Antidepressants Effective, Safe for Patients After Heart Attacks

Antidepressants effectively treat depression in patients who have a history of heart attacks without adversely impacting their long-term prognosis, according to a study issued in BMC Psychiatry. Additionally, antidepressants were linked to a decreased risk of heart attack recurrence.

“Meta-analyses indicate that post–[heart attack] depression is associated with a 1.6- to 2.7-fold increased risk of mortality and cardiovascular events during long-term follow-up, highlighting the critical need for effective interventions,” wrote Hongquan Wan and colleagues at The First Hospital of Jilin University in Changchun, China.

Wan and colleagues conducted a meta-analysis of 12 studies assessing antidepressants as a post–heart attack depression intervention; the studies included more than 15,000 patients and had follow-up periods that ranged from six months to more than eight years. Depression severity was measured by validated tools such as the Beck Depression Inventory and the Hamilton Depression Rating Scale.

Though baseline depression scores did not differ between the control and treatment groups, antidepressant treatment significantly reduced depression scores at long-term follow-up. Antidepressants did not increase the risk of adverse cardiac events, all-cause mortality, or rehospitalization for heart disease.

Antidepressant treatment was associated with about a 21% reduced risk of heart attack recurrence and a 14% reduced risk of needing coronary stents. However, the researchers noted that these potential benefits should be interpreted cautiously given that a large observational study found the opposite outcome.

Depression after heart attacks “is an established independent risk factor for poor cardiac prognosis,” the authors wrote. “While some reports have raised concerns about the potential cardiac risks of antidepressants, the overall evidence suggests that they are safe and effective when appropriately prescribed.”

For related information, see the Psychiatric News article “Antidepressants May Lower Heart Attack Risk in Diabetes.”

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Long Sleep Duration Linked to Poorer Cognitive Performance

Getting too much sleep each night may affect cognitive function, especially in adults with depression, according to a study in Alzheimer’s & Dementia.

Vanessa M. Young, M.S., of the University of Texas Health Science Center at San Antonio, and colleagues examined data from 1,853 Framingham Heart Study participants ranging from 27 to 85 years old (mean age of 50) who did not have dementia or stroke. They asked the participants about antidepressant use and assessed the participants for depression. They then divided the participants into four groups:

• No depressive symptoms, not taking antidepressants
• Depressive symptoms, not taking antidepressants
• No depressive symptoms, taking antidepressants
• Depressive symptoms, taking antidepressants

In each group, participants self-reported the number of hours they slept per night and were categorized as having short sleep (six hours or less), average sleep (between six and nine hours), and long sleep (nine hours or more). They also took a battery of tests to assess their cognitive performance.

Overall, compared with participants with average sleep, those with long sleep had poorer performance in global cognition, executive function, visuospatial memory, and verbal learning/memory tasks.

“These findings suggest that sleeping ≥ 9 hours per night is associated with cognitive differences equivalent to 6.5 years of brain aging,” Young and colleagues wrote.

Among individual patient groups, the strongest negative associations between long sleep and cognition were among individuals with depressive symptoms, regardless of antidepressant usage. There was a smaller effect of long sleep among adults with no depression and no antidepressant use, while no cognitive effect of long sleep was seen in adults who took antidepressants but had no depressive symptoms.

Young and colleagues suggested that antidepressant use among those with no depressive symptoms may reduce nighttime awakenings, improve restorative sleep, or stabilize sleep–wake timing. “However, whether this observation reflects antidepressant treatment, symptom remission, or other unmeasured aspects of sleep health remains unclear, given the limitations of our sleep measures.”

The researchers also did not find a statistically significant relationship between short sleep and cognitive performance.

“These results diverge from some studies that have identified short sleep as a risk factor for cognitive impairment,” they wrote. “The precision of this association may increase with greater statistical power or in older populations in which short sleep and cognitive impairment may be more prevalent.”

For related information, see the Psychiatric News article “Poor Quality Sleep in Midlife Linked to Poor Cognition 11 Years Later.”

