SSRIs and SNRIs May Be Best Frontline Medications for Anxiety in Older Adults

Antidepressants may be the preferred choice to treat anxiety in older adults, according to the results of a meta-analysis published in the Lancet Psychiatry. Further, selective serotonin reuptake inhibitors (SSRIs) may produce more pronounced symptom improvements than serotonin norepinephrine reuptake inhibitors (SNRIs), though both types have similar chances of producing anxiety remission.

Sarah E. Neil-Sztramko, Ph.D., of McMaster University in Hamilton, Ontario, and colleagues compiled data from 19 randomized clinical trials assessing anxiety medications in adults ages 60 and older; the combined sample included 2,336 participants (68% female), primarily with generalized anxiety but also some with panic disorder or agoraphobia. Nine of the trials tested antidepressants, four tested benzodiazepines, and the remainder tested quetiapine, pregabalin, or buspirone.

The researchers found that antidepressants as a group were superior to placebo or waitlist control at reducing anxiety symptoms. Overall, 40% of participants taking antidepressants achieved a response (50% or greater reduction in symptoms) or anxiety remission compared with 24% of those on placebo or waitlist. SSRIs produced greater anxiety symptom improvements over control groups compared with SNRIs, though both classes showed similar rates of response and remission.

“In contrast, findings from other drug classes indicated low certainty evidence for the use of quetiapine and buspirone, and very low certainty evidence for pregabalin and benzodiazepines,” Neil-Sztramko and colleagues wrote. “In conjunction with the use of non-pharmacological interventions, our findings indicate antidepressants should be the first-line pharmacological treatment for anxiety disorders and clinically significant anxiety symptoms in older adults, aligning with guidelines for the general adult populations.”

The researchers said that their analysis was limited by the small number of available studies, most of which were published before 2012. The included studies also had fragmented data on side effects and tolerability, so the analysis could not definitively state the safety profile for these medications.

“Despite limitations, this review and meta-analysis has synthesized the best available evidence to help inform clinical guidelines and has drawn attention to the scarcity of recent, high-quality studies, studies of difficult-to-treat anxiety, and pragmatic trials in older adults,” they concluded.

For related information, see the Focus article “Pharmacotherapy for Anxiety Disorders: From First-Line Options to Treatment Resistance.”

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Above Average Social Media Use May Contribute to Depressive Symptoms in Young Adolescents

Higher-than-average social media use as a tween was associated with greater depression the following year, according to a study issued by JAMA Network Open.

“Although correlations between social media use and depressive symptoms have been previously identified, the directionality of this relationship remains unclear,” wrote Jason M. Nagata, M.D., and colleagues. “[Our] findings provide initial evidence of temporal ordering and could suggest that social media use is a potential contributing factor to adolescent depressive symptoms rather than merely a correlate or consequence of such symptoms.”

Nagata and colleagues collected data from the Adolescent Brain Cognitive Development Study, which assessed 11,876 children aged 9 to 10 years on their self-reported social media use and depression symptoms (from the Child Behavior Checklist) at baseline and once a year for three years.

On a within-person basis, youth reporting higher than average social media use at baseline did not have elevated depressive symptoms at year one. However, above average social media use at year one or year two was associated with depressive symptoms the following year. These associations held after accounting for demographic and family-level factors that may influence mental health and social media use, such as parental media monitoring or family conflict.

Depressive symptoms were not associated with later social media use at any of the three intervals

The researchers noted that some adolescents may be more susceptible to negative media effects due to factors like their disposition, self-esteem, developmental stage, and family dynamic. Differential susceptibilities may also explain why some social media may be beneficial for certain individuals while detrimental to others.

“Clinicians should consider inquiring about social media use among children and adolescents, particularly those younger than the recommended age limits (the minimum age requirement for most social media platforms is 13 years), and providing anticipatory guidance as needed,” the researchers wrote. “Interventions that promote mindful, purpose-driven social media use, such as encouraging adolescents to prioritize social connection, may help mitigate negative outcomes and support better mental health.”

For related information, see the Psychiatric News article “Ask Young Patients About Social Media Use” and the Psychiatric News alert “Youth With Internalizing Conditions Spend More Time on Social Media, Feel Lack of Control Online.”

