Stimulant Prescription Via Telehealth Does Not Increase Substance Misuse Risk, Studies Find

Patients who are prescribed stimulants for attention-deficit/hyperactivity disorder (ADHD) via telehealth do not have a greater risk of developing a substance use disorder (SUD) compared with those who receive prescriptions in person, according to a study published this week in The American Journal of Psychiatry (AJP). Patients prescribed via telehealth did have a higher risk of developing a stimulant use disorder, but the authors suggested this may be due to confounding factors.

Vinod Rao, M.D., Ph.D., of Massachusetts General Hospital, and colleagues used electronic health record data to identify 7,944 patients ages 12 and older (57% female, 81% White) who received an initial stimulant prescription for ADHD via telehealth (54% of total) or in-person care (46%) between March 2020 and August 2023.  Overall, 432 patients developed a stimulant use or other SUD.

The patients who initially received their stimulant prescriptions via telehealth did not have a significantly higher risk for developing an SUD. However, those patients were six times more likely than those who received their initial prescription in-person to develop a stimulant use disorder after adjusting for covariates.

“While this finding may be spurious, it may also suggest a bias toward those receiving telehealth care being at higher risk specifically for [stimulant use disorder],” Rao and colleagues wrote. “It may be that in the present analyses, unmeasured patient characteristics associated with a greater likelihood of engaging in telehealth over in-person care (e.g., difficulty accessing reliable transportation) also produce a bias toward the development of [stimulant use disorder].”

This conclusion was supported by a second AJP study published the same day in which Y. Nina Gao, M.D., Ph.D., and Mark Olfson, M.D., M.P.H., of Columbia University, examined data from 63,795 adults who reported having at least one health care visit in the last year in the 2021-2022 National Survey of Drug Use and Health. The survey included information on past-year prescription opioid, benzodiazepine, or stimulant misuse, as well as whether the participants spoke with a health practitioner via telehealth or in-person.

While the unadjusted odds of past-year misuse of prescription opioids, benzodiazepines, and stimulants were between 25% and 46% higher among respondents reporting telehealth use, this association was no longer significant for any of these substances after controlling for participants’ history of misuse of that substance.

“These findings bear on an ongoing policy debate balancing the desire to maintain increased patient access to care while minimizing the potential harms of controlled substance prescribing,” Gao and Olfson wrote. “Although differences in average risk between in-person and telehealth cohorts have sometimes been interpreted negatively as ‘doctor shopping’ (i.e., differential selection across providers), it is important to recognize that some patients with higher risk for substance misuse also struggle to access appropriate general and behavioral health care.”

For related information, see the Psychiatric News Alert “One in 10 Patients Starts Buprenorphine Treatment for OUD via Telehealth.”

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Care Management Improves Outcomes for Adults With First-Time Psychiatric Admission

A brief care management intervention offered to adults following their first psychiatric hospitalization can reduce readmission rates while increasing rates of outpatient aftercare, reports a study published today in Psychiatric Services.

“Although inpatient service is considered a poor outcome of behavioral health care, it provides an opportunity for care management intervention to address medication access, discharge and recovery planning, and connection to aftercare and other resources for continuity of care,” wrote Shari L. Hutchison, M.S., P.M.P., of Community Care in Pittsburgh, and colleagues

While Community Care—a nonprofit behavioral health managed care organization that is part of the University of Pittsburgh Medical Center Insurance Services Division—had already been offering a care management program to Medicaid-enrolled adults with multiple psychiatric admissions, the organization tested an expansion of the intervention to individuals with no prior inpatient history.

Hutchison and colleagues identified 5,140 Medicaid-enrolled adults across 71 facilities in Pennsylvania who had a first-time psychiatric admission in 2022 or 2023. Of this group, 48% received the 10- to 20-minute intervention from a trained care manager, while the remainder did not for various reasons (e.g., coordination issues, early discharge).

Overall, the 30-day psychiatric readmission rate was 9% among those who received the intervention and 11% among those who did not. After adjusting for differences in demographic characteristics and diagnoses between the groups, the researchers calculated that not receiving the intervention increased the odds of readmission by 28%. In addition, 26% of adults who received the care management intervention went to an outpatient appointment within 30 days of discharge, compared with 21% of those who did not.

The reduced readmission rate led to cost savings, with direct expenditures totaling $2.3 million for the intervention group, compared with $2.8 million for the comparison group. The researchers noted that further cost savings from providing this intervention early in an individual’s illness trajectory could be realized in the long term.