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Oral and Injectable Naltrexone Found Equally Effective in Hospitalized Patients With AUD

Hospitalized patients with alcohol use disorder (AUD) who received either daily oral or extended-release injectable naltrexone upon discharge experienced similar reductions in heavy drinking days, according to a report in JAMA Internal Medicine. Acute and alcohol-related health care utilization after 90 days were also not significantly different between the two groups.

For this reason, the choice of oral versus injectable naltrexone should be driven by practical considerations, and adherence may improve with flexibility in patient choice of treatment, wrote Kara S. Magane, M.S., of Boston University School of Public Health, and colleagues. “In clinical practice, the most effective medication may vary based on patient preference, availability, cost, and post-discharge follow-up logistics.”

The researchers analyzed data on 248 hospitalized patients (80.2% male) with AUD as part of the Alcohol Disorder Hospital Treatment (ADOPT) study, a randomized clinical trial conducted at an urban teaching hospital between June 2016 and March 2020. Participants received either 30 days of oral naltrexone or an injection of monthly naltrexone upon discharge; medications were resupplied during monthly medical management visits with a research nurse who specialized in addiction.

The primary outcome, assessed at three-month follow-up, was change in percentage of heavy drinking days (HDDs) over the previous 30 days. An HDD was defined as five drinks or more per day for males and four drinks or more for females. The secondary outcome was any emergency department use or hospitalization over the previous 90 days.

The average percentage of heavy drinking days over 30 days was reduced in the oral naltrexone group from 66.7% at baseline to 27.4% at follow-up and from 70.7% at baseline in the extended-release naltrexone group to 23.8% at follow-up; the difference between groups was not statistically significant.

The odds of emergency department (ED) use or hospitalization was also not statistically different: At follow-up, 54.1% of participants in the oral naltrexone group and 61.1% of those in the extended-release naltrexone group reported a hospitalization or ED visit in the prior 90 days.

“By addressing AUD in hospitalized patients, care can potentially yield better overall health outcomes,” the researchers concluded. “Given the evidence that AUD medication provided in the hospital helps to reduce HDDs, future trials should assess optimal implementation of this strategy from clinician, patient, and payer perspectives.”

For related information, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy” and the Psychiatric News Special Report “Psychiatrists Critical in Screening, Treatment of Alcohol Use Disorder.”

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New Drug Shows Promise for Helping Patients Quit Smoking

Adults who took cytisinicline for six or 12 weeks were three or four times more likely to quit smoking, respectively, at the end of their treatment than those taking placebo, according to clinical trial results published in JAMA Internal Medicine.

The Food and Drug Administration (FDA) has approved various nicotine replacement products, as well as the medications bupropion and varenicline as smoking cessation aids. “However, their long-term smoking cessation rates are modest, adverse effects can limit their use, and many individuals have already tried them without success,” wrote Nancy A. Rigotti, M.D., of Massachusetts General Hospital and Harvard Medical School, and colleagues. “New options are urgently needed because no cessation medication has been approved for use in the US since 2006.”

Cytisinicline is a plant-based alkaloid that binds to nicotine receptors and is used as a smoking cessation aid in several European countries. Drugmaker Achieve Life Sciences conducted the trial in support of their application for approval to the FDA.

Rigotti and colleagues recruited 792 adults who sought to quit smoking, from 20 sites across the United States. Participants took either 3 mg cytisinicline three times a day for 12 weeks; 3 mg cytisinicline three times a day for six weeks followed by placebo for six weeks; or placebo three times a day for 12 weeks. Smoking cessation was biochemically verified (carbon monoxide <10 ppm). All groups received substantial behavioral support and were followed for 24 weeks.

Participants who took cytisinicline for six weeks were 2.9 times more likely to be abstinent from smoking at the end of treatment than those taking only placebo (15% versus 6%, respectively). Similarly, participants taking cytisinicline for 12 weeks were 4.4 times more likely to be abstinent by treatment’s end compared with placebo (30% versus 9%, respectively). The benefits of cytisinicline extended through week 24 in both treatment groups.

