SSRIs Associated With Faster Cognitive Decline in Patients With Dementia

Patients with dementia taking some antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), experienced faster cognitive decline compared with those not taking these medications, according to a study issued this week in BMC Medicine.

Minjia Mo, Ph.D., of the Karolinska Institutet in Stockholm, and colleagues used Swedish nationwide registries to identify 18,740 individuals (54% women, average age of 78 years) who were diagnosed with dementia from 2007 to 2018. The registries included information on prescription medications and participants’ cognitive trajectories, evaluated at baseline and follow-ups using the Mini-Mental State Examination (MMSE). Severe dementia was defined as an MMSE score of less than 10 (lower scores indicate worse cognition). Nearly 23% of participants received at least one prescription for an antidepressant during the six months leading up to their initial dementia diagnosis or a subsequent follow-up, with SSRIs accounting for about 65% of prescriptions.

Adults taking antidepressants experienced faster cognitive decline during follow-up compared with non-use (an additional 0.3-point loss on the MMSE per year). Among adults who had severe dementia at baseline, those taking antidepressants experience an additional 1.5-point loss on the MMSE per year.

The researchers also individually examined the six most common antidepressants prescribed. All three SSRIs on the list—escitalopram, sertraline, and citalopram—were associated with greater cognitive decline compared with non-use. Compared with sertraline, escitalopram presented with faster cognitive decline, while citalopram was linked to a slower cognitive decline. Mirtazapine, a noradrenergic and specific serotonergic antidepressant, was also associated with faster cognitive decline compared with non-use, whereas venlafaxine (a serotonin norepinephrine reuptake inhibitor) and amitriptyline (a tricyclic) were not.

“Sertraline and escitalopram are firsthand choices for depression among older individuals in Sweden,” Mo and colleagues wrote. “However, antidepressants do not seem to work as well in patients with dementia.” They said their findings support the idea that depression in dementia is different from depression in people with intact cognition.

“Future research is needed to further elucidate the complex interplay between antidepressant use, dementia severity, and cognitive decline,” the authors continued. “Our study cannot distinguish whether these findings are due to the antidepressants or the underlying psychiatric indication.”

For related information, see the Psychiatric News Alert “SSRIs May Increase Risks Associated With Anti-Amyloid Alzheimer’s Medications.”

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Agreeable Adolescents May Be Less Likely to Drink Heavily as Adults

Adolescents who are highly extroverted have a higher risk of being heavy drinkers in adulthood, whereas those who are highly agreeable have a reduced risk of heavy drinking, according to a study published in Addictive Behaviors.

No personality traits prior to adolescence were found to be predictive of heavy drinking in adulthood, wrote Ingmar Franken, Ph.D., of Erasmus University Rotterdam, and Peter Prinzie, Ph.D., of Ghent University in Belgium.

“Although personality traits are more or less stable across the lifespan, there are effective interventions targeting personality traits that could be used as early alcohol interventions to prevent heavy drinking,” they wrote.

Franken and Prinzie made use of the Flemish Study on Parenting, Personality, and Development to explore which “Big Five” personality traits—agreeableness, conscientiousness, extraversion, neuroticism, and openness—might predict heavy alcohol use. In the Flemish Study, children and their families were assessed at 10 different waves from early childhood through age 30. For this analysis, the researchers used data from six waves that spanned ages 6 to 19 (which included personality assessments) and 27 to 30 (which included assessments of alcohol consumption).

From ages 6 to 12, no personality traits predicted future alcohol consumption. However, in early, mid, and late adolescence, agreeableness and extroversion predicted heavy drinking—in opposite directions. Whereas higher levels of extroversion correlated with a higher frequency and quantity of drinking in adulthood, higher levels of agreeableness correlated with less heavy drinking in adulthood.

Franken and Prinzie noted that the link between extroversion and drinking is consistent with several theories of personality, while the protective role of agreeableness is less theoretically established. “Agreeableness is a prosocial trait and reflects an endorsement of social rules and social harmony … and it might be that agreeable individuals are more likely to imitate behaviors and form relationships with peers who engage in prosocial behaviors rather than substance use,” they wrote.

For related information, see the Psychiatric News articles “Easily Obtainable Demographic Data Said to Be Best Predictor of Teen Substance Use” and “Multipronged Interventions Needed for Collegiate AUD Risk.”