“[S]ervices are often prioritized for those with the highest need and costs, such as crisis or residential services targeted to individuals with multiple psychiatric admissions,” the researchers wrote. “Our findings support the necessity of having a diverse array of services within a behavioral health system of care.”

For related information, see the Psychiatric Services article “Care Management for Serious Mental Illness: A Systematic Review and Meta-Analysis.”

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Weekly Pill May Replace Daily Medications for Patients With Schizophrenia

A single, long-acting oral capsule can provide patients with schizophrenia or schizoaffective disorder with a stable dose of medication for one week, according to findings of an open-label study from Lyndra Therapeutics published yesterday in Lancet Psychiatry.

“One of the biggest obstacles in the care of people with chronic illnesses in general is that medications are not taken consistently. This leads to worsening symptoms, and in the case of schizophrenia, potential relapse and hospitalization,” study co-author Leslie Citrome, M.D., M.P.H., of New York Medical College, said in a news release. “Having the option to take medication by mouth once a week represents an important option that can assist with adherence for the many patients who would prefer oral medications versus injectable formulations.”

Citrome and colleagues recruited 83 patients with schizophrenia or schizoaffective disorder from five sites across the United States (25% female, average age 49 years, 81% Black or African American). Before starting the open-label study, participants were given daily, immediate-release risperidone (an antipsychotic) for one week. They then received five of the Lyndra Therapeutics devices, each loaded with a weekly dose of risperidone—either 15 mg or 45 mg.

The device—composed of various polymers—has six arms that are folded inside a capsule about the size of a multivitamin. Once it reaches the stomach, the capsule dissolves and the arms spring out. The device is then too large to exit the stomach, so it remains freely floating and slowly releases risperidone. After about a week, the arms break off and the device remnants pass through the digestive tract.

The participants had risperidone levels at or above the minimum therapeutic concentration across the five-week dosing period relative to corresponding daily dose, and well below the peak concentrations of immediate-release risperidone. This suggests stable drug delivery that may reduce the risk of extrapyramidal side effects, the authors wrote. Similarly, participants’ symptoms remained stable throughout the study period, as assessed with the Positive and Negative Syndrome Scale.

There were some gastrointestinal-related adverse events (such as reflux or constipation) during the first week in which participants took the device, but those decreased over time. Females were more likely to report gastrointestinal-related adverse events than males.

“This really demonstrates … what we had hypothesized a decade ago, which is that a single capsule providing a drug depot within the GI tract could be possible,” study co-author Giovanni Traverso, Ph.D., of the Massachusetts Institute of Technology, said in the news release.

For related information, see the Psychiatric News article “Studies Point to Benefits of Early Treatment With Long-Acting Antipsychotics.”

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Noninvasive Electrical Stimulation Improves Fibromyalgia Symptoms

An at-home electrical stimulation intervention, coupled with exercise and pain education, can significantly reduce fibromyalgia-associated pain, according to results of a clinical trial published yesterday in JAMA Network Open.

Wolnei Caumo, M.D., Ph.D., at the Universidade Federal do Rio Grande do Sul in Porto Alegre, Brazil, and colleagues enrolled 112 adult women ages 18 to 65 with fibromyalgia for their clinical study. Half of the women received a home-based transcranial direct current stimulation (tDCS) headset, which has the anode situated over the left dorsolateral prefrontal cortex (DLPFC) and the cathode placed over the right DLPFC and continuously delivers 2 mA of current. The protocol involved five 20-minute stimulation sessions each week for four weeks.

The other half of the participants received a sham headset that appeared the same but only delivered current for 30-second segments at the beginning, middle, and end of the 20-minute session. All participants also received a chronic pain-management package that included a motivational interview, a suite of educational videos, and an exercise program. At the trial’s start, all women received one sham stimulation session to see if they were prone to experiencing a placebo response.

The women reported their Multidimensional Pain Interference Index (MPII) each week during treatment and again at a three-month follow-up. The MPII measures levels of pain across seven daily activities (general activity, walking, work, mood, enjoyment of life, relationships, and sleep).

After four weeks, MPII scores dropped significantly more in the tDCS group than the sham group across the treatment period and follow-up, with slightly greater decreases seen in placebo responders (49.3% reduction) than non-responders (40.6% reduction). Overall, 62.5% of women in the tDCS group cut their MPII scores in half or more, compared with 37.5% of women in the sham group. Further, nearly 85% of women in the tDCS group reported feeling moderately better or much better after four weeks.

The treatment benefits persisted at the three-month follow-up, though overall MPII scores did rise slightly.