The researchers noted that White adults accounted for about 80% of the participants, so the findings may not be generalizable to other racial or ethnic groups. Other study limitations include the exclusion of individuals with suicidal ideation, moderate to severe depression symptoms, and current cannabis or illicit drug use.

“Cytisinicline holds substantial promise, offering efficacy similar to varenicline but a more favorable adverse effect profile,” researchers wrote. “Changes in craving and cotinine biomarkers over time support the proposed mechanism of action of cytisinicline as a partial nicotine agonist. These findings also highlight the potential for cytisinicline to serve as a versatile tool for nicotine cessation, not only for traditional cigarettes but also for other nicotine delivery products.”

For related information, see the Psychiatric News article “Cytisinicline Promising for Vaping Cessation.”

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Less Time Outside Linked to Anxiety Symptoms in Early Childhood

Infants and toddlers who do not spend a lot of time outside may have an increased risk of anxiety symptoms, according to a study in BMC Psychiatry.

Jian-Bo Wu, of Shenzhen Longhua Maternity and Child Healthcare Hospital in China, and colleagues analyzed data from 69,571 preschoolers in the 2021 survey of the Longhua Children’s Study. The children’s parents reported on the frequency and duration of the children’s daytime outdoor activity when the children were infants (less than a year old) and toddlers (one to three years old), and the researchers measured the children’s current anxiety symptoms using the Chinese version of the Spence Preschool Anxiety Scale.

Overall, the less time the children spent outside as infants and toddlers, the greater their odds of having anxiety symptoms. Among infants, those who had less than seven sessions of outdoor activity per week had between 1.19 and 2.55 times the odds of having anxiety symptoms compared with those who had seven or more outdoor sessions per week. In addition, infants whose outdoor sessions lasted less than two hours had between 1.12 and 1.62 times the odds of having anxiety symptoms compared with infants whose outdoor sessions lasted two hours or more.

Among toddlers, those who had less than seven sessions of outdoor activity per week had between 1.42 and 3.10 times the odds of having anxiety symptoms compared with those who had seven or more outdoor sessions per week. In addition, toddlers whose outdoor sessions lasted less than two hours had between 1.22 and 2.07 times the odds of having anxiety symptoms compared with toddlers whose outdoor sessions lasted two hours or more.

The researchers noted several reasons why outdoor activity may affect anxiety symptoms, including sensory input; opportunities for exercise, social interaction, and emotional support; and exposure to natural light.

“These findings provide actionable insights for parents and caregivers, highlighting the importance of promoting outdoor activity in early childhood care and parenting practices,” Lu and colleagues wrote. “Future studies should further explore the causal relationship between outdoor activity and the prevention of anxiety.”

For related information, see the Psychiatric News article “Residential Green Space Provides Behavioral Benefits During Early Childhood.”

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As Debate Over Medicaid Cuts Begins, APA Wants Members’ Voices Heard

Later this month, Congress will begin debating a budget reconciliation bill that could propose sweeping funding cuts to health-related programs such as Medicaid. The House of Representatives’ proposed budget includes a directive for the House Energy and Commerce Committee—which oversees Medicare and Medicaid—to reduce spending by $880 billion over the next 10 years as part of goal of $2 trillion in gross deficit reductions.

(The Senate budget requires only $4 billion in gross deficit reductions and allows a $5.8 trillion net deficit increase.)

“We need all hands-on deck to let elected officials know about how devastating these cuts will be to patients,” APA President Ramaswamy Viswanathan, M.D., Dr.MedSc., and APA CEO and Medical Director Marketa M. Wills, M.D., M.B.A., said in a letter to APA membership.

Viswanathan and Wills noted that Medicaid is the single-largest payer for behavioral health services in the United States, the second-largest payer for pediatric care, and a critical source of health insurance for individuals in rural communities.

To help members and other mental health professionals get their voices heard, APA has created a Medicaid Advocacy Toolkit with resources on Medicaid and the budget reconciliation process, tips on how to meet with legislators, and links to other ways to get involved in policy. APA has also initiated a social media campaign—#VoicesForMedicaid—to amplify the message.