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Female Physicians—but Not Male Ones—Face Higher Suicide Risk Than General Population

Female physicians are at higher risk of suicide than female nonphysicians, whereas male physicians have a lower risk of suicide relative to the general male population. These discordant findings were part of a study published today in JAMA Psychiatry.

Hirsh Makhija, M.S., of the University of California, San Diego School of Medicine, and colleagues noted that their analysis of data from the National Violent Death Reporting System (NVDRS) could not pinpoint which factors might explain the discrepancy. “Possible contributors include under recognition for similar work and achievements, inequitable pay and opportunities for promotion, greater domestic responsibilities leading to work-life imbalance, and risk of sexual harassment,” they wrote.

The researchers compiled NVDRS data from 2017 to 2021 on suicide decedents ages 25 and older across 30 states and the District of Columbia (the jurisdictions which had consistent suicide data during the five-year period). Their sample included 448 physician and 97,467 nonphysician suicides. Association of American Medical Colleges workforce reports and U.S. Census Bureau data were used to estimate physician and nonphysician populations in the 31 chosen jurisdictions.

After adjusting for demographic variables, the researchers found that female physicians had a 53% greater risk of suicide compared with nonphysicians, while male physicians had a 16% reduced risk of suicide compared with nonphysicians. Both male and female physicians had a higher incidence of suicide from 2017 to 2019 (before COVID-19) compared with 2020 to 2021.

Compared with the general population, physicians who died by suicide (male and female) were:

• About 61% more likely to leave a suicide note.
• More likely to have experienced a job problem, legal problem, or mental health problem prior to suicide, but less likely to have experienced a family problem or substance use problem.
• More likely to use poison or sharp instruments as the method of suicide, and less likely to use firearms.

In an accompanying editorial, Elena Frank, Ph.D., of the University of Michigan, and colleagues wrote that “a shift in culture around work and family within medicine is critical to improving workplace conditions and mental health for female physicians.” Suggestions they noted included improving access to childcare that aligns with physicians’ work schedules and implementing formal coverage systems for last-minute schedule changes.

“As women now represent the majority of medical school graduates and a growing proportion of the physician workforce, the institution of medicine must recognize the unique combination of stressors that female physicians face and endeavor to make real change moving forward,” Frank and colleagues concluded.

For related information, see the Psychiatric News article “Physician Support Line Looks Beyond the Pandemic.”

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FDA Announces Elimination of Clozapine REMS

A long and determined advocacy effort has reached the summit: The Food and Drug Administration (FDA) announced that it will no longer expect prescribers, pharmacies, and patients to participate in the risk evaluation and mitigation strategies (REMS) program for clozapine. This includes the requirement that prescribers report results of absolute neutrophil count blood tests before pharmacies can dispense clozapine.

“Although the risk of severe neutropenia with clozapine still exists, FDA has determined that the REMS program for clozapine is no longer necessary to ensure the benefits of the medicine outweigh that risk,” the announcement said. “FDA has notified the manufacturers that the clozapine REMS must be eliminated.”

The announcement follows a November 2024 meeting of the FDA’s Clozapine REMS advisory committee, which voted 14-1 to eliminate key provisions of the REMS after prescribers and patient advocacy groups, including APA, testified that the REMS creates significant administrative and logistical burdens for prescribers and pharmacies, sometimes causing life-threatening treatment interruptions for patients.

The FDA still recommends that prescribers monitor patients’ neutrophil count according to the frequencies described in the prescribing information. Information about severe neutropenia will remain in the prescribing information for all clozapine medicines, including in the existing boxed warnings.

In response to the announcement, Robert Cotes, M.D., professor of psychiatry at Emory University and director of the clinical and research program for psychosis at Grady Health System, told Psychiatric News, “The FDA’s decision to end the Clozapine REMS marks an important step in improving access to this life-saving medication.”

Cotes has been a longtime champion for wider access to clozapine. “I am especially grateful to all the patients and families who shared their stories at the FDA advisory committee meeting, whose voices and advocacy were instrumental in driving this important change,” he said. “While this is a huge milestone, we still have much more work to do to ensure that clozapine is used appropriately and widely enough to help all those who need it.”

The FDA said that in the coming months, the administration will work with clozapine manufacturers to update the prescribing information and eliminate the Clozapine REMS. Look for further coverage in Psychiatric News.

