital, and William J. Barbaresi, M.D., with Harvard University, wrote that the analysis didn’t factor in the increasing number of children being diagnosed with ADHD every year, thus underestimating the number of children who are now going without treatment. Furthermore, the findings do not adequately capture the profound impact of the medication shortages on children who have been forced to switch to other stimulant medications and their families, they wrote.

For related information, see the Psychiatric News articles “Months Later, Stimulant Shortage Persists” and “Stimulant Prescriptions Spiked During Pandemic, CDC Finds.”

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Meta-Analysis Reveals Disappointing Efficacy for Esketamine in Depression, Suicidality

Patients with treatment-resistant depression may only receive a modest, short-term benefit from using intranasal esketamine as an add-on treatment, according to a meta-analysis published today in the American Journal of Psychiatry. Moreover, the analysis reveals almost no benefit from esketamine for suicidality compared with placebo.

The study renders sobering judgement on a drug that spurred much excitement after the Food and Drug Administration (FDA) approved it as an adjunct therapy for treatment-resistant depression in 2019. Last week, the FDA expanded the approval to allow esketamine as a stand-alone treatment in adults with treatment-resistant depression.

“The trial data concerning the efficacy of intranasal esketamine as an add-on treatment in depression are mostly negative after the first few days, despite a significantly greater early improvement in comparison to placebo,” wrote Konstantinos N. Fountoulakis, M.D., of the Aristotle University of Thessaloniki, Greece, and colleagues.

The authors analyzed 87 English-language articles about esketamine, including randomized control trials (RCTs), open-label trials, case reports, retrospective chart reviews, and post-hoc analyses of previous RCTs.

Across all of these, results for the efficacy of esketamine for depressive symptoms were modest at best. For instance, among 10 RCTs testing acute depressive response (using the Montgomery-Åsberg Depression Rating Scale) in 979 patients randomized to esketamine and 795 to placebo, almost all results showed esketamine was superior during the first four days but then was inconsistent after one week and not superior to placebo by week four.

A meta-analysis combining these 10 studies suggested that esketamine may be slightly efficacious at four weeks, but the improvements were no better than those seen in patients who augment their antidepressant with an antipsychotic medication.

Similarly, among 11 RCTs examining the effect of esketamine on suicidality, results suggest a significant positive effect two to four hours after administration. But the 24 hour data was inconsistent, and all seven trials reporting on suicidality around week four were negative.

Fountoulakis and colleagues did cite the positive results of a clinical trial comparing esketamine monotherapy to placebo, which the FDA used to grant its new approval. “While these results, if verified, point to an efficacy of esketamine as monotherapy, they are not superior to the results expected by continuing the same antidepressant or switching to a new one,” they wrote.

The authors also drew attention to concerns about safety and potential for abuse and addiction associated with esketamine, and to the fact that long-term effects of the drug on cognition are unknown.

For related information, see the American Journal of Psychiatry article, “Synthesizing the Evidence for Ketamine and Esketamine in Treatment-Resistant Depression: An International Expert Opinion on the Available Evidence and Implementation.”

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Only One-Third of Daily Fentanyl Users Report Success With Low-Dose Buprenorphine

Low-dose buprenorphine initiation among individuals who use fentanyl daily is often unsuccessful, suggesting that clinicians may need to provide more support for withdrawal symptoms in these individuals, according to a study issued in JAMA Network Open.

“… [F]entanyl is hypothesized to accumulate in fat stores much longer than other opioids, and individuals initiating buprenorphine can still undergo severe precipitated withdrawal, despite waiting until experiencing withdrawal [to begin buprenorphine treatment],” wrote Leslie W. Suen, M.D., of the University of California, San Francisco, and colleagues. “The emerging practice of low-dose initiation of buprenorphine presents an opportunity to improve outcomes in the fentanyl era.”

Suen and colleagues analyzed medical records for 126 adults with opioid use disorder who self-reported daily fentanyl use and requested to receive low-dose buprenorphine initiation using a four-day or seven-day protocol.

Success was defined as self-reported initiation completion and subsequent pickup of a refill prescription of buprenorphine within one month of initiation; the researchers also assessed buprenorphine retention rates.

Researchers adjusted the results for multiple attempts and demographic data, including housing status.

Overall, the 126 participants underwent 175 initiation attempts. Low-dose buprenorphine initiation attempts were successful in 60 participants (34%), including 27 among four-day protocol and 29 among seven-day protocol attempts. The researchers’ analysis found no significant differences between successful initiation and protocol length. However, repeated attempts had lower odds of success.

Buprenorphine treatment retention rate at 28 days was 21% for a four-day protocol and 18% for a seven-day protocol. Unadjusted and adjusted models did not detect a significant difference in retention between protocol type.