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Adoption of Collaborative Care Spread Dramatically in Recent Years

Adoption of the collaborative care model has expanded dramatically across all major insurance coverage types since the introduction of dedicated billing codes in 2018, according to an analysis performed by Stoddard Davenport, M.P.H., and colleagues at Milliman.

“This expansion is evident through the substantial increase in provider and patient participation, as well as the volume of services provided across Original Medicare, Medicare Advantage, Medicaid and the Children’s Health Insurance Program (CHIP), and commercial markets,” according to the Milliman report, which was commissioned by APA and the Mental Health Policy Institute.

For instance, between 2018 and 2022, the number of patients receiving collaborative care services increased from 4,095 to 21,160 individuals with original Medicare; 2,605 to 20,780 with Medicare Advantage; 3,380 to 30,930 with Medicaid and CHIP; and 1,649 to 27,444 individuals with commercial insurance.

Similarly, between 2018 and 2022, the number of physicians billing for collaborative care increased nationally from 881 to 5,131 for Original Medicare, 568 to 5,660 for Medicare Advantage, 629 to 5,389 for Medicaid and CHIP, and 545 to 3,741for commercial insurance, according to the report.

The researchers compiled their findings using multiple insurance claim datasets available from the Centers for Medicare and Medicaid Services as well as their own proprietary dataset of commercially insured individuals. Collectively, the datasets included the health care encounters of approximately 219 million individuals.

The Milliman analysis noted that while adoption of collaborative care has increased overall, there are significant differences between geographic areas. “Adoption of collaborative care is generally lower in rural areas across all insurance coverage types, and the level of adoption in Medicaid and CHIP is notably higher in states that have activated [collaborative care] codes for their Medicaid plans compared to states that have not,” according to Milliman.

In a statement released by Path Forward, a coalition of organizations dedicated to ensuring equitable access to quality mental health and substance use care, APA CEO and Medical Director Marketa M. Wills, M.D., M.B.A., said: “ Given the ongoing mental health crisis, the opioid epidemic, and high rates of suicide, the widespread implementation of this model is now more essential than ever to reach the growing number of Americans in need of quality mental health services. Simply stated, the more we adopt the Collaborative Care Model, the more patients can access it, and the more lives we will save.”

For more information, see the Psychiatric News article “Collaborative Care Has a Pivotal Role in Digital Health, Experts Say.”

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Hearing-Loss Treatment May Help Preserve Social Connection in Older People

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Older adults with hearing loss who receive treatment may retain greater social connections over time than those who do not receive treatment, according to a study in JAMA Internal Medicine.

Nicholas S. Reed, Au.D., Ph.D., of New York University, and colleagues examined data from 977 adults (mean age of 76.3) with untreated hearing loss and no substantial cognitive impairment. Participants were randomized to two groups: One group received a hearing intervention consisting of four sessions with a certified study audiologist, hearing aids, counseling, and education, with booster visits every six months. The control group received health education consisting of four sessions with a certified educator on chronic disease and disability prevention, including goal-setting, activities, stretching, and counseling. The researchers measured the participants’ social connections and loneliness at baseline, six months, and one, two, and three years.

At baseline, the mean social network size was 22.6 in the intervention group and 22.3 in the control group. After three years, the mean social network size declined to 21.3 in the intervention group and 19.8 in the control group. Adults in the intervention group also retained more social network diversity (number of relationship roles such as parent, child, or neighbor) after three years.

The intervention group’s mean loneliness scores (assessed via the UCLA Loneliness Scale) improved from 32.8 at baseline to 32.3 at three years, whereas the control group’s scores worsened from 32.7 at baseline to 33.5 at three years.

“Given the high prevalence of hearing loss among older adults and already established delivery models, hearing intervention represents a public health target for population-level reductions in social isolation and loneliness,” the researchers wrote, noting that hearing interventions are scalable and low-risk efforts. “Additional efforts to incorporate coverage for hearing care and audiological support services … into Medicare benefits may further help improve access and affordability of hearing care for older adults.”

For related information, see the Psychiatric News article “Special Report: Lifting the Veil on Loneliness and Alienation.”

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Shorter Time Between Antipsychotic Initiation and CSC Referral Improves Outcomes

Individuals with first-episode psychosis who experience a shorter period between first use of an antipsychotic and enrollment in a coordinated specialty care (CSC) program show improved functioning and quality of life at six months, according to a report in Schizophrenia Bulletin.