For related information, see the Psychiatric News article “Patient Advocacy Groups Demand Significant Changes to Clozapine REMS” and “‘Godfather of Clozapine’ Calls for End to REMS.”

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Flexible ACT Generally Comparable to Standard ACT or Intensive Case Management—With One Caveat

Conventional assertive community treatment (ACT), flexible ACT, and intensive case management are comparable when it comes to reducing inpatient hospital stays among people with serious mental illness, a study in Psychiatric Services has found. Individuals receiving flexible ACT (FACT) did have higher rates of emergency department (ED) visits, however.

ACT—in which a multidisciplinary team provides integrated outpatient care to people with conditions such as schizophrenia or bipolar disorder—is considered a gold standard for high-intensity, community-based care. Intensive case management (ICM) is also an established approach, with case managers overseeing care for patients but maintaining a moderate caseload, so they can coordinate intensive services. FACT is a newer model of team-based care in which service teams adjust the intensity of their care as needed.

In June 2021, three community clinics associated with Toronto’s Centre for Addiction and Mental Health (CAMH) began transitioning their ACT and ICM programs toward a FACT model. Martin Rotenberg, M.D., M.Sc., and colleagues at CAMH examined how the transition affected inpatient hospital admissions, length of hospital stays, and ED visits.

“The inclusion of ED service use was important in the context of the teams we studied, because these teams did not provide after-hours crisis interventions that may be standard in other jurisdictions,” the researchers wrote.

The final sample compared 237 patients who received FACT at the clinic that began implementing this model in June with a matched group who received ACT or ICM at the other two clinics that transitioned to FACT many months later. The researchers followed the patients for 10 months (until March 31, 2022), with the first four months considered a transitional period and the latter six the fully implemented period.

Overall, the researchers found no difference in the number of inpatient admissions, or the average length of inpatient stay between individuals who received FACT versus those receiving ACT or ICM during either period. Across the first four months, there was also no observed difference in ED visits. However, when FACT was fully implemented, there were 65% more ED visits in the FACT group versus ACT/ICM (52 versus 31, respectively)

Rotenberg and colleagues suggested that the increase in ED encounters under FACT might be related to changes in the caseloads of the primary case managers following the transition. “Despite the higher rate of ED visits in the FACT group post-transition,” they wrote, “the hospitalization rate did not increase, suggesting that FACT was responsive to continued crisis service needs after an ED visit.”

For related information, see the Psychiatric Services article “Patient Outcomes of Flexible Assertive Community Treatment Compared With Assertive Community Treatment.”

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Emergency Clinicians in California Increased Rate of Buprenorphine Prescriptions

Following the expansion of a statewide program, the rate of California patients receiving their first buprenorphine prescription from an emergency room clinician increased from 0.1% in 2017 to 5% in 2022, according to a study issued this week in JAMA.

There is robust evidence supporting the use of buprenorphine and other medications for opioid use disorder (OUD), but many patients with OUD do not receive this treatment, wrote Annette M. Dekker, M.D., M.S., of the University of California, Los Angeles, and colleagues. In California, the CA Bridge program has encouraged buprenorphine initiation in the emergency department (ED) since 2019.

“Bridge has worked with more than 80% of California’s 331 acute care hospitals to establish the ED as a low-threshold point of treatment entry and support,” the authors wrote. “This has included training emergency clinicians and staff on the provision of buprenorphine for OUD and hiring of patient navigators to engage patients and connect them to community addiction treatment programs for continuation of buprenorphine.”

Dekker and colleagues used a database of Schedule II to V controlled substance prescriptions dispensed in California to identify all buprenorphine prescriptions for patients with OUD written between 2017 and 2022.

Emergency clinicians accounted for just 2% of all buprenorphine prescribers in 2017, but by 2022 they accounted for 16% of all prescribers. Further, emergency clinicians who prescribed buprenorphine for the first time increased from 70 in 2017 to 941 in 2022. Among individuals who initiated buprenorphine in the ED, one in three went on to receive a second prescription within 40 days. Finally, for every nine patients who had buprenorphine initiated by an emergency clinician, one patient achieved 180 days or more of continuous prescriptions within one year.