Success and treatment retention rates for low-dose buprenorphine initiation were significantly lower than those in prior studies among people using heroin or prescription opioids in the pre-fentanyl era, the researchers noted. This is due in part to “the pharmacologic challenges associated with chronic fentanyl use and the higher risk for precipitated withdrawal, although the significantly lower rate of success highlights the need to improve buprenorphine care and retention,” they wrote.

“Individuals using low-dose initiation may need more frequent support from clinicians on how to manage withdrawal symptoms,” the researchers continued. They noted that clinicians can normalize some withdrawal during counseling, consider prescribing more adjunctive medications, utilize bubble-pack medications to reduce user errors, offer support through closer follow-up calls, and provide a contact person to call for issues.

For related information, see the Psychiatric News article “Are Buprenorphine Doses Too Low?”

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Motivational Intervention May Help Adolescents Get More Sleep

A motivational group-based sleep intervention with regular electronic text reminders may help sleep-deprived adolescents get more sleep on weeknights and improve their daytime alertness, a study in the Journal of Child Psychology and Psychiatry has found.

Ngan Yin Chan, Ph.D., of the Chinese University of Hong Kong, and colleagues recruited 212 adolescents between 12 and 18 years old who reported getting less than seven hours of sleep per weeknight for the past month for this randomized study. Half of the adolescents received the motivational intervention, which consisted of weekly 60-to-75-minute treatment sessions in groups of six to eight participants for four weeks and three weeks of electronic text reminders provided every night. The sessions included:

• Basic sleep knowledge and motivational enhancement
• Identifying the discrepancy between current maladaptive behavior and their values by reviewing individual sleep habits/sleep diary
• Strategies facilitating the implementation of the targeted behavior
• Setting specific goal behavior/bedtime based on individual sleep habits

Participants kept a sleep diary and wore an actigraphy watch for seven consecutive days at each assessment point. All participants were assessed at baseline, postintervention, three months, and six months.

Among 203 participants included in the final analysis, those in the intervention group reported getting 20 to 35 minutes more sleep per day after the intervention compared with before the intervention. Sleep diary and actigraphy data showed that these participants had earlier weekday bedtimes at postintervention and later wake-up times at the three-month follow-up compared with the control group.

“A delay in wake-up time observed in the intervention group was an unanticipated but somehow reasonable result, which might partly indicate that the motivational-based sleep intervention raised a more lasting awareness about the importance of sleep,” Chan and colleagues wrote.

At the six-month follow-up, participants in the intervention group had maintained their earlier bedtimes and longer sleep duration. They also reported reduced daytime sleepiness and slightly better academic performance. However, even though their sleep duration improved, they were still averaging slightly more than six hours per day after the study, which is not adequate for adolescents.

“The study findings suggested the need to include motivational group-based sleep intervention with regular text reminders into school health intervention with the ultimate aim to improve sleep duration and daytime functioning in school-aged adolescents,” the researchers concluded.

For related information, see the Psychiatric News article “Sleep Problems in Late Childhood, Early Adolescence Linked to Psychiatric Symptoms.”

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Study Finds Clozapine Is Most Effective Option for Preventing Second Psychosis Relapse

Among individuals with schizophrenia who experienced their first relapse while taking an oral antipsychotic, only those who switched to clozapine lowered their risk of a second relapse. These findings, based on Finnish population data, were published in Lancet Psychiatry.

“When a patient with first-episode schizophrenia has their first psychosis relapse, despite the use of a non-clozapine oral antipsychotic, continuation with the same antipsychotic strategy or switching to another non-clozapine oral antipsychotic is as unhelpful as switching to non-use of antipsychotics,” wrote Heidi Taipale, Ph.D., of the University of Eastern Finland, and colleagues. “This finding challenges the current treatment guidelines, which suggest clozapine should be used after at least two different non-clozapine antipsychotics.”

Taipale and colleagues identified 3,000 individuals in Finland who were hospitalized for first-episode schizophrenia between 1996 and 2014 and experienced a relapse within five years. To ensure the study population reflected a true “first episode,” eligible individuals had to be age 45 or under and not taking any antipsychotics in the year prior to hospitalization.

Among this group, 45.5% were not taking any antipsychotics prior to their first relapse, 32.4% were taking a non-clozapine oral antipsychotic, and 10.4% were taking clozapine; the remaining individuals were taking injectable antipsychotics or multiple oral antipsychotics. Not surprisingly, of those not taking any antipsychotic prior to a first relapse, switching to any antipsychotic therapy lowered their odds of a second relapse within two years. However, switching to clozapine was the most beneficial, with a 48% reduced relapse risk compared with staying off medication.

In patients who were taking an oral antipsychotic, switching to clozapine reduced relapse risk by 34% compared with staying on the same medication. No other treatment strategy—not even switching to long-acting injections—appeared to offer any benefit.