For related information, see the American Journal of Psychiatry article “Spaced Transcranial Direct Current Stimulation for Major Depression” and the accompanying editorial “Spaced Transcranial Direct Current Stimulation for Depression: The Road Less Traveled.”

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Frequent Mental Distress Varies by Occupation

People who work in the arts, design, entertainment, sports, and the media have a higher prevalence of frequent mental distress than those in other fields, according to a study published in JAMA Network Open.

Aaron L. Sussell, Ph.D., of the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health, and colleagues analyzed data from the 2015 through 2019 Behavioral Risk Factor Surveillance System (BRFSS) surveys, which included an optional module on industry and occupation. Their sample included 536,279 employed individuals, among whom 469,126 reported their industry or occupation.

The researchers looked at three key measures of mental health among the participants:

• Lifetime depression, defined as a positive response to the BRFSS question “Has a doctor, nurse, or other health professional ever told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?”
• Mentally unhealthy days (MUD), based on responses to the BRFSS question “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”
• Frequent mental distress, defined as a MUD score of 14 or higher.

Overall, 14.2% of participants reported lifetime depression and 9.6% reported frequent mental distress.

To calculate adjusted prevalence ratios for frequent mental distress among various occupations, the researchers chose workers in transportation and material moving as a reference group. The median lifetime depression prevalence in this group is near the median of the occupational groups in the study.

Compared with workers in the reference group, workers in the arts, design, entertainment, sports, and media had 1.32 times the prevalence of frequent mental distress. Workers in food preparation and serving (1.20 times), health care support (1.19 times), and sales and related occupations (1.13 times) also had statistically higher prevalence of frequent mental distress compared with the reference group. Workers in community and social services had the highest adjusted prevalence of depression compared with the reference group (1.47 times), followed by workers in the arts, design, entertainment, sports, and media (1.34 times).

“Workplaces can play a role in identifying and reducing psychosocial hazards and promoting workers’ mental health,” the researchers wrote. “More research is needed to evaluate work-related factors and workplace intervention effectiveness.”

For related information, see the Psychiatric News article “New Instrument Developed to Assess Workplace Depression.”

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Majority of Callers Say 988 Lifeline Saved Their Lives

Almost all the callers who reached out to the National Suicide Prevention Lifeline (now the 988 Suicide and Crisis Lifeline) say their calls helped them, with 88% saying that it stopped them from killing themselves, a study published in Suicide and Life-Threatening Behavior found.

“Suicide continues to be an alarming public health problem in the United States,” wrote Madelyn S. Gould, Ph.D., M.P.H., of Columbia University, and colleagues, noting that age-adjusted suicide rates increased by 30% from 2002 to 2022. “The establishment of the 988 Suicide and Crisis Lifeline is a leading response to this national crisis.”

Gould and colleagues interviewed 437 adults (59% female, 72% between the ages of 18 and 34) who called the Lifeline between April 15, 2020, and August 15, 2021 (the network’s dialing code became 988 in 2022). The callers were identified as suicidal based on their Lifeline counselors’ clinical risk assessments. Callers were interviewed about two weeks after their initial calls to the Lifeline. Interviewers assessed the callers’ demographics, clinical characteristics (including history of suicidal ideation and suicide risk at the time of the call), and perceptions of counselor practices and their calls’ outcomes.

Over half of the callers reported being at least somewhat likely to act on their suicidal thoughts at the time of their call. However, nearly 72% of callers reported that calling the Lifeline helped them a lot, and a further 26% said it helped them a little. Asian callers were significantly less likely than other races to say their call helped them a lot (just 42%), which the researchers said might have been due to increased discrimination faced by Asian Americans during the COVID pandemic, when the interviews took place.

Additionally:

• About 59% of callers said they’d had no thoughts of killing themselves since the call.
• Callers nearly universally said their counselors engaged in Lifeline best practices (fostering engagement/connection, collaborative problem-solving, and safety/assessment management).
• Callers’ perceptions of their counselors’ behaviors were significantly and clinically meaningfully associated with positive call outcomes.

“While it might be expected that callers would rate counselor behaviors favorably on calls they found helpful and effective, it is notable that favorable ratings of the assessed domains of counselor behavior were also associated with lower rates of recurrence of suicidal thoughts,” the researchers wrote. “[O]ur study provides empirical evidence for the effectiveness of Lifeline’s telephone crisis services from the perspective of callers themselves.”

For related information, see the Psychiatric News article “988 Finally Connects Callers to Local Resources.”