The study shows that, with adequate state investments, EDs can play a crucial role in connecting patients with OUD to life-saving treatment, even if it’s not always clear where patients can go to follow up, wrote Gail D’Onofrio, M.D., M.S., of the Yale School of Medicine, and colleagues in an accompanying commentary. “Challenges to treatment access are frequently insurmountable during the chaos of addiction,” they wrote. “Thus, prompt ED buprenorphine initiation has value even if follow-up is tenuous.”

For related information, see the Psychiatric News articles “Trauma Lingers in Prescribing Practices for Buprenorphine” and “Congress Removes X-Waiver Requirement.”

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LAI Antipsychotics Associated With Diminishing Risk of Relapse but Risk Remains High

While long-acting injectable (LAI) antipsychotics help people with schizophrenia stay more adherent to their treatment relative to oral medications, nearly half of patients receiving LAI antipsychotics after their first episode still relapsed over a 10-year period, according to a study that appears today in AJP.

The risk of relapse was highest during the first year after initiating an LAI antipsychotic and then diminished over time, with almost no events occurring after five years. This finding indicates that long-term, continuous antipsychotic use does not cause the brain to become supersensitive to dopamine and thus reduce antipsychotic efficacy, wrote lead author Jari Tiihonen, M.D., of the University of Eastern Finland, and colleagues.

The researchers used a Finnish national registry of inpatient care to identify all persons age 45 or younger who experienced first-episode psychosis between 1996 and 2014. Of these, 305 patients (average age 31.7; 66.2% men) started using LAI antipsychotics within the first 30 days of follow-up. Among these patients, 122 (40%) received risperidone, 57 (19%) received zuclopenthixol, 52 (17%) received perphenazine, 32 (10%) received olanzapine, 23 (8%) received haloperidol, and 19 (6%) received other LAIs.

They were followed for up to 10 years. The primary outcome was severe relapse leading to hospitalization; the secondary outcome was the incidence of relapse from year to year, calculated by dividing the number of events by person-years during each period of interest.

Cumulatively over the 10-year period, 45% of patients using LAI antipsychotics experienced a relapse. However, the incidence of relapse diminished dramatically over time—from 0.26 events per person-year during the first year to 0.05 during the fifth year. During years six to 10, only four relapses occurred over 128 person-years.

“Our results argue against breakthrough psychosis being attributable to long-term D2 [receptor] blockade and putative development of dopamine supersensitivity,” the researchers wrote. Rather, they suggest “that neurotransmitters other than dopamine or other biological processes likely contribute to reemerging symptoms.”

But because many relapses cannot be prevented even with continuous D2 receptor blockade, treatments with novel mechanisms of action are needed, the researchers continued.

For additional information, see the Psychiatric News article “LAI Antipsychotics Beat Oral Meds for Preventing Relapse, Hospitalization.”

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Mentalization-Based Treatment Shows Promise for Antisocial Personality Disorder

A mentalization-based psychotherapy approach can significantly reduce violence and aggression in men diagnosed with antisocial personality disorder, according to a study published yesterday in The Lancet Psychiatry. Mentalization-based treatment aims to help people understand their own thoughts and feelings, as well as those of others, which then improves individuals’ empathy, emotional regulation, and decision making.

“Antisocial personality disorder is a major health and social problem, but scepticism about its treatability has restricted development of the evidence base for psychological treatments,” wrote Peter Fonagy, Ph.D., of University College, London, and colleagues.

Fonagy and colleagues enrolled 313 adult males in England and Wales who had antisocial personality disorder and were on probation for a criminal offense related to their behavior. The participants were randomly divided to receive either a 12-month course of mentalization-based therapy alongside their standard probation services or probation services alone.

The mentalization-based treatment involved weekly 75-minute group therapy sessions alongside monthly 50-minute individual therapy sessions. The group session explored the mental states that underlie various behaviors, particularly in situations involving conflict, while the individual sessions trained individuals how to improve skills such as self-awareness, empathy for others, and reflective thinking.

After 12 months, the adults receiving mentalization-based treatment showed significantly greater reductions in their aggression, with an average score of 90 on the Overt Aggression Scale Modified (down from a baseline of 158), compared with an average of 186 in the control group (up from a baseline of 169). Participants receiving the mentalization-based treatment also had greater reductions in antisocial symptoms such as hostility or impulsiveness after 12 months.

After three years, available data suggested that individuals who received mentalization-based treatment committed 46% fewer “re-offences” that resulted in a guilty verdict than those receiving standard probation services.