Hadar Hazan, M.D., of Yale University School of Medicine, and colleagues wrote that shorter duration of untreated psychosis (DUP) has been repeatedly shown to improve patient outcomes. Their study examined both parts of the treatment pathway: the time between the onset of symptoms and first use of antipsychotic medication (termed DUP-Demand) and the time between antipsychotic initiation and CSC enrollment (DUP-Supply). “Much can occur between the first effort to treat psychosis in an emergency room or psychiatric hospital and eventual entry into a local CSC, including multiple help-seeking events that can involve many community stakeholders,” they wrote.

The researchers examined outcomes for 147 first-episode psychosis patients enrolled from 2014 to 2019 in Specialized Treatment in Early Psychosis (STEP), a CSC in New Haven, Connecticut, that ran a dedicated four-year early detection campaign focused on raising public awareness of psychosis, training health professionals to identify symptoms, and streamlining the CSC referral process. STEP patients were compared with 75 patients enrolled in a CSC in Boston with standard early detection protocols.

Average total DUP for patients enrolled in STEP was 5.9 months shorter than those in the CSC with standard detection protocols. This included a 1.3-month reduction in DUP-Demand and a 4.6-month reduction in DUP-Supply.

This time reduction translated into improvements in functional outcomes: At six months, STEP participants showed significantly greater improvements on their Global Assessment of Function and Quality of Life scales than individuals at the comparison CSC. Further analysis showed that shorter DUP-Supply was the primary driver of these improvements, particularly for quality of life; shorter DUP-Demand time was not significantly associated with either improved functioning or improved quality of life.

The authors said these results demonstrate the value of early detection in CSC. “While reducing DUP may not be easy or cheap, the costs of early detection can be offset by reduced hospitalization and may interact with other health-economic benefits of CSC, including reduced criminal justice involvement,” they wrote.

For related information, see the Psychiatric News article, “New Network Collects Real-Time Data to Improve Treatment of Early Psychosis.”

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Texas Abortion Ban Increased Women’s Mental Distress

Implementation of the strictest abortion law in the nation in 2021 was associated with worsening mental health among women, particularly younger adult women, according to a study published by JAMA Network Open.

“In September 2021, Texas implemented the Texas Heartbeat Act Senate Bill 8 (SB8), which essentially banned abortion after detection of embryonic cardiac activity,” wrote Jusung Lee, Ph.D., of the University of Texas at San Antonio, and colleagues. “Because Texas banned abortion earlier than other states, the Texas experience provides much of what is known about the consequences of abortion bans on health.”

Lee and colleagues collected responses from 15,614 adult women and 14,500 adult men in Texas who completed the Behavioral Risk Factor Surveillance System—a federal survey that collects state-level health data—between 2012 and 2022. All included respondents were of reproductive age (18 to 44 years old).

The researchers analyzed changes in frequent mental distress—defined as 14 or more days of self-reported poor mental health during the previous 30 days—between women and men in Texas before and after SB8 implementation. To account for the COVID-19 pandemic or other unidentified events, the researchers also compared the Texas results against those of 34,559 women in five conservative states with similar COVID-19 policies that banned abortion later. They also compared the women in Texas to 14,936 women in California, which did not restrict abortion but is demographically like Texas.

On average, 14.2% of Texas women experienced frequent mental distress each year prior to SB8 implementation, compared with 21.9% in the year after implementation; among Texas men, frequent mental distress rose from 11.1% to 15%. After adjusting for differences between the two groups, the implementation of SB8 was associated with a 6.8 percentage point increase in frequent mental distress among women compared with men in the state. Further, SB8 was associated with a 5.3 percentage point increase in mental distress compared with women in other conservative states and a 7.1 percentage point increase compared with women in California.

Implementation of the law appeared to have the biggest impact on women ages 18 to 29, which was not surprising to the researchers. “Even before early abortion bans were enacted, young people reported experiencing numerous challenges in accessing abortion care, including difficulty traveling for abortion care and a lack of support from adults,” they wrote. “The increasingly restrictive policy environment creates even larger obstacles for young people seeking abortion care, a group less able to overcome barriers than their older counterparts.”