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TMS May Be More Effective With Symptom Provocation for OCD, Nicotine Dependence

Individuals with obsessive-compulsive disorder (OCD) or nicotine dependence may have an improved response to transcranial magnetic stimulation (TMS) when their symptoms are provoked through audio and/or visual cues, according to a report published yesterday in JAMA Psychiatry.

Daniel Bello, B.S., of Vanderbilt University Medical Center, and colleagues noted that “provoking symptoms may shift the brain into a state that is more susceptible to the effect of TMS.” For example, the FDA-cleared protocol for smoking cessation involves a five-minute procedure where patients imagine their greatest craving trigger, listen to a recording instructing them to handle a cigarette and lighter, and then view smoking images.

However, most trials using provocation have been small, and there have been no head-to-head comparisons of TMS with or without provocation, the researchers continued. “A major question for TMS treatment remains: does brain state affect clinical response?”

Bello and colleagues compiled data from 71 randomized clinical trials evaluating TMS in adults with OCD (n=44) or nicotine dependence (n=27)—either with or without symptom provocation. Approved TMS protocols for depression do not involve symptom provocation and were not included in the analysis.

For OCD studies, active TMS was associated with better clinical response (improvement on the Yale-Brown Obsessive-Compulsive Scale) than sham stimulation both with and without symptom provocation, though the effect size was larger in trials with provocation (0.51 versus 0.29). For nicotine dependence, however, active TMS was statistically associated with better clinical response (cravings, dependence severity, and/or cigarettes smoked) than sham stimulation only when used with symptom provocation (effect size of 0.56).

“Additional research is warranted to more accurately estimate any added benefit of symptom provocation,” Bello and colleagues wrote. “If beneficial, using symptom provocation with TMS protocols would be broadly accessible and could be readily implemented in TMS clinics across the globe.”

However, they cautioned that provoking symptoms is often uncomfortable for both the patient and the TMS technician and could cause some study participants to drop out or relapse. “Therefore, it is worth empirically determining if symptom provocation is safe and effective before it is applied universally in TMS protocols,” the researchers wrote. “Symptom provocation should be used where effective but avoided when there is no clear benefit.”

For more information, see the Psychiatric News article “From Heretical Idea to Mainstream Psychiatry: Brain Stimulation Has Ridden a Wave.”

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Researchers Look to Unlock GLP-1 Drugs’ Potential in Psychiatry

Researchers are exploring the potential of glucagon-like peptide 1 (GLP-1) receptor agonists to treat neuropsychiatric disorders such as cognitive dysfunction and alcohol use disorder, according to a panel held last week at the American Society of Clinical Psychopharmacology’s annual meeting in Phoenix.

GLP-1 receptor agonists such as semaglutide and tirzepatide mimic the effects of GLP-1, a peptide produced in the intestinal mucosa, and are known for leading to remarkable weight loss in both the general population and individuals with antipsychotic-induced weight gain.

GLP-1 medications do not increase resting metabolic rate or promote physical activity, but “they do have a very robust signal in reducing caloric intake,” explained Rodrigo Mansur, M.D., Ph.D., research scientist, psychiatrist at the University Health Network, and assistant professor of psychiatry at the University of Toronto. “Patients tell us, ‘They reduce feelings of hunger, they promote feelings of satiety.’”

These medications are believed to modulate the rewarding aspects of food—and potentially other substances. A recent Phase 2 trial found that weekly low-dose semaglutide significantly reduced the amount of alcohol consumed by adults with alcohol use disorder during a self-administration task taken after four weeks of treatment, according to panelist Christian Hendershot, Ph.D., a professor of population and public health sciences at Keck School of Medicine at the University of Southern California, who conducted the trial with colleagues.

Research on GLP-1 medications in animal models suggest the compounds also have neuroprotective and anti-inflammatory actions, which has led to expanded research on their potential to treat neuropsychiatric disorders, said Greg Nigel, Ph.D., chief of the drug design and development section at the Intramural Research Program at the National Institute on Aging. GLP-1 receptors are found throughout the brain, and studies are showing they may prove valuable in a host of neurodegenerative disorders that are prevalent in late life, such as Parkinson’s and Alzheimer’s disease.

Mansur discussed a recent randomized trial that he and colleagues undertook to explore semaglutide’s potential for improving executive function in individuals with major depressive disorder (MDD), 80% of whom had a lifetime history of suicidality. Over the 16-week trial, Mansur and colleagues found no difference in executive function scores between the semaglutide and placebo groups. However, the researchers did find a statistical improvement in global cognition for semaglutide compared with placebo—suggesting it may work in other cognitive domains.