“Future research should explore [mentalization-based treatment’s] applicability to broader populations, including those who engage in the most frequent and socially damaging forms of serious violent behaviour affecting public safety such as intimate partner violence,” Fonagy and colleagues wrote. “Criminal justice interventions, including carceral punishment, have failed to reduce reoffending from domestic abuse in general. A therapeutic intervention based on an understanding of the origin of aggression could offer the prospect of a step change.”

For additional information, see the Psychiatric News Special Report “Antisocial Personality Disorder—The Patient in Need Often Overlooked.”

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Suicidal Characteristics Among Patients With Schizophrenia May Vary by Length of Illness

Among patients with schizophrenia who died by suicide, those who had the illness for less than a year had fewer characteristics commonly associated with suicide risk, such as substance use or a history of self-harm, according to a study issued this week in Schizophrenia Bulletin.

The findings suggest that some patients’ lives are severely disrupted by their diagnosis, and they require additional support earlier in the course of their illness, wrote Alison Baird, Ph.D., of the University of Manchester, and colleagues. “Services need to be aware of the disruption recent onset of schizophrenia has to social circumstances, such as relationships and work, and help to reduce this by providing intensive and regular support.”

Baird and colleagues used the National Confidential Inquiry into Suicide and Safety in Mental Health to collect clinical and demographic data on 2,828 people (average age of 42 and 75% male) in England and Wales who were diagnosed with schizophrenia and died by suicide between 2008 and 2021. Of this group, 288 patients died by suicide less than a year after they received their diagnosis.

Patients who died a year or more after their schizophrenia diagnosis were more likely to have characteristics known to be commonly associated with suicide, including being unemployed, being unmarried or living alone, and misusing alcohol and/or drugs. Those who died less than a year after their diagnosis were more likely to be younger (under 25 years old), have a comorbid affective disorder, and to have been in contact with mental health services in the week prior to their death. Further, 52% of those who died less than a year after their diagnosis were either a current inpatient, discharged from inpatient care within the last three months, or receiving crisis treatment at home.

“This study highlights how common established characteristics for suicide can vary at different stages of illness and so can direct clinical focus to where care and suicide prevention efforts can be improved most effectively for particular patient groups,” the authors wrote. “Suicide deaths among the recent onset group were more common in early discharge from inpatient care and under the care of [home services], presenting opportunities for intervention in these settings.”

For related information, see the Psychiatric News article “Early Intervention in Psychosis: Balancing Promise and Pitfalls.”

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Trump’s ‘Make America Healthy Again’ EO to Examine Use of Psychotropic Medications for Youth

President Trump issued an Executive Order yesterday establishing a commission on health to address childhood disease—in part by putting psychotropic treatments for youth under scrutiny.

The order comes as Congress is considering significant cuts to the Medicaid program, which along with the State Children’s Health Insurance Program provides health care—including mental health care—to as many as half of the nation’s children.

“Overall, the global comparison data demonstrates that the health of Americans is on an alarming trajectory that requires immediate action,” according to the order. “This concern applies urgently to America’s children.”

The executive order details that nearly 41% of children have at least one childhood health condition such as allergies or asthma, while autism spectrum disorder now affects 1 in 36 children. The order also noted elevated rates of diseases among adolescents and young adults, including fatty liver (18%), prediabetes (30%), and overweight or obesity (40%). “These health burdens have continued to increase alongside the increased prescription of medication,” according to the order.

The order establishes the “Make America Healthy Again” Commission, to be chaired by Health and Human Services Secretary Robert F. Kennedy Jr., which must complete a study of “the childhood chronic disease crisis” within 100 days and a strategy to respond to it within 180 days. Among the instructions to the commission are to “assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs.”

In a message sent to APA members in response to the executive order today, APA CEO and Medical Director Marketa Wills, M.D., M.B.A., wrote: “We know from the evidence and from our own clinical practice that the psychiatric drugs mentioned in the order when prescribed and used as directed by properly trained psychiatrists are safe, effective, and in some cases, lifesaving. APA stands for evidence-based science and will protect the treatments and practices that are so vital to many children and adolescents suffering from mental and substance use disorders.”

