Friday, February 7, 2025

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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Thursday, February 6, 2025

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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Wednesday, February 5, 2025

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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Tuesday, February 4, 2025

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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Monday, February 3, 2025

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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