Stigma, Unfamiliarity Identified as Patient Barriers to Medications for AUD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Clozapine Linked to Lower Mortality in Older Patients With Schizophrenia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Childhood Trauma, Early Puberty Associated With Internalizing Symptoms in Girls

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

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

Participants followed three distinct patterns of pubertal development:

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

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

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

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

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

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

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

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

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

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

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

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Psychotherapy by Nonspecialists via Telehealth Can Be Effective for Perinatal Depression

A brief, manualized psychotherapy provided by trained and supervised nonspecialists was just as effective at helping perinatal women resolve their depression and anxiety as the same care delivered by mental health professionals in person, according to a study published in Nature Medicine.

“One in five women experience depression or anxiety during the perinatal period (pregnancy up to the year following childbirth). Treatment is essential, given the negative, long-term, and intergenerational impact on maternal and child developmental outcomes,” wrote Daisy R. Singla, Ph.D., of the University of Toronto, and colleagues. “However, access is limited, with barriers including cost, stigma, and the inequitable distribution of mental health professionals. As a result, only 10% of affected perinatal patients in high-income countries receive psychotherapy.”

Singla and colleagues recruited 1,230 racially diverse pregnant or postpartum women from five sites across North America from January 2020 to October 2023. All participants scored 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS), indicating at least minor depression; the average score at baseline was 16, indicating moderate depression.

The participants each received six to eight weekly, manualized behavioral activation (BA) sessions; however, they were randomized to receive care either from trained, nonspecialist health care providers, such as nurses or midwives, via telehealth (472) or in person (145); or from mental health professionals via telehealth (469) or in person (144). Participants’ depressive and anxiety symptoms were assessed three months post-randomization with the EPDS and Generalized Anxiety Disorder-7 (GAD-7), respectively.

After three months, EPDS scores dropped by an average of seven points, regardless of type of provider or delivery. A change of four points on the EPDS is generally considered to represent a real and clinically meaningful difference in depression symptoms. Similarly, participants’ GAD-7 scores dropped by an average of six points (from a baseline average of 12), regardless of specialist type or delivery.

“The key to this success was the rigorous training and structured supervision throughout the study that was provided by experienced mental health professionals, who in this case had five years of experience, at minimum,” study co-author Samantha Meltzer-Brody, M.D., M.P.H., director of the University of North Carolina Center for Women’s Mood Disorders and executive dean at UNC School of Medicine, told Psychiatric News Alert. She added that one mental health professional can provide training and supervision to many nurses, doulas, and midwives. “This structure allows us to markedly expand the reach of perinatal mental health care in a powerful way.”

For related information, see the Psychiatric News article “Perinatal Treatment Requires Careful Risks, Benefit Consideration.”

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CBT Focused on Shifting Attention to External Cues Found Most Effective for Social Anxiety Disorder

Cognitive behavioral therapy (CBT) is the most efficacious psychotherapy for social anxiety disorder, according to a meta-analysis in the Journal of Affective Disorders.

Linghan Sun, of Southwest University in Chongqing, China, and colleagues analyzed data from 92 studies covering 90 randomized control trials and involving 6,971 participants. The selected studies examined multiple CBT protocols as well as cognitive restructuring, exposure therapy, psychodynamic therapy, interpersonal therapy, and/or mindfulness-based interventions to control conditions such as treatment as usual, placebo, and a waitlist. The researchers also explored the efficacy of different delivery formats (e.g., face-to-face versus online).

Overall, CBT modalities were the most efficacious, particularly the Clark and Wells protocols, which aim to help individuals with social anxiety disorder (SAD) shift their attention away from internal negative thoughts and toward external cues in social situations. The Hope, Heimberg, and Turk CBT protocols, which focus on verbal cognitive restructuring and exposure to feared situations, were also effective. Among the CBT models developed specifically for the online treatment of SAD, the Andersson and Carlbring protocols, which center on behavioral activation, had the highest efficacy. In terms of treatment delivery, clinician-guided, individual face-to-face CBT yielded the best efficacy, whereas self-help book–based CBT was the least effective. Psychodynamic therapy was the most effective non-CBT treatment.

“[B]y ranking treatments based on their relative effectiveness in reducing severity of SAD symptoms, clinicians could make more informed decisions about which psychotherapy might be most suitable for their patients,” the researchers wrote. “Furthermore, clinicians will be able to flexibly choose the suitable delivery formats of CBT based on the specific situation.”

For related information, see the Focus article “Cognitive-Behavioral Treatments for Anxiety and Stress-Related Disorders.”

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One in 10 Patients Starts Buprenorphine Treatment for OUD via Telehealth

One in 10 buprenorphine initiations is provided via telehealth, and about 20% of those involved no in-person visit within two years prior or 30 days after, according to a study in today’s JAMA Network Open.

“Our findings suggest that telehealth initiation of buprenorphine without a prior in-person visit is an important pathway for accessing this lifesaving treatment for adults with opioid use disorder,” lead investigator Beth McGinty, Ph.D., M.S., of Weill Cornell Medicine, told Psychiatric News. “The pending final rule on telehealth would support this access, and given that we know buprenorphine reduces risk of opioid overdose by 50%, it would save lives.”

The Drug Enforcement Administration issued a final rule in the waning days of the Biden administration that would allow a clinician to teleprescribe up to six months of buprenorphine without an in-person visit as long as the clinician reviewed the prescription drug monitoring program for the state where the patient resides. The rule had been scheduled to take effect in mid-February, but the Trump administration issued an executive order pausing all federal rules not yet in effect, pending further review.

McGinty and colleagues used IQVIA data to assess buprenorphine initiations from March 2020 through November 2022. The researchers included physicians who continuously practiced from 2018 to 2022 and who had treated at least one patient with opioid use disorder. They measured their proportion of telehealth initiations that had no in-person visit with the prescribing clinician within two years prior, and no in-person visit within two years prior or 30 days after.

During the study timeframe, about 10% of the 228,598 total buprenorphine initiations were via telehealth, involving 3,950 clinicians and 21,220 patients. Among these telehealth initiations, 28% had no in-person visit with the prescribing clinician in the prior two years, while 20% had no in-person visit with the prescriber two years prior or 30 days after. The proportion of telehealth initiations with no in-person visit before or after was higher among behavioral health physicians (27% of all telehealth initiations) than primary care physicians (15%) and nurse practitioners or physician assistants (22%).

“In-person visit requirements can impede access due to limited in-person provider appointment availability and other barriers, such as transportation,” McGinty said. “Additional research is needed to compare the effectiveness of telehealth buprenorphine initiations with and without in-person visits to determine if six months is the ‘right’ duration and to consider … whether fully remote telehealth models with no in-person visits are able to deliver comparably safe and effective care.”

For related information, see the Psychiatric News article “New Rules Allow Telehealth Prescribing, but ‘Special Registration’ Proposal May Create Barriers to Care.”

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