Gabrielle L. Shapiro, M.D., secretary of the APA Board of Trustees and a general, child, and adolescent psychiatrist at the Icahn School of Medicine at Mount Sinai in New York, agreed. “There are children who need psychotropic medication and benefit from it,” Shapiro told Psychiatric News. “Child and adolescent psychiatrists are the best, most well-trained clinicians to treat these mental health concerns.”

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Advocacy Alert: Protect Critical NIH Research Funding

On February 7th, the Trump administration announced a new policy to cap facilities and administration costs associated with National Institutes of Health (NIH) grants at 15%. This cap could significantly hinder vital biomedical research across the country, including research aimed at developing effective treatments and prevention strategies for mental health and substance use disorders. The courts have issued a pause on the administration’s plan, but your elected officials need to hear from you!

Transient Ischemic Attack Associated With Annual Decline in Cognitive Function Similar to Stroke

Individuals who have a transient ischemic attack (TIA), also known as a mini stroke, are likely to experience an annual rate of cognitive decline similar to that experienced by people with stroke, according to a report in JAMA Neurology.

Lead author Victor Del Bene, Ph.D., of the University of Alabama, and colleagues said the findings call for more aggressive screening and treatment following TIA to minimize cognitive risks. “Despite the quick resolution of symptoms and no radiological evidence of injury, TIA appears to be sufficient either directly or indirectly to initiate a pathological process leading to long-term changes in cognition,” they wrote.

The researchers analyzed data from the Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort following more than 30,000 community-dwelling Black and White adults in the United States. For this report, they examined cognitive outcomes of 356 individuals diagnosed with first-time TIA after enrolling, 965 individuals diagnosed with first-time stroke, and 14,882 adults with neither event (asymptomatic community control group). TIA was defined as an acute ischemic event that resolved in less than 24 hours and showed up negative for injury on an MRI scan.

A computer-assisted telephone interview was used to collect baseline demographic and medical data, and to administer a cognitive test battery including assessments of verbal learning, verbal recall, cognitive processing speed, and executive function at two-year intervals. The primary outcome was a composite score on the four tests; secondary outcomes included individual test scores.

The group with stroke showed a significantly larger decline in cognition immediately following their event compared with the group with TIA. However, the subsequent annual rate of cognitive decline for the group with TIA did not differ significantly from the group with stroke and was more pronounced than seen among the asymptomatic community control group. Individual test scores showed these changes were driven largely by declines in immediate and delayed memory recall rather than verbal fluency.

Del Bene and colleagues wrote that “cognitive decline after TIA is likely multifactorial in origin” and may involve the interaction with vascular risk factors, the presence of amyloid in the brain, and increased neuroinflammation, among other pathophysiological processes.

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

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Injury-Related Emergency Department Visits Higher Among Children with ADHD, ASD

Children with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or both have higher rates of injury-related emergency department visits than children without either disorder, a study in JAMA Network Open has found. However, the types of injuries varied among groups.

Dorit Shmueli, M.D., of Clalit Health Services in Tel Aviv, and colleagues examined data from the medical records of 325,412 children born between 2005 and 2009 and followed up until the end of 2021. The researchers separated the children into four groups: ASD, ADHD, ASD and ADHD, and control.

Compared with the control group:

• Children with ASD, ADHD, or both had 1.48, 1.45, and 1.29 times the rate of total emergency department visits, respectively.
• Children with ASD, ADHD, or both had 1.57, 1.41, and 1.80 times the rate of emergency department visits for ingestion/inhalation injuries, respectively.
• Children with ASD had lower rates of orthopedic injuries and animal-inflicted injuries, children with both ASD and ADHD had lower rates of orthopedic injuries and similar rates of animal-inflicted injuries, and children with only ADHD had higher rates of both these injuries.

The researchers offered possible explanations for why children with ASD had lower rates of physical injuries such as orthopedic and animal-inflicted injuries. “Many children with ASD exhibit significant levels of comorbid anxiety, which tends to deter them from engaging in various physical activities, thereby reducing their exposure to physical injuries,” they wrote. Shmueli and colleagues added that Israeli law requires closer daily supervision for children with ASD than those with ADHD, and this may also have contributed to differences in injury rates.

“Thus, further studies should focus on evaluating the effects of adult supervision on the rates of injuries among children with ASD, ADHD, or both ASD and ADHD and examine possible injury prevention programs that can highlight the type of support that is most beneficial for these children,” they concluded.