For related information, see the Psychiatric News article “Ensuring Women’s Right to Full Spectrum of Reproductive Care: We Must Do More.”

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Stimulants Do Not Cause Psychotic Experiences in Children and Adolescents, Study Finds

A study issued yesterday in Pediatrics did not identify a causal link between stimulant prescriptions and psychotic experiences (subclinical hallucinations and delusions) among youth between ages nine and 14 years.

“[O]ur findings suggest that although there is an increased risk of psychotic experiences in children and adolescents who are prescribed stimulant medication, this increased risk is driven by patient characteristics rather than by stimulant treatment itself,” wrote Kirstie O’Hare, Ph.D., of the University of Edinburgh, and colleagues.

O’Hare and colleagues emulated a randomized clinical trial using observational data from 8,391 youth (50% female) enrolled in the Adolescent Brain Cognitive Development Study between the ages of nine to 14. During annual assessments, caregivers reported what medications the youth started in the previous year while participants self-reported psychotic experiences using the Prodromal Questionnaire–Brief. This questionnaire asks about a range of unusual thoughts or feelings and how much distress they are causing.

Overall, about 19% of participants reported one or more psychotic experiences of at least moderate distress at their baseline assessment (most commonly paranoid ideas, auditory hallucinations, and perceiving a supernatural presence), 15% reported one or more psychotic experiences at the one-year follow-up, and 5.5% reported initiating a stimulant prescription between baseline and follow-up.

The researchers found that youth who started stimulant medications were 46% more likely to have psychotic experiences at follow-up. But the reverse was also true: Those who reported psychotic experiences at baseline were nearly twice as likely to subsequently receive a stimulant prescription. When the authors applied rigorous modeling to ensure individuals in the stimulant and non-stimulant groups were evenly matched in sociodemographic variables and medical history, there was no evidence of a causal effect of stimulant prescription on the subsequent occurrence of psychotic experiences. The authors found similar results when they restricted the sample to 3,260 participants who had a parental history of mental illness.

The authors noted that their findings relate to psychotic experiences, not to psychotic disorders. “Psychotic experiences, although associated with an increased risk of psychotic disorders, are below the severity threshold required for a psychotic disorder diagnosis,” they wrote.

“We know that many children with ADHD can benefit from medication treatment,” the study’s lead author, Ian Kelleher, M.D., Ph.D., told Psychiatric News in an email. “The results of our study are reassuring for young people and their families that routine ADHD medication treatment is unlikely to cause psychotic experiences.”

For related information, see the Psychiatric News article “Prescription Amphetamines Boost Risk for New Psychosis or Mania.”

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Nearly 19 Million Children May Be Living With a Parent With SUD

About one-quarter of children in the United States may be living in a household where one or more parents have a substance use disorder (SUD), according to a research letter published today in JAMA Pediatrics. This number includes about 6 million children who may be living with a parent with an SUD and comorbid mental illness.

“Children in such households are more likely to develop adverse health outcomes than their peers without exposure to parental SUD,” wrote Sean Esteban McCabe, Ph.D., of the University of Michigan, and colleagues. “These findings signal the need for more attention at the federal, state, and local levels on the children and families affected by addiction.”

McCabe and colleagues calculated national estimates of children (anyone under 18) exposed to parental SUDs using data from the 2023 National Survey on Drug Use and Health—which included DSM-5–based questions related to SUD. They found that nearly 19 million children lived with a parent who met DSM-5 criteria for past-year SUD. Of this total, around 11.3 million children had a parent with mild SUD, while 7.6 million had a parent with moderate to severe SUD. Further, around 3.4 million children were estimated to live with a parent with multiple SUDs.

The most common parental SUD was alcohol use disorder, which affected more than 12 million children, followed distantly by cannabis use disorder and then prescription medication use disorder (encompassing prescription opioids, benzodiazepines, sedatives, tranquilizers, and stimulants).

For related information, see the American Journal of Psychiatry article “Pattern of Risks for Psychiatric and Substance Use Disorders in the Offspring of Parents With Alcohol Use Disorder.”

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Motivation to Change Lifestyle Decreases After Patients Learn Dementia Risk, Study Shows

Learning the status of their amyloid beta protein buildup—a defining feature of Alzheimer’s disease (AD)—does not have negative psychological effects on individuals, but it does reduce their motivation to make lifestyle changes, according to a study issued this week in Alzheimer’s & Dementia.