For more information about APA’s advocacy efforts and how you can lend your voice, visit APA’s Advocacy Action Center.

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CBT Most Effective for PTSD, Specific Phobias

While cognitive behavioral therapy (CBT) is an effective treatment for a range of mental health disorders, a meta-analysis issued this week in JAMA Psychiatry found that it is most effective for posttraumatic stress disorder (PTSD) and specific phobias, and potentially least effective for bipolar and psychotic disorders.

Pim Cuijpers, Ph.D., of Amsterdam Public Health Research Institute, and colleagues analyzed data from 375 randomized clinical trials comparing CBT with a control treatment such as a waiting list, usual care, or a placebo pill. The trials included 32,968 adults (average age 43 years, 68% female) who were diagnosed with one of the following: depressive disorder, PTSD, obsessive-compulsive disorder, psychotic disorder, bipolar disorder, an anxiety disorder (including panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobia), or an eating disorder (including anorexia nervosa, bulimia nervosa, and binge eating disorder).

While CBT was effective for all disorders, it was particularly effective for PTSD and specific phobias, which had effect sizes of 1.27 and 1.17, respectively. (Effect sizes are standardized values used to quantify changes such as symptom improvements, with values over 1 generally reflecting a very large change.) Bipolar disorder and psychotic disorders had the lowest effect sizes at .31 and .43, respectively. Effect sizes for the other disorders ranged from .84 for depressive disorder to .98 for obsessive-compulsive disorder.

The authors found that using waitlist control groups resulted in larger effect sizes than a control of usual care. This was an important distinction because most of the trials assessing bipolar and psychotic disorders employed usual care as the control group, which tended to vary from trial to trial and had a higher dropout rate than a waitlist control. This could potentially lead to an overestimation of the effect sizes for some disorders, the authors wrote.

“Although these findings confirm that CBT is effective in treating mental disorders, caution is needed because of considerable risk of bias, high levels of heterogeneity, and potential publication bias in several disorders,” the authors wrote.

For related information, see the Psychiatric News article “Brief CBT Interventions May Stop Depression Before It Starts.”

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Autism Rate Rises Again, CDC Data Shows—Likely Due to Improved Screening and Detection

One in 31 8-year-old children had autism spectrum disorder (ASD) in 2022, according to a new report from the Centers for Disease Control and Prevention (CDC). This represents an increase from the one in 36 children identified in 2020 and a significant jump from the one in 150 children reported back in 2000. The findings were published in the CDC’s Morbidity and Mortality Weekly Report.

While the overall rate of ASD was 32.2 per 1,000 children, prevalence varied widely across sites, from 9.7 in Laredo, Texas to 53.1 in San Diego, California.

“Research has not demonstrated that living in certain communities puts children at greater risk for developing ASD,” wrote Kelly A. Shaw, Ph.D., of the CDC’s National Center on Birth Defects and Developmental Disabilities, and colleagues. “Differences in the prevalence of children identified with ASD across communities might be due to differences in availability of services for early detection and evaluation and diagnostic practices.” For example, San Diego’s Get SET Early initiative has trained hundreds of local pediatricians to screen and refer children for assessment as early as possible.

The report also showed that the prevalence of ASD or suspected ASD among 4-year-olds was higher in 2022 than four years prior, further supporting that continued improvements in early identification of ASD are contributing to the prevalence increase.

“Opportunities exist to learn from successful policies, systems, and practices in different communities and implement approaches for equitable identification or service eligibility to help families or persons receive the support they need as early as possible,” Shaw and colleagues wrote.

Other findings in the latest CDC data include:

• ASD was about 3.4 times more prevalent in boys than girls.
• ASD prevalence was higher among Asian or Pacific Islander, Black, and Hispanic children compared with White children at age 8, continuing a pattern first observed in 2020.
• About 40% of children with ASD had co-occurring intellectual disability (ID), with Asian or Pacific Islander, Black, and Hispanic children being more likely than White children to have ID.