Finally, among individuals who relapsed while taking clozapine, those who were switched to another antipsychotic had about twice the odds of a second relapse compared with individuals who stayed on clozapine.

“Clozapine is associated with risks of rare but potentially severe adverse effects, such as agranulocytosis,” Taipale and colleagues wrote. “However, there is accumulating evidence … suggesting that clozapine is the safest antipsychotic concerning overall survival, in addition to being associated with greater symptomatic improvement, including in patients without treatment-resistant schizophrenia.”

For related information, see the Psychiatric News article “Clozapine Found Most Effective in Patients With Schizophrenia and Conduct Disorder.”

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Most Patients With IED Have Comorbid Psychiatric Diagnoses, Study Finds

Nearly 96% of patients with intermittent explosive disorder (IED) have at least one additional psychiatric diagnosis, according to a study issued yesterday in JAMA Psychiatry.

IED is typically diagnosed when patients have clinically significant, impulsive aggressive behavior that is not better explained by another condition, such as bipolar disorder, borderline personality disorder, intoxication, or withdrawal from substances, wrote Yanli Zhang-James, M.D., Ph.D., of SUNY Upstate Medical University, and colleagues.

Using data from the TriNetX Research Network, which includes records from 117.7 million patients from 87 health care systems, Zhang-James and colleagues identified 33,410 individuals who had at least one diagnostic record of IED—just 0.03% of patients in the network. The researchers successfully matched 30,357 of these patients with demographically similar individuals who did not have IED.

Patients with IED had extensive medical comorbidities, and only 4.3% did not have another psychiatric diagnosis. Additional findings include:

• Patients with IED were on average 12 years younger at their first health care visit compared with those without IED and were more likely to be male, White, and non-Hispanic. They also had more health care encounters and a longer history of medical records.
• Patients with IED had a substantially higher risk for all psychiatric diseases compared with those without IED. For example, patients with IED were nearly 20 times as likely to have an intellectual disability and 76 times as likely to have a disorder of adult personality and behavior. They were also much more likely to have schizoaffective disorders.
• Among neurological conditions, patients with IED had the highest risk for neurodegenerative diseases, followed by movement disorders, cerebral palsy, and sleep disorders.

The authors noted that other epidemiological studies of IED have reported a prevalence that is much higher than 0.03%. They suggested that clinicians “should consider applying the diagnosis of IED more frequently when warranted.

“Highlighting aggression as a separate diagnosis may focus more attention on aggressive behavior and facilitate the development of targeted treatments. Otherwise, aggressive behavior remains somewhat hidden as a feature within other disorders,” they wrote.

For related information, see the Psychiatric News alert “History of Anger Attacks May Point to Soldiers at Greatest Risk of Anxiety Disorder, Suicidal Ideation.”

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Mindfulness Training May Reduce Craving in Patients With OUD Receiving Buprenorphine

Individuals being treated with buprenorphine for opioid use disorder (OUD) who also received group mindfulness training experienced significantly less opioid craving compared with those receiving group recovery support, according to a report in JAMA Network Open.

Patients in both groups experienced significant decreases in anxiety and had similar levels of opioid, cocaine, or benzodiazepine use, according to the report.

“Mindfulness training appears to increase individuals’ capacities for self-regulation through enhanced attentional control, cognitive control, and emotion regulation,” wrote lead author Zev Schuman-Olivier, M.D., of the Cambridge Health Alliance, and colleagues.

The researchers recruited 196 patients with OUD who were on a stable dose of buprenorphine. Participants were randomized to receive 24 weeks of either the mindfulness intervention—known as Mindful Recovery Opioid Use Disorder Care Continuum (M-ROCC)—or the recovery support intervention. Both interventions were delivered virtually between January 21, 2021, and September 19, 2023.

M-ROCC involves three stages: a four-week orientation focused on fostering group engagement; a four-week low-dose mindfulness group focused on learning mindfulness and increasing daily formal mindfulness practice time; and a 16-week intensive recovery-focused mindful behavior change program.

The recovery support intervention included eight weeks of group-building orientation followed by 16 weeks of evidence-based treatment techniques for substance use disorders, such as cognitive behavioral therapy, motivational interviewing, and 12-step program attendance.

The primary outcome was the number of two-week periods with both self-reported and biochemically confirmed abstinence from illicit opioid use during study weeks 13 to 24. Secondary outcomes included abstinence from cocaine or benzodiazepines and changes in opioid craving as measured by the Opioid Craving Scale.

There was no statistical difference between the two groups in the number of time periods with abstinence from opioids (13.4% in the M-ROCC group and 12.7% in the recovery support group) or other assessed illicit substances. However, M-ROCC patients experienced a statistically significant 67% percent decrease in opioid craving compared with44% for those in the supported recovery group. Both groups demonstrated similarly large reductions in anxiety.