Amyloid buildup can be detected years or even decades before AD symptom onset, wrote Sapir Golan Shekhtman, Ph.D., of the Sheba Medical Center in Israel, and colleagues. While a non-elevated amyloid beta status can rule out a current AD diagnosis, it cannot foresee future AD. The possibility that patients will make inaccurate assumptions about their future risk is why testing and disclosing amyloid beta status is not recommended in asymptomatic individuals, the authors continued. But as progress is made toward developing preventive therapies, asymptomatic patients are more likely to be screened to determine if they would benefit from treatment.

Shekhtman and colleagues provided questionnaires to 199 cognitively normal adults (median age 65) immediately before they received PET scans to determine their amyloid beta status. The participants were asked to rate their levels of depression and anxiety regarding the possibility of elevated amyloid beta on a five-point scale, as well as their motivation to make lifestyle changes to reduce their future risk of developing AD. Six months after their amyloid beta status was disclosed, participants were again asked to rate their level of depression and anxiety regarding their results, as well as their motivation to make lifestyle changes.

A large majority of the 178 participants whose PET scans revealed they did not have an elevated amyloid beta status reported a decrease in their anxiety and/or depression scores between their first and second questionnaires. Meanwhile, among the 21 participants with an elevated status, there was no significant change in average depression and anxiety scores. More than 80% of participants in both groups reported high or very high motivation to change their lifestyles before their PET scans. After they were informed of their amyloid beta status, 112 participants (63%) in the non-elevated group and 11 individuals (52%) in the elevated group reported lower motivation to change their lifestyles.

While decreased motivation to make lifestyle changes may be understandable in the non-elevated group, the authors wrote, it is undesirable in both groups, as “keeping a healthy, active lifestyle is one of the current key recommendations for the prevention of AD.” They concluded that this finding “warns against false reassurance during the disclosure process.”

For related information, see the Psychiatric News article “Blood Test Accurately Detects Alzheimer’s Disease.”

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Patients Receiving Court-Mandated Outpatient Treatment Show Broad Improvements

Individuals with serious mental illness who received assisted outpatient treatment (AOT) experienced improvements across a broad range of clinical outcomes, including adherence to treatment, symptoms, and self-reported quality of life, according to a report in Psychiatric Research and Clinical Practice. They also had substantially fewer episodes of violent behavior, arrests, and rehospitalizations.

The length of mandated treatment was also found to be important, noted Kiersten Johnson, Ph.D., of RTI International, and colleagues.

Court-mandated AOT extends the state’s civil commitment authority from hospital‐based care to outpatient services, including managed pharmacotherapy, intensive case management, and, often, access to subsidized housing. A 2020 position statement by the APA Board of Trustees endorsed AOT, saying that it “can be a useful tool in the effort to treat patients with severe mental illness with clinical histories of relapse and re-hospitalization.”

The researchers analyzed data on 392 patients receiving mandated treatment at six AOT sites across the country. The primary data came from structured clinical interviews with participants conducted at baseline and at six‐ and 12-month follow‐ups. Three of six sites provided supplemental data on Medicaid/non‐Medicaid service encounters, local/state arrest records, and/or public/private hospitalization data.

Patients who completed AOT had significant improvements in their psychiatric symptoms (as assessed using the Modified Colorado Symptom Index), perceived mental health, life satisfaction, and therapeutic alliance. Appointment adherence increased by more than 24%, while medication adherence increased by 20%. Additionally, violent behavior was reduced by more than 19% and suicidal ideation by more than 24%. Illicit drug use and risk of homelessness also decreased following AOT completion.

The average length of an AOT order with renewals was 228.7 days. Compared with patients who had an AOT order of less than six months, those with orders of six months or longer experienced greater reductions in likelihood of violence (24.5% versus 14.7%), suicidal ideation (27.4% versus 21.4%), and inpatient hospital nights (14.5 fewer nights versus 8.3).

“There were no noted differences in outcomes between those who are referred from the community (step‐up) and from inpatient hospitalization or jail stay (step‐down),” Johnson and colleagues wrote. “In contrast, criminal justice involvement at time of initiation of the AOT order was associated with subsequently greater reductions in violent behavior and arrests, suggesting that this population is within the scope of AOT’s effectiveness.”