The 2022 edition of the Autism and Developmental Disabilities Monitoring Network included data from 4- and 8-year-olds from 16 surveillance sites (one each in Arizona, Arkansas, California, Georgia, Indiana, Maryland, Minnesota, Missouri, New Jersey, Pennsylvania, Puerto Rico, Tennessee, Utah, and Wisconsin; and two sites in Texas).

For related information, see the Psychiatric News article “For ASD, Psychiatrists Must Continuously Monitor Patients, Assess Therapies.”

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Experience With Pharmacogenetic Testing Improves Confidence Among Clinicians

Clinicians expressed greater comfort with and confidence in pharmacogenetic testing (PGx) after participation in a clinical trial that employed PGx for depressed patients, according to a report published today in Psychiatric Services.

Some clinicians were uncertain about which patients might be best served by these tests, while others expressed concerns about cost. But there was a general perception that part of the test’s value was its potential to help patients with buy-in and confidence regarding medication treatment.

“Exposure to this novel practice is necessary to help providers understand its potential usefulness and how they may apply testing results in their clinical management of patients with depression,” wrote Bonnie M. Vest, Ph.D., of the State University of New York–University at Buffalo, and colleagues.

The Precision Medicine in Mental Health Care (PRIME Care) study was a randomized controlled trial to assess whether using a commercially available PGx test improved outcomes in patients with depression. All participating clinicians completed a baseline survey between July 2017 and January 2021. The survey assessed demographic information as well as comfort with and perceptions of PGx testing rated on a five-point Likert scale.

A follow-up survey was conducted between December 2020 and March 2021 after PRIME Care concluded. A total of 217 clinicians completed both surveys, and 61 also took part in qualitative interviews. Overall, 72% of those who completed the survey and 80% of those who participated in interviews worked in specialty mental health clinics; 62% and 72%, respectively, completed medical training.

Following the trial, 31% of clinicians strongly agreed with the statement “I feel comfortable ordering a pharmacogenetic test to predict risk of adverse events or the likelihood of a treatment response” compared with 15% before the study. Further, 38% strongly agreed with the statement “I feel well informed about the role of pharmacogenetic testing in choosing a psychotropic medication” compared with 21% before the trial. Mental health clinicians were much more likely than primary care ones to provide positive answers.

Qualitative interviews revealed more nuance. One provider responded: “I do feel patients have felt more confident about trying medications with that information, so I think there is some positive value.... I wouldn’t say it’s game changing.” Another provider said: “If it’s cost-effective enough to do it at the beginning, it might be worth it just to eliminate a lot of the guesswork…. I think cost would be prohibitive as far as just doing it on every patient.”

The authors concluded: “A pressing need exists for further research, including cost-benefit analyses, to inform decisions about PGx implementation. Specifically, our findings highlight providers’ concerns about patient-level criteria and when during treatment PGx testing is most beneficial.”

For related information, see the Psychiatric News article “Pharmacogenomic Testing May Help Achieve Better Patient Outcomes, Less Toxicity.”

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Preterm Birth Linked to Cognitive Problems in Childhood

Moderately preterm birth—birth about seven or eight weeks early—is associated with cognitive problems in childhood, a study in JAMA Network Open suggests.

Samson Nivins, Ph.D., and colleagues at the Karolinska Institutet in Stockholm analyzed data from 5,946 children ages 9 to 10 years who were part of the Adolescent Brain and Cognitive Development Study. The researchers grouped the children according to gestational age: very preterm (28 to 31 weeks), moderately preterm (32 to 33 weeks), late preterm (34 to 36 weeks), early term (37 to 38 weeks), and full term (at least 39 weeks). The researchers then combined the children’s scores on various neurocognitive tasks such as picture vocabulary, oral reading recognition, list sorting, and picture sequence memory into a single composite cognitive score.

After adjusting for socioeconomic status, genetics, and other risk factors, the researchers found that children who were born moderately preterm had lower composite cognitive scores as well as lower scores in vocabulary, working memory, episodic memory, and delayed recall compared with children who were born full term. They did not find significant differences in composite cognitive scores among children born very preterm, late preterm, or early term compared with full-term children.