“Mindfulness-based groups may be particularly useful for reducing craving among patients with OUD who are experiencing residual opioid craving during buprenorphine treatment,” Schuman-Olivier and colleagues wrote.

For related information, see the Psychiatric News article “Meditation, CBT May Ease Opioid-Treated Pain.”

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APA Offers Resources in Response to California Wildfires

As the Los Angeles wildfires continue to impact lives, homes, and communities, APA and the APA Foundation are collectively mobilizing their efforts and working with the Southern California Psychiatric Society (SCPS) to better understand the needs of local APA members, their families, and their patients, and to provide support.

APA’s Committee on Psychiatric Dimensions of Disaster has also been in communication with SCPS leaders, and compiled a list of free resources for any mental health clinicians who are helping during recovery efforts. This includes evidence-based tools such as a Rapid Psychological First Aid pocket card and information on helping to calm individuals experiencing an acute stress response. Additionally, the Center for the Study of Traumatic Stress developed a list of resources for anyone impacted by the fires or anyone seeking to help those who are in distress.

Further, APA staff continues to monitor the situation ahead of the 2025 Annual Meeting, scheduled for May 17-21 at the Los Angeles Convention Center, which has not been affected by the wildfires. Efforts are underway to develop additional programming specifically related to the wildfires and to partner with a local organization to connect interested members with volunteer opportunities.

“The tragic impact these fires have had on the people of Los Angeles is heartbreaking, and we at APA are committed to providing support, both immediately and as the recovery continues,” said APA CEO and Medical Director Marketa Wills, M.D., M.B.A. “We are hopeful that the Annual Meeting will provide an opportunity for the APA community to come together and show our unwavering support for Los Angeles, including providing economic stimulus as L.A. recovers and rebuilds from this event.”

APA will continue to provide updates as it works to respond to this disaster. Those seeking to help immediately can donate through the American Red Cross or World Central Kitchen. APA’s resources for psychiatrists on Disaster Mental Health also include research, educational and volunteer opportunities, fact sheets, and more.

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Low Level of Medical Mistrust May Not Discourage Mental Health Care Seeking in Black Adults

Black adults who have a low level of mistrust toward medical professionals may be more willing to seek mental health services than those with no medical mistrust, reports a study published today in Psychiatric Services. Above a certain threshold, however, more medical mistrust was linked with less mental health care seeking.

“This finding suggests that a certain degree of wariness may have a counterintuitive positive effect in terms of promoting mental health care,” wrote Aderonke Bamgbose Pederson, M.D., of Harvard Medical School, and colleagues. “Patients with high levels of trust may not feel the need to seek mental health services, because they feel their clinicians will make decisions on their behalf and will tell them whether such services are needed.”

Pederson and colleagues conducted an online survey of 1,043 Black adults living in the United States. Participants completed the Group-Based Medical Mistrust Scale, which includes eight questions about negative feelings toward doctors and health care workers (mistrust) and four questions asking whether respondents receive the same care as other ethnicities (trust); all answers were on a five-point scale. Participants were also asked how likely they would be—on a seven-point scale—to seek help from a mental health professional for personal or emotional problems or for suicidal ideation.

After adjusting for sociodemographic factors such as age, education level, and citizenship status, the researchers found that among Black adults with an average mistrust score of three or less, each unit increase of medical mistrust was associated with a 55% increased likelihood of seeking help for a personal or emotional problem and a 44% increased likelihood of seeking help for suicidal ideation. Above a score of three, each unit increase of medical mistrust decreased the likelihood of mental health care seeking by 25% for both issues. A similar pattern was seen for the trust-related questions, wherein adults with the highest medical trust scores reported a lower likelihood of mental health care seeking.

“In light of our findings, acknowledging and addressing medical mistrust may have more benefit in improving health-seeking behavior, and perhaps health outcomes, than would eliminating mistrust,” Pederson and colleagues wrote. “In addition, an approach that prioritizes institutional reform might avoid placing the burden of overcoming mistrust on the population that has experienced systemic marginalization.”

For more information, see the Psychiatric News article “From Competence to Humility: Advancing Culturally Responsive Mental Health Care.”

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New Federal Rules Boost Telehealth Flexibility When Treating OUD

As part of a flurry of end-of-term activity, the Drug Enforcement Administration (DEA) along with the U.S. Department of Health and Human Services (HHS) has finalized two rules that permanently expand some telehealth prescribing options and proposed a third rule that would create a new special registration for telehealth prescribing.

Expansion of Buprenorphine Treatment via Telemedicine Encounter

This final rule authorizes registered clinicians to prescribe controlled substances in Schedules III to V for the treatment of opioid use disorder (OUD) via a telemedicine appointment or an audio-only visit, without first seeing the patient in person.