For related information, see the Psychiatric Services article “Characteristics of Patients Served by a Statewide Child Psychiatry Access Program.”

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APA Announces Results of 2025 Election

APA members have chosen Mark Rapaport, M.D., as president-elect, subject to final approval at the March meeting of APA’s Board of Trustees.

“I’m truly honored to step into the role as APA president-elect to use the convening power of the APA, and my existing relationships, to bring together leaders in policy, philanthropy, other mental health organizations, and business to create a common agenda around parity,” said Rapaport, who is Founding CEO, Emeritus of the Huntsman Mental Health Institute, the William H. and Edna D. Stimson Presidential Endowed Chair, and professor of psychiatry at the University of Utah. “Together, we will flip the dialogue and make it clear that psychiatry is an investment in our shared future.”

Rapaport’s work has focused on the interactions between the brain and the immune system, as well as clinical psychopharmacology and complementary medicine. Rapaport is also editor in chief of the APA journal Focus, which he co-founded; the journal is designed to help busy clinicians stay up to date with advances in the field of psychiatry. Focus was the first major journal in the field to devote entire issues to LGBTQ+ and underrepresented mental health concerns.

"It’s exciting to welcome such a well-regarded leader like Dr. Rapaport onto our board,” said APA CEO and Medical Director Marketa M. Wills, M.D., M.B.A. “His focus on defeating stigma, compassionate patient care, research, and education as well as his long-term involvement with APA positions him well as we look toward our field’s future.”

APA President-Elect Theresa Miskimen Rivera, M.D., begins her term as president in May at the conclusion of the APA 2025 Annual Meeting, and Rapaport’s term will begin in May 2026.

Other election results, subject to board approval, are as follows:

Secretary:
Gabrielle L. Shapiro, M.D.

Minority/Underrepresented Representative Trustee:
Kamalika Roy, M.D., M.C.R.

Area 3 Trustee:
Kenneth Certa, M.D.

Area 6 Trustee:
Lawrence Malak, M.D.

Resident-Fellow Member Trustee-Elect:
Tariq Salem, M.D.

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Many Psychiatrists Unaware of Out-of-State Exemptions for Patients—or Unwilling to Use Them

Many psychiatrists are unaware of state licensing exemptions that permit them to treat patients who regularly move across state lines, such as college students, according to a study in Psychiatric Services. The findings also revealed that once informed of state exemptions, psychiatrists are split on their willingness to treat patients outside their state.

Rachel Conrad, M.D., of Brattleboro Retreat in Brattleboro, Vermont, and colleagues contacted 901 psychiatrists during the summer of 2023. All these psychiatrists advertised their services on an online platform. The investigators simulated an inquiry from a student who attends college in another state—one that offers exemptions for out-of-state psychiatrists—but wants to initiate treatment for new-onset depression while staying with their parents in the psychiatrist’s home state during the summer. 

After extensive phone and email attempts, the researchers established contact with 143 psychiatrists who were accepting new patients. Of these, just seven (5%) were aware of potential state medical licensure and/or telehealth exemptions. In these instances, the “student” offered an overview of the relevant laws that would allow for continuity of care once they returned to campus.

Among the 136 psychiatrists initially unaware of state laws:

• Forty-three (30%) were willing to establish care with students attending college in another state regardless of state laws, while 51 (36%) were unwilling to do so even when permitted by law.
• The remaining 42 (29%) wanted to learn more about licensure exemptions, though nine of this group subsequently declined to provide care to the student.

Conrad and colleagues noted that most of the psychiatrists they attempted to reach were in private practice and may not represent the field as a whole.

Still, the high rates of noncommunication, lack of state legal knowledge, and unwillingness to rely on medical licensure exemptions highlight the many barriers facing college students seeking mental health care, the researchers continued. Citing a federal law passed in 2018 that allows clinicians traveling with a sports team to practice in any other state, they suggested further federal licensure exemptions may be more effective at improving access to care.

For related information, see the Psychiatric Services study “Availability of Outpatient Child Psychiatric Care During COVID-19: A Simulated-Patient Study in Three U.S. Cities.”

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Digital Workplace Mental Health Benefit Is Cost-Effective, Study Finds

For every $100 invested in an employer-sponsored mental health benefit, employers save $190 in medical claims costs, according to an analysis issued this week in JAMA Network Open. The study assessed the Spring Health program from Spring Care Inc. and included investigators from the program.