“Considering that cognitive impairment is often associated with lower academic achievement and reduced quality of life, our study emphasizes the importance of early screening and targeted interventions for these students,” the researchers wrote.

In addition, moderately preterm children had lower composite scores compared with those born very preterm. “This paradox may be explained by selective survival for which advances in neonatal care mean very preterm children in our study may represent a more resilient subgroup. Furthermore, very preterm children are often identified as high risk and receive targeted early interventions, potentially mitigating cognitive deficits,” Nivins and colleagues wrote. “In contrast, moderately preterm children may not be recognized as needing such support, leaving them more vulnerable to cognitive challenges over time.”

The researchers added that the smaller sample size in the very preterm group—less than 1% of children in the study—could limit the ability to detect differences between very preterm children and the children in the other groups.

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Digital Behavioral Activation App Shows Depression-Fighting Potential

A digital app based on behavioral activation—which involves engaging individuals in rewarding activities to offset negative mood—is effective at reducing depressive symptoms among adults receiving primary care, according to a clinical trial published today in JAMA Internal Medicine.

“Expanding the behavioral health workforce is unlikely to meet the mental health needs of all adults treated in the primary care setting,” wrote Jennifer Dahne, Ph.D., of the Medical University of South Carolina, and colleagues. “However, expanding the workforce could be complemented with self-guided digital mental health interventions … [that] give patients on-demand access with the ability to self-select the frequency and duration of sessions.”

The app used in this trial was Moodivate, which enables users to set goals across certain life areas as well as measurable activities to reach a goal; for example, under a goal of building relationships, users could task themselves to go out to dinner with a friend once a week. Gamification elements such as badges are included to promote long-term engagement with Moodivate.

Dahne and colleagues randomized 649 adults with at least moderate depression from primary care/family medicine clinics across South Carolina to receive Moodivate (n=437) or continue with their usual care (n=212) for 12 weeks. The adults who had Moodivate were further randomized into those who had the regular app or who had an app linked to their electronic health record (EHR), which allowed their doctors to review a patient’s engagement and progress. Depression symptoms were assessed with the Beck Depression Inventory II (BDI-II) every week for the first eight weeks and then again at week 12.

At baseline, average BDI-II scores were around 33 for all adults. After 12 weeks, BDI-II scores dropped by 10.3 points for adults using Moodivate, 9.88 points for adults with Moodivate-EHR, and 5.94 points for adults receiving usual care. Adults in both Moodivate groups were also more than twice as likely to achieve depression remission than those receiving usual care. Participant engagement was 100% during the first week and 33% by week 12. However, only 14% of these adults’ physicians with access used the EHR functionality, but the researchers were encouraged that physician engagement was not crucial for improving depression.

“Although Moodivate needs further testing in other clinical settings and at scale, this self-guided digital behavioral activation intervention may provide an accessible and valuable depression treatment option,” they concluded.

For related information, see the Psychiatric News articles “Multi-App Package Provides Tailored Behavioral Care” and “Smartphone App Shows Promise in Some Patients With Bipolar I.”

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SSRI/SNRI Use While Pregnant Does Not Seem to Increase Risk of Depression or Anxiety in Children

Children of mothers who took selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) during pregnancy likely do not have a higher risk of depression or anxiety compared with those whose mothers who did not take these medications during pregnancy. The findings were issued this week in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Most first-line serotonergic antidepressants such as SSRIs and SNRIs have reassuring safety profiles pertaining to risks of major birth defects and serious adverse neonatal events, particularly when compared to untreated perinatal depression,” wrote Ardesheer Talati, Ph.D., of Columbia University Irving Medical Center, and colleagues. “However, less has been known about longer-term neuropsychiatric risks.”

Talati and colleagues used data from the Mayo Clinic network’s Rochester Epidemiology Project to identify 837 children born to mothers who were prescribed SSRIs or SNRIs during their pregnancies from 1997 to 2010. They also identified 863 children born to mothers who took no antidepressants during their pregnancies and 399 children whose mothers took antidepressants in the year prior to pregnancy. Finally, a general psychiatrist and a child and adolescent psychiatrist reviewed the children’s electronic health records up to 2021 to identify probable cases of depression or anxiety.