APA has long advocated for a permanent extension to the telemedicine prescribing flexibility that was allowed during the COVID-19 public health emergency and later extended three times. This flexibility prevents lapses of care and expands access to OUD treatment to patients who might not have transportation or a psychiatrist in their area.

“This final rule is a huge win for our patients and colleagues, and key components were directly shaped by feedback from APA and allied organizations,” said Lief Fenno, M.D., Ph.D, assistant professor of neuroscience and psychiatry at the Mulva Clinic for the Neurosciences at the University of Texas at Austin. “The rule reduces the potential for gaps in treatment, lowers barriers to access, and expands the use of life-saving buprenorphine.”

Continuity of Care via Telemedicine for Veterans Affairs Patients

DEA and HHS yesterday also issued a final rule that applies only to VA patients who have previously received an in-person medical evaluation with a VA practitioner. For such patients, the final rule authorizes a different VA practitioner to prescribe Schedule II-V controlled substances via telemedicine, without being limited to a 30-day supply.

The rule stipulates that prescribing VA clinicians must first review the patient’s VA internal prescription database and prescription drug monitoring program (PDMP) data prior to prescribing controlled substances via telemedicine. If unavailable, clinicians are limited to providing a seven-day supply via telehealth.

Both rules take effect 30 days from their date of publication in the Federal Register, which is expected this week.

Special Registration Proposed for Telehealth Controlled Substances Prescribing

The DEA also proposed a new rule to establish three types of special registrations to allow for prescribing and dispensing of controlled substances by registered practitioners and online telemedicine platforms. The separation would mean that only specialized clinicians, such as psychiatrists, neurologists, and board-certified mid-level practitioners (hospice nurses), can prescribe Schedule II substances, while those without this “advanced registration” can prescribe Schedules III-V.

The proposed rule also makes heightened changes to prescriptions, recordkeeping, and reporting. For example, three years after implementation of the rule, clinicians must perform a nationwide PDMP check prior to prescribing controlled substances. For the first three years, clinicians must perform a PDMP check for the patient’s location, clinician’s location, and states with reciprocity agreements.

Public comments about this proposed rule will be due within 60 days after publication in the Federal Register, which is expected this week.

For related information, see the Psychiatric News article “APA Members Urge Congress to Protect Telehealth Access.”

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School-Based Personality-Focused Intervention May Reduce Teen Substance Use

Seventh-grade students who received a cognitive behavioral therapy (CBT) intervention matched to their personality type were less likely to use substances over the following five years of adolescence than students who did not receive the intervention, according to a report today in the American Journal of Psychiatry.

“Most school-based prevention programs are universal and use some combination of alcohol and drug awareness, testimonials, flyers, brochures, peer education, and alcohol/drug-free activities,” wrote Patricia Conrod, Ph.D., of the University of Montreal, and colleagues. “These have been shown to have weak positive or even negative effects, but programs that promote general coping and drug-refusal skills are more promising.”

Thirty-one high schools in the greater Montreal area were randomly assigned either to receive a group CBT intervention known as PreVenture (n=15) or to continue treatment-as-usual (n=16). PreVenture groups youth by one of four personality traits associated with substance use risk: anxiety, hopelessness, impulsivity, or sensation seeking. Across two 90-minute sessions, counselors help students understand their specific risk trait and learn personality-specific cognitive and behavioral strategies to build self-efficacy and reduce their need to use substances to cope with interpersonal or intrapersonal challenges.

Overall, 705 seventh graders in the intervention schools and 964 in the control schools reported elevated scores on at least one of the four selected personality traits, as assessed with the Substance Use Risk Profile Scale, and were included in the final sample. Students in both school groups were assessed for substance use annually over the next five years.

Over the following five years, students at schools receiving PreVenture demonstrated a 35% reduction in the annual increase in substance use disorder (SUD) rate relative to students in the control group. At year five, students receiving PreVenture were 21% less likely to screen positive for SUD compared with those in the control schools.

Conrod and colleagues said the study showed for the first time that personality-targeted interventions might protect against longer-term development of SUD.

“The next phase of research on this intervention approach should focus on biologically and clinically confirmed SUD outcomes and structural and contextual factors that might enhance or interfere with program implementation and effectiveness,” they wrote. “It will also be important to understand the implementation resources necessary to ensure effective and equitable scaling out and scaling up of this preventive intervention across larger jurisdictions.”

For related information see the Psychiatric News article, “Easily Obtainable Demographic Data Said to be Best Predictor of Teen Substance Use.”

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Dementia Cases Projected to Double: Here’s Who’s at Highest Risk

More than 40% of older adults in the United States today may develop dementia by the age of 95, with higher risk in women, Black adults, and carriers of the apolipoprotein ε4 (APOE ε4) gene variant, according to the results of a study issued yesterday by Nature Medicine.

Researchers projected a near-doubling of new annual dementia cases over the next four decades—from about 514,000 in 2020 to about 1 million in 2060—a trend largely driven by the sizable baby boom generation reaching older ages.