For related information, see the Psychiatric News article “Award Winner Describes Efforts to Improve Cognition in People With Bipolar Disorder.”

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Just a Third of SUD Treatment Facilities Offer Perinatal Programs

Less than one-third of facilities that offer treatment for substance use disorder (SUD) or combined SUD and mental health disorders offer a perinatal program, a study in the Journal of Substance Use and Addiction Treatment has found.

Brooke N. Lombardi, Ph.D., M.S.W., of the University of North Carolina at Chapel Hill, and colleagues analyzed data from the 2022 National Substance Use and Mental Health Services Survey, an annual survey of all known public and private SUD and mental health treatment facilities in the United States. The sample consisted of 6,995 facilities providing only SUD treatment (SUD-only) and 9,134 facilities offering combined SUD and mental health treatment.

Overall, only 32.7% of SUD-only facilities and 31.1% of combined facilities reported offering a program or group that is specifically tailored for pregnant/postpartum women.

“While these percentages are relatively low, they represent an increase from those reported in previous research, suggesting that the availability of these essential programs may be growing,” Lombardi and colleagues wrote.

Services that were considered under-provided at these facilities included:

• Detoxification (31.9% of SUD-only, 24.3% of SUD and mental health)
• Integrated primary care (20.9% of SUD-only, 38.4% of SUD and mental health)
• Childcare (11.4% of SUD-only, 7.9% of SUD and mental health)
• Beds for children (8.8% of SUD-only, 4% of SUD and mental health)

However, the researchers noted that more than half of treatment facilities provided other services identified in prior research as particularly important for the perinatal population, including:

• Assistance with accessing social services (80.9% of SUD-only, 80.2% of SUD and mental health)
• Telehealth (75.4% of SUD-only, 87% of SUD and mental health)
• Trauma-related therapy (69.9% of SUD-only, 90.5% of SUD and mental health)
• Transportation assistance (52.2% of SUD-only, 56.3% of SUD and mental health)

Available services were primarily offered in outpatient settings, with less than 25% of facilities providing residential services and less than 10 % offering inpatient care.

“Effective care for perinatal SUDs and [mental health disorders] must extend beyond the provision of behavioral health treatment alone,” the researchers wrote. “To promote the health of both parents and children, facilities must also provide essential medical services such as integrated primary care and detoxification. Additionally, increasing the availability of childcare services and accommodations for clients’ children is crucial for maintaining the integrity of the parent-child relationship.”

For related information, see the Psychiatric News article “It Takes a Village: Mothers With SUDs Often Lack Support in Getting Treatment.”

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ACT-Based Group Therapy Improves Management of Comorbid Asthma and ADHD

A group intervention based on acceptance and commitment therapy can help parents of children with comorbid asthma and attention-deficit/hyperactivity disorder (ADHD) build resilience and self-efficacy—leading to better health outcomes for the children in the long term. These findings were published today in JAMA Pediatrics.

Yuen Yu Chong, Ph.D., of the Chinese University of Hong Kong, and colleagues enrolled 118 parents who had a child between ages 3 and 11 with a diagnosis of asthma and ADHD. Half the parents received usual asthma care, which included regular follow-ups, one group educational session on asthma management, and referrals for ADHD services. The other half received usual care along with six weeks of acceptance and commitment therapy for parenting in asthma management (ACT-PAM); this small-group therapy taught parents how to make action plans to manage their child’s asthma and ADHD using principles such as acceptance, mindfulness, and positive parenting.

Twelve months after the intervention ended, the parents who received ACT-PAM—and their children—showed significant improvements in a variety of measures. Children in the ACT-PAM group had about 67% fewer unscheduled health care visits for asthma exacerbations on average compared with the usual care group (0.5 versus 1.3). “While modest, this reduction is clinically meaningful, particularly for children with ADHD, who face exacerbation risk due to attentional and behavioral challenges,” the researchers wrote.

Parents in ACT-PAM also reported greater reductions in their child’s ADHD symptoms than the usual care group, as well as greater reductions in their own psychological inflexibility and greater confidence in managing their child’s asthma.

“Integrating positive parenting with ACT provided a holistic intervention that improved asthma management, behavioral outcomes, and parental resilience, which are often neglected in traditional single-diagnosis asthma care,” Chong and colleagues wrote. Further, “ACT helped parents shift from experiential avoidance to values-based caregiving, indirectly improving child ADHD outcomes.”

For related information, see the American Journal of Psychotherapy article “Acceptance and Commitment Therapy for Posttraumatic Psychopathology: A Group-Based Telehealth Intervention.”

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