On a surface level, exposure to antidepressants in pregnancy was associated with about a 40% increased incidence of depression or anxiety among children compared with non-exposure. However, the association was no longer significant after adjusting for maternal depression during pregnancy. Further, there were no differences in the incidence of depression or anxiety between children whose mothers used SSRIs or SNRIs in the year prior to pregnancy and those who used them during pregnancy.

“Together these results suggest that increased rates of depression and anxiety observed in the [SSRI- or SNRI-]exposed children are more likely to be driven by maternal depression or underlying propensity for depression rather than direct pharmacological effects of [SSRI or SNRI] exposure,” the authors concluded.

For related information, see the Psychiatric News article “Treating Family Members Can Break Depression Cycle, Says Expert.”

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Narcissism, Immature Defense Mechanisms Linked to Maladaptive Daydreaming, Study Shows

Individuals with a high degree of narcissism may be more likely to engage in excessive daydreaming that significantly affects their lives and daily function, according to a report in the Journal of Psychiatric Research and Clinical Practice. Those with narcissism who employ immature defensive reactions—such as denial, projection, and/or acting out—appear to be at the highest risk of maladaptive daydreaming.

Although not recognized in DSM, maladaptive daydreaming is a condition “characterized by an excessively immersive use of fantasy and imagination, involving detailed and vivid scenarios that significantly impact an individual’s daily life,” wrote Alessia Renzi, Ph.D., and Rachele Mariana, Ph.D., of Rome University. They added: “Preliminary findings from a population study estimate that approximately 2.5% of people experience clinical‐level impairment due to these immersive daydreams.”

A total of 562 individuals completed an online survey that included a demographic questionnaire and three measurement tools:

• The 16‐item Maladaptive Daydreaming Scale (MDS), in which participants rate their daydreaming experiences on a scale from zero (never/none of the time) to 100% (extremely frequent/all the time).
• The Defense Mechanism Rating Scales‐Self‐Report, which assesses 30 individual defense mechanisms categorized into mature, immature, and neurotic defenses.
• The Pathological Narcissism Inventory (PNI), which measures seven dimensions of narcissism (entitlement rage, exploitativeness, grandiose fantasy, self‐sacrificing self‐enhancement, contingent self‐esteem, hiding the self, and devaluing).

The researchers found that 29% of individuals reported an MDS score of 40 or higher, suggesting probable maladaptive daydreaming. There was a significant positive association between narcissism symptomatology and MDS scores—both for overall PNI score and scores on each of the seven narcissistic traits.

“Narcissism therefore both in its grandiose aspects and in its more intimate manifestations presents a close relationship with the controlled creation of daytime fantasies,” Renzi and Mariana wrote.

The link between narcissistic traits and MDS scores was mediated in part through the use of immature defenses, whereas mature defenses offered some protection against maladaptive daydreaming.

The researchers said that the results highlight “how possible treatments and clinical interventions that promote the use of mature defense mechanisms can help people, especially young adults, to cope with psychological distress caused by narcissistic fragility.” They added that “treatments with a psychodynamic orientation (such as defense‐based therapies, transference‐focus therapy or mentalizing‐based therapy) seem best suited to … reflecting on one’s defensive dynamics and promoting the use of mature ones.”

For related information, see the Psychiatric News Special Report “How to Work With Patients Using Problem-Focused Psychodynamic Psychotherapies.”

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ADHD Medications Cause Small Changes in Patients’ Cardiovascular Function, Short-Term

A wide variety of medications for attention-deficit hyperactivity disorder (ADHD)—not just stimulants—can increase blood pressure and pulse in the short term among children, adolescents, and adults, according to a meta-analysis issued in Lancet Psychiatry.