For related information, see the Psychiatric Services article “Association Between Hospitalization and Delivery of Assisted Outpatient Treatment With and Without Assertive Community Treatment.”

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Brain Scans Yield Clues on How Psylocibin Works to Alleviate Depression

A study involving brain scans of depressed patients treated with the selective serotonin reuptake inhibitor (SSRI) escitalopram or the psychedelic substance psilocybin is shedding light on how these compounds work differently to alleviate depression. The findings were published today in the American Journal of Psychiatry.

Previous research has shown that soon after beginning a course of SSRIs, patients with depression as well as healthy subjects experience a decreased amygdala responsiveness to emotional stimuli, noted Matthew B. Wall, Ph.D., of Perceptive Inc. and Imperial College London, and colleagues. “Researchers hypothesize that this emotional (amygdala) blunting is the key to SSRI’s therapeutic effect.”

Wall and colleagues conducted functional magnetic resonance imaging (fMRI) on 46 adults with moderate to severe depression who were participating in a randomized clinical trial. Of these, 25 received two dosing sessions with 25 mg psilocybin each—a dose expected to trigger profound acute effects—three weeks apart, plus six weeks of daily placebo. The remaining 21 participants received 1 mg psilocybin—a “placebo dose” with no psychedelic effects—plus six weeks of escitalopram (10 mg a day for three weeks, then 20 mg a day for three weeks).

At baseline and six weeks later, researchers used fMRI to assess participants’ brain activity when viewing three types of facial expressions (fearful, happy, and neutral); they also assessed participants’ depressive symptoms, anhedonia, and emotional intensity.

Both groups experienced significant reductions in depressive symptoms and anhedonia at the end of treatment. Participants who received escitalopram showed a significant reduction in emotional responses to all three types of facial expressions, while participants who received psilocybin showed no change in response to happy or fearful faces, and a slight increase in response to neutral faces. An exploratory analysis looking for connections between imaging and clinical outcomes suggested that symptom improvement in the escitalopram group was correlated with decreases in emotional intensity. However, in the psilocybin group, symptom improvement correlated with increases in emotional intensity.

“I think the key takeaway is that the two therapies we studied, escitalopram and psilocybin, work in very different ways,” Wall told Psychiatric News Alert via email. “Both have antidepressant effects, but escitalopram has an overall blunting effect on emotions in at least some patients, whereas psilocybin seems not to. Psilocybin therapy might therefore be a good option in the future for those patients who may be struggling with the emotional blunting effects of SSRIs.”

For related information, see the Psychiatric News articles “Depression Improves Following Single Dose of Psilocybin” and “Psychedelic Use in Psychiatry Demands New Informed Consent Process, Bioethicists Say.”

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Conversion Therapy Linked to High Blood Pressure, Other Cardiovascular Risk

Exposure to conversion therapy, which attempts to change one’s sexual orientation and/or gender identity, may increase several risk factors for cardiovascular disease in young people, a study published today in JAMA Network Open has found.

James K. Gibb, M.Sc., M.A., of Northwestern University, and colleagues examined data from 703 people who participated in RADAR, an observational study following transgender women, gender-nonconforming individuals, and men who have sex with men between the ages of 16 and 29. Participants in RADAR have follow-up visits every six months at which they provide blood samples, have their blood pressure taken, and are evaluated for HIV risk, substance use, and other social and psychological measures.

This analysis included data from the follow-up visit scheduled between December 2023 and October 2024; this marked the first visit in which researchers assessed the participants’ exposure to conversion therapy by asking, “Have you or any person with authority (parent, caregiver, counselor, community leader, etc.) ever tried to change your sexual orientation or gender identity?”

Overall, 10.2% of the sample reported exposure to conversion therapy. Among those, 58.3% reported a year or less of exposure, while 41.7% reported more than a year. The mean age of first exposure was about 13 years, with the mean age of last exposure about 16.5 years. More than half reported exposure due to a parent.

After adjusting for sociodemographics, the researchers found that systolic blood pressure, diastolic blood pressure, and systemic inflammation index (based on levels of inflammatory proteins in blood samples) were 4.45 mm Hg, 3.58 mm Hg, and .72 points higher, respectively, in participants who were exposed to conversion therapy compared with those without exposure. The increases were more profound in participants with more than a year of exposure. Results were similar after the researchers further adjusted for body mass index, HIV status, and tobacco use.