“Previous studies suggest that 11-14% of men and 19-23% of women in the United States will develop dementia during their lives,” wrote Michael Fang, Ph.D., M.H.S., at Johns Hopkins Bloomberg School of Public Health, and colleagues. “However, these estimates were based on older data with limited dementia ascertainment, potentially resulting in underestimation. Racial disparities in the lifetime risk of dementia are also poorly characterized, as population-based analyses have typically been limited to Non-Hispanic White populations.”

Fang and colleagues used data from 15,043 diverse participants of a long-running community study (median follow-up of 23 years) to estimate the lifetime risk of dementia from ages 55 to 95; all included participants were dementia-free at age 55. During the study follow-up, 3,252 participants developed dementia, 5,803 died without dementia, and 2,131 left the study.

The researchers applied the data from the study to U.S. census projections to evaluate the potential number of incident dementia cases from 2020 to 2060. They reported the following:

• The lifetime risk of dementia after age 55 years was 42%.
• The cumulative incidence of dementia remained low up to age 75 (4%), then increased progressively faster.
• The median age of dementia diagnosis was 81 years.
• Lifetime risks were higher in women versus men (48% vs. 35%) and Black adults versus White adults (44% vs. 41%).
• Adults with two copies of the APOE ε4 alle had a substantially higher lifetime risk of dementia (59%) compared with those with one copy (48%) and those with no copies (39%), with differences seen beginning at about 70 years of age.

“Our results suggest that the current lifetime risk of dementia may be substantially higher than previously thought, emphasizing the importance of prevention throughout the life course,” Fang and colleagues wrote. “Policies focused on optimizing cardiovascular health and preserving hearing may be particularly important. Accumulating data from clinical trials have linked healthy lifestyle behaviors, the absence of vascular risk factors, and hearing rehabilitation with improved cognitive outcomes.”

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

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ADHD Diagnoses Climb in Adults, Level Off in Adolescents

Diagnoses of attention-deficit/hyperactivity disorder (ADHD) have risen among adults in recent years but remained stable among adolescents, according to a study published today in Psychiatric Research and Clinical Practice.

Margaret L. Paul, M.S., of Saint Louis University, and colleagues analyzed data from 144,103 adults and adolescents with no history of ADHD who were regular users of health care services at Sisters of Saint Mary, a large health care system located in four Midwest states. The participants’ mean age was 33.8 years; 84% were adults (ages 19 to 50 in 2016) and 16.1% were adolescents (ages 10 to 18 in 2016).

The researchers used ICD-10 codes to identify new ADHD diagnoses in patient charts from 2016 to 2023. The ADHD incidence among adults increased from .78% in 2016 to .93% in 2023. Between 2016 and 2020, the relative annual decrease in ADHD incidence in adults was 10.6%, but between 2020 and 2023, the trend reversed, and the average relative increase was 15.2%.

The ADHD incidence among adolescents decreased from 2.89% in 2016 to 1.67% in 2023. Between 2016 and 2020, the relative annual decrease in ADHD incidence in adolescents was 26.1%, but there was no statistically significant change from 2020 to 2023.

“Fluctuations in incidence rates are likely due to a complex interplay of various factors, such as increased knowledge and destigmatization of ADHD, changes in diagnostic practices, increased access to healthcare services and treatment‐seeking patterns, and the impact of the COVID‐19 pandemic on mental health,” the researchers wrote. “Increased awareness and destigmatization of ADHD can lead to more diagnoses being made, resulting in higher incidence rates. As knowledge about ADHD symptoms improves among healthcare providers, parents, and teachers, more cases may be identified and diagnosed.”

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

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Low Doses of CBD Do Not Appear to Impair Driving Ability

Although cannabidiol (CBD) is considered safe, it does come with side effects such as drowsiness that can pose risks—for example, when someone is driving. But a study published this week in Addiction suggests that CBD taken at standard doses does not appear to adversely impact driving ability.

Sonia Ortiz-Peregrina, Ph.D., at the University of Granada, Spain, and colleagues enrolled 30 participants (70% male) from the university community to perform driving simulations. All participants were occasional users (less than four times a week) of CBD and/or cannabis. Each participant completed a 20-minute driving session and had their visual function assessed after inhaling either 16 mg CBD, 32 mg CBD, or placebo compound. The participants completed three sessions under each condition in a random order, spaced about a week apart.

The researchers found no difference in participants’ overall driving performance score following CBD versus placebo inhalation, nor any difference in individual driving parameters such as frequency of lane deviations, reaction time, or rate of collisions. Likewise, visual function was largely unchanged following CBD inhalation, except for a slight decrease in motion detection sensitivity after taking the 32 mg CBD dose.