Matt Hawrilenko, Ph.D., of Spring Health, and colleagues examined data from 13,990 employees (average age of 37 years, 65% female) who received a behavioral health diagnosis (primarily anxiety and mood disorders) from one of seven United States employers that had implemented Spring Health. Participants were randomized either to enroll in the behavioral health program (n=4,907) or to a control group (n=9,083). The researchers determined monthly medical spending using medical and prescription claims incurred in the year before and after each participant’s behavioral health diagnosis.

Those enrolled in the program received behavioral health care through a digital platform that provided unlimited care navigation sessions, self-guided digital content, and six to 12 free psychotherapy sessions with a clinician, up to two of which could be used for medication evaluation and treatment. Those in the control group received treatment as usual through their health plan, which could include behavioral health care, general care from a nonspecialist (such as a primary care physician), or a behavioral health diagnosis without follow-up treatment.

After 12 months, total medical costs were lower in the program group compared with the control group, with a net difference of $164 per member per month. This corresponded to savings of $1,070 per participant in the first year of the program, after factoring in program costs. Savings were larger for participants who had a higher medical risk. While there was a 47% increase in behavioral care use among participants receiving the program compared with the year before launch, the costs of this additional care were offset by decreases in physical health costs.

Molly Candon, Ph.D., and Rebecca Stewart, Ph.D., of the University of Pennsylvania, wrote in an accompanying commentary that it is important to demonstrate the cost savings of employer-sponsored programs, “because it could encourage more employers to value, invest in, and improve the mental well-being of their employees.”

But Candon and Stewart emphasized that the true value of mental wellness is difficult, or even impossible, to capture. “Given the growing rates of anxiety, depression, and other mental health conditions in the U.S. and the idea that employer-sponsored programs may be our single greatest opportunity to expand mental health care for much of the country, we should consider more than just cost savings when justifying new programs with far-reaching consequences to improve mental wellness,” they wrote.

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Formulary Restrictions for LAI Antipsychotics Are Infrequent in Medicare

Medicare patients who might benefit from long-acting injectable antipsychotic medications (LAIAPs) are not often subject to restrictions such as prior authorization or step therapy (which involves using less expensive medications first), according to a survey study appearing in Psychiatric Services.

These findings suggest that other factors are likely responsible for the low utilization of LAIAPs in clinical practice, despite their demonstrated effectiveness in numerous research studies. “This discrepancy may be due to a low awareness of LAIAPs among patients with psychotic illnesses and missed opportunities in clinical practice to discuss transition to an LAIAP with patients,” wrote Samuel Bunting, M.D., M.S., of the University of Chicago, and colleagues.

The researchers used publicly available databases of the Centers for Medicare and Medicaid Services to examine the frequency of prior authorization or step therapy restrictions during the third quarters of 2019 to 2023 in Medicare Advantage, dual Medicare-Medicaid eligibility plans, and Medicare Part D prescription drug plans. Results were weighted by the number of enrollees in those plans. A total of 2,494 Medicare plans were available in every year, representing 1,694 Medicare Advantage plans, 296 dual Medicare-Medicaid plans, and 504 Part D plans.

Nine LAIAPs were included in the analysis: two formulations of aripiprazole, fluphenazine, haloperidol, olanzapine, two formulations of paliperidone, and two formulations of risperidone.

Prior-authorization requirements for LAIAPs were generally low (between 1 and 11%) across the three plan groups and declined slightly between 2019 and 2023. The exception was olanzapine, which carries warnings due to a risk of post-injection sedation or delirium. In 2019, for example, 25% of enrollees in Medicare Advantage, 25.9% in dual plans, and 50.5% in Part D plans were subject to prior authorization for olanzapine.

Use of step therapy was similarly uncommon across the three plan groups, with rates generally at 1% or less by 2023. Step-therapy requirements were higher for olanzapine for Medicare Part D enrollees (2.6% in 2023 compared with 0.1% for other LAIAPs).

“Additional education of patients and clinicians is likely needed to address other barriers in order to improve use of these medications,” the researchers wrote. “More research is needed to determine specific barriers from the perspectives of both patients and psychiatric providers to ensure that LAIAPs reach appropriate patients.”

For related information, see the Psychiatric News article “Too Little, Too Late: LAIs Remain Underused.”

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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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