“Although on average the effects are relatively small for most medications, there could be individual-level variability,” wrote Luis C. Farhat, Ph.D, at the Universidade de São Paolo in Brazil, and colleagues. “Therefore, practitioners should closely follow clinical guidelines and monitor blood pressure and pulse before and during treatment for ADHD.”

Farhat and colleagues combined data from 102 randomized controlled trials (encompassing 13,315 children and adolescents and 9,387 adults) that compared various ADHD pharmacotherapies against each other or placebo. Pharmacotherapies included antidepressants (bupropion, atomoxetine, and viloxazine), alpha-agonists (clonidine, guanfacine), and stimulants (amphetamines, lisdexamfetamine, methylphenidate, modafinil). The primary outcomes were the short-term (~12 weeks) changes in pulse, measured in heart beats per minute, and changes in blood pressure, measured at mm Hg.

Key results included:

• In children and adolescents, atomoxetine, lisdexamfetamine, methylphenidate, and viloxazine produced small increases in pulse and blood pressure; amphetamines produced small increases in blood pressure only.
• In adults, amphetamines, atomoxetine, lisdexamfetamine, and methylphenidate produced small increases in pulse and blood pressure; viloxazine produced small increases in pulse only.
• The increases in blood pressure in adults taking atomoxetine or methylphenidate were not observed when the medications were restricted to their FDA-licensed doses.
• Stimulants were not associated with larger increases in blood pressure or pulse compared with atomoxetine or viloxazine.
• By contrast, guanfacine was associated with decreases in pulse and blood pressure in both youth and adults.

Steven R. Pliszka, M.D., at the University of Texas Health Science Center at San Antonio, wrote in an accompanying editorial that small average increases—such as a 5 mm Hg elevation in blood pressure and a 5 beats per minute increase in pulse observed in one included study—typically “will not place the patient outside of the healthy range…. The more difficult question relates to determining whether there are any long-term consequences of mild but chronically elevated blood pressure and pulse over the course of possibly life-long ADHD medication treatment.” Only four of the 102 trials examined the cardiovascular effects of these medications up to 26 weeks, and none included 52-week data.

Overall, Pliszka said that the medications are not associated with increased natural mortality, but are associated with reduced mortality due to unnatural causes. “The overall benefits of ADHD medication treatment continue to outweigh still the risk.”

For related information, see the Psychiatric News article “ADHD Meds Linked to Cardiovascular Risk.”

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Comprehensive Care Improves Chances of Hospitalized Patients Starting OUD Medications

Providing comprehensive diagnostic assessments, clinical recommendations, and discharge plans increases the likelihood that inpatients with opioid use disorder (OUD) will not only initiate medications for OUD during hospitalization but connect with OUD care after discharge, according to a study in JAMA Internal Medicine.

Allison J. Ober, Ph.D., of RAND Corporation in Santa Monica, California, and colleagues analyzed data from a clinical trial of the Substance Use Treatment and Recovery Team (START) addiction consult service. START is a collaborative care model in which an addiction medicine specialist and a case management team provide a tailored intervention based on motivational interviewing, addiction-focused discharge planning, and one month of follow-up calls.

The START study was conducted at three sites and included 325 adult inpatients who had a probable OUD diagnosis; 164 patients were randomized to START, while 161 received usual care, which consisted of each hospital’s practices for managing patients with OUD. For example, one site had an existing consultation-liaison service with psychiatrists and social workers who could discuss opioid use with patients.

Overall, 57.3% of patients receiving START initiated medications for OUD while they were hospitalized, compared with 26.7% of those who received usual care. In addition, 72% of START participants attended at least one OUD-related care visit within 30 days of discharge, compared with 48.1% of those who received usual care.

“The START [addiction consult service] model addresses key barriers to treating substance use disorders in hospital settings, including insufficient expertise within inpatient teams, low patient readiness, and the need for transitional care and outreach,” the researchers wrote. “By tackling these challenges, [this] model bridges critical gaps and enhances the likelihood of successful treatment for individuals with OUD.”

For related information, see the American Journal of Psychiatry article “Treatment of Opioid Use Disorder in the General Hospital.”

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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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