“The results of this study suggest that vaporized CBD seems to be a safe substance for visual function and vision-dependent tasks such as driving,” Ortiz-Peregrina and colleagues wrote, while noting that study participants were younger adults with normal visual function. “Future work should, therefore, explore higher doses, larger sample sizes with similar gender distribution, and different profiles of user to obtain more evidence to support safety and efficacy of CBD.”

For related information, see the Psychiatric News story “Be Prepared to Discuss CBD Products With Patients.”

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Personality Traits, Education Impact Early Psychosis Intervention Outcomes

An intervention that blends in-person therapy with a smartphone app is effective in treating symptoms of early psychosis, particularly in individuals who have extroverted personality traits and who are highly educated, according to a study issued this week in Translational Psychiatry.

Acceptance and Commitment Therapy in Daily Life (ACT-DL) has shown promise for treating early psychosis, wrote Rafaël A. Bonnier, M.S., of the Center for Contextual Psychiatry at KU Leuven University in Belgium, and colleagues. ACT-DL combines face-to-face therapy sessions aimed at improving individuals’ psychological flexibility with an app that assesses their current psychological state and provides exercises related to their most recent therapy session.

To determine who may benefit most from the intervention, Bonnier and colleagues conducted a secondary analysis of data from the INTERACT study; this randomized controlled trial assessed the efficacy of eight weeks of ACT-DL in 71 individuals (59% female) who either had first-episode psychosis or were at an ultra-high risk for psychosis.

The researchers assessed participants’ distress associated with psychotic symptoms, global and social functioning, and negative symptoms (avolition, blunted affect, anhedonia, alogia, and asociality) at baseline, immediately after the intervention, and during six- and 12-month follow-ups. Additionally, they assessed participants’ education levels, personality traits (how extroverted they were and their negative affectivity, or their tendency to experience negative emotions), and frequency and severity of childhood abuse and neglect.

Overall, ACT-DL was generally effective in improving clinical outcomes, but certain sociodemographic characteristics and personality traits predicted clinical outcomes:

• Participants with a higher educational background showed more significant improvement in global functioning at both the six- and 12-month follow-ups compared with those with a lower educational background.
• Female participants showed greater improvements in psychotic distress compared with males at the 12-month follow-up.
• Participants with lower levels of extroversion showed greater improvement in negative symptoms compared with more extroverted participants at the 12-month follow-up.
• Extroverted participants, however, showed significantly greater improvement in global functioning immediately post-intervention and at the six-month follow-up compared with those with lower extroversion. This finding was not evident at the 12-month follow-up.
• Those with higher negative affectivity showed more improvement in negative symptoms and higher psychological flexibility at the 12-month follow-up compared with those with lower negative affectivity.

“Our findings suggest that while ACT-DL improves clinical outcomes in individuals with early psychosis, the improvement rate is dissimilar for individuals and predictable by baseline characteristics,” the authors wrote. “If replicated, these findings enable precision medicine approaches in allocating ACT-DL for early psychosis.”

For related information, see the Psychiatric News article “Special Report: Precise, Personalized, and Preventive Psychiatry”

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Study Highlights Social Determinants Most Highly Associated With Suicide

Individuals involved with the criminal justice system or recently released from incarceration are among those at greatest risk of suicide mortality, according to an “umbrella analysis” published in in JAMA Psychiatry.

This analysis of how social determinants of health (SDOH) affect suicidality also found that exposure to parental suicide, experiencing divorce or unemployment in mid-life, and accessibility to firearms were strongly associated with suicide mortality.

“Routine assessment of social constructs that are strongly associated with suicide mortality, suicide attempt, and suicidal ideation should be built in daily clinical practice,” wrote Peter Jongho Na, M.D., M.P.H., of the West Haven VA Medical Center, and colleagues. “Efforts to develop and validate brief and practical standardized assessment measures will be critical in screening and monitoring subpopulations at heightened risk.”

The researchers combined data from 46 separate meta-analyses looking at the effect of various SDOH domains on suicide mortality, suicide attempts and suicidal ideation. The domains included: social networks, childhood maltreatment, racism and discrimination, incarceration, nativity status, geographic location, education, employment, homelessness, poverty, environmental factors, exposure to violence, and gender or sexual minority status.

Different SDOH were prominent for each of the three outcomes. For instance, experiencing repetitive childhood abuse and identifying as lesbian, gay, or bisexual were the strongest risk factors for suicide attempts; identifying as bisexual and experiencing intimate partner violence as a woman were the strongest risk factors for suicidal ideation.

However, there were also some protective SDOH. Religious affiliation and being married were protective against the risk of suicide mortality, and school connectedness showed protective associations against suicide attempt and suicidal ideation.

The researchers recommended the following overarching priorities:

• Focusing supportive policies and interventions on individuals with a history of justice system involvement or foster care in childhood.
• Prioritizing resources and interventions for suicide loss survivors.
• Promoting firearm counseling, safe storage practices and gun licensing requirements.
• Developing policies to relieve the financial and social burden of unemployed individuals in midlife.
• Addressing discrimination against LGBTQ+ youth, ascertaining gender identity and sexual orientation in clinical settings and expanding trauma-informed, and LGBTQ+-informed mental health care services.

Past APA President Dilip Jeste, M.D., a senior author of the report, told Psychiatric News that suicide is one of the most urgent public health priorities and that the findings in the report need to be incorporated into daily clinical practice and social policy. “We have a moral and social obligation to address these factors,” he said.

For related information see the Psychiatric News article, “New Group Seeks to Make Management of Social Determinants a Reality in Health Care.”

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Addressing Adults’ Social Anxiety, Depression May Boost Employment Success

Symptoms of social anxiety or depression may serve as a barrier to seeking or maintaining employment, according to a study issued by Psychiatric Research and Clinical Practice. However, working more hours may not by itself reduce depression or social anxiety symptoms.

“Social anxiety is associated with a lower likelihood of receiving and accepting job offers, poor job performance, increased work absences, and higher rates of terminations and resignations. However, bidirectional associations between social anxiety and unemployment are untested,” wrote Olivia M. Losiewicz, M.A., of the University of California, Los Angeles, and colleagues.

The researchers recruited 250 diverse adults with diagnoses of social anxiety disorder, more than half of whom were homeless or in transient housing, who were job-seeking at vocational centers in Detroit or Los Angeles. Depression and social anxiety were assessed at weeks four, 12, 26, and 52 using the eight‐item Patient Health Questionnaire (PHQ–8) and the Liebowitz Social anxiety scale.

Participants estimated the number of hours they worked for pay every two weeks by responding to a text-message prompt. The researchers averaged the number of hours participants worked for three time periods: weeks five to 12, 13 to 26, and 27 to 52. They also examined participants’ substance use, psychosis, homelessness, racial minority status, and household income.

After factoring in the above variables, the researchers reported that greater social anxiety and depression symptoms at one period predicted fewer subsequent hours worked for pay. However, contrary to their hypothesis, working more hours during a period was not significantly associated with reduced social anxiety or depression symptoms later.

“Findings suggest that clinicians should monitor employment‐related factors, such as work attendance and time spent working, when treating patients with depression or social anxiety, as symptoms may lead to significant functional impairment,” Losiewicz and colleagues wrote. “Furthermore, this study highlights the potential importance of mental health interventions to simultaneously address occupational concerns. Since symptoms of social anxiety or depression may serve as a barrier to seeking or maintaining employment, effective treatments, such as cognitive behavioral therapy, may indirectly help individuals obtain or maintain employment.”

For related information, see the Psychiatric News article “‘I Don’t Feel Like a Productive Member of Society.’”

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Glutamatergic Medications May Reduce Symptoms of Obsessive-Compulsive, Related Disorders

Glutamatergic medications such as N-acetylcysteine (NAC) and memantine may help reduce symptoms of obsessive-compulsive and related disorders (OCRDs), according to a meta-analysis in JAMA Network Open.

David R. A. Coelho, M.D., M.P.H., of Harvard T.H. Chan School of Public Health, and colleagues analyzed data from 27 randomized clinical trials involving 1,369 patients with OCRDs, including 23 studies of patients with obsessive-compulsive disorder, two studies of patients with trichotillomania, and two studies of patients with skin-picking disorder. Ten studies investigated NAC, four explored memantine, three each assessed lamotrigine and riluzole, two examined topiramate, and one study each assessed amantadine, glycine, L-carnosine, minocycline, and pregabalin. Outcomes were improvements in OCRD symptoms. The patients’ symptoms were measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and other standardized assessments.

Overall, 688 patients in the studies were taking glutamatergic medications and 681 were not. Those who took glutamatergic medications had significantly fewer symptoms of their disorders than those in the control group (effect size of 0.8). In the 23 studies that focused on obsessive-compulsive disorder, those who took glutamatergic medications reduced their Y-BOCS scores by an average of 4.17 more points compared with those in the control group.

“Glutamatergic medications can modulate synaptic plasticity and neuronal excitability, potentially alleviating OCRD symptoms,” Coelho and colleagues wrote. “For instance, NAC has been shown to increase glutathione levels and modulate the glutamatergic system, reducing oxidative stress.”

However, the researchers noted several limitations to their meta-analysis, including the relatively small sample sizes of the trials and the limited number of studies for several medications as well as disorders outside of obsessive-compulsive disorder.

“Future research with larger sample sizes should focus on dose dependent effects, additional OCRD subtypes, and novel glutamatergic treatments to enhance our understanding and treatment strategies,” the researchers wrote.

For related information, see the American Journal of Psychiatry article “Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder.”

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