The researchers noted several possible mechanisms for increased cardiovascular risk after exposure to conversion therapy, including chronic stress and epigenetic changes.

“Our findings support and extend the evidence illustrating a deleterious effect of [conversion therapy] on psychosocial health,” the researchers wrote. “Our findings also support bans on [conversion therapy] and enforcement of existing bans to eventually eliminate the adverse health consequences associated with these practices.”

For related information, see the Psychiatric News article “‘Conversion Therapy’ Misleads, Harms Patients.”

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Youth With Internalizing Conditions Spend More Time on Social Media, Feel Lack of Control Online

Youth with mental illness spend significantly more time on social media than those without, reports a study published today in Nature Human Behavior. However, only youth with internalizing conditions such as depression or anxiety disorders were more likely to feel a lack of control about their social media use or engage in other unhealthy online behaviors.

Luisa Fassi, M.Sc., of the University of Cambridge, and colleagues examined data from 3,340 English youth ages 11 to 19 (50% female) who participated in the 2017 Mental Health of Children and Young People study and identified themselves as using at least one social media site. In addition to completing online surveys, the youth had face-to-face clinical interviews to identify the presence and severity of mental health symptoms. In total, 529 youth in the sample (16%) had a mental illness.

Overall, youth who had a mental illness spent significantly more time on social media weekly than those without (average 2.8 hours versus 1.9 hours, respectively) and were also less satisfied on average with their number of online friends. When looking at subcategories of mental illness, the researchers uncovered additional differences. Youth with an internalizing condition not only spent more time online (around three hours weekly) and were less happy about their online friend count, but they also engaged more frequently in online social comparisons, were more likely to say that social media feedback (e.g., number of likes) impacted their mood, and were more likely to feel lack of control about their time spent online.

Contrary to the researchers’ hypothesis, a lack of control was not a problem among youth with an externalizing condition such as a conduct disorder or attention deficit/hyperactivity disorder. In fact, the only meaningful difference for youth with an externalizing condition relative to youth with no mental illness was that they spent more time online, the researchers wrote.

“The results have implications for clinical practice. Specifically, we find key aspects of social media engagement that could inform the creation of guidelines for patient consultations and early intervention strategies,” Fassi and colleagues continued. Examples would be psychoeducation and behavioral therapies focusing on social comparisons and social media feedback, especially in youth with internalizing symptoms.

For related information, see the Psychiatric News article “Ask Young Patients About Social Media Use.”

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More Patients Receiving Psychotherapy Without Medication, Study Finds

White House Releases Budget Proposal; APA Continues to Monitor Process Today, the White House released its FY 2026 partial budget proposal that calls for $163 billion in cuts to federal spending in the next fiscal year. This includes a $1 billion proposed reduction in SAMHSA’s budget. This proposal lays out broad priorities and requests Congress to enact certain spending levels but does not spell out specific program reductions. APA is closely monitoring the budget process and will be working with appropriators in Congress to prevent cuts to these vital programs.

Between 2018 and 2021, the proportion of adults receiving outpatient mental health care that was solely psychotherapy rose, while the proportion of those taking only psychotropic medications declined, according to a study published yesterday in the American Journal of Psychiatry.

“Psychotherapy has long been viewed as a core clinical activity of mental health specialists,” wrote Mark Olfson, M.D., M.P.H., of the Columbia University Mailman School of Public Health and colleagues. “Between 1998 and 2007, however, there was a significant decline in the percentage of adult mental health outpatients in the United States who received psychotherapy either with or without psychotropic medications.”

Olfson and colleagues calculated national outpatient mental health care trends using data from the Medical Expenditure Panel Survey from 2018 to 2021, which included information on 17,821 outpatient mental health visits, including 6,415 psychotherapy visits. The data also included information on participants’ mental health conditions, such as depression, schizophrenia, and other disorders.

The estimated number of adults who received any outpatient mental health care increased from 11.2% in 2018 to 12.4% in 2021. Among this group:

• The percentage of patients who received psychotherapy without medications rose significantly from 11.5% in 2018 to 15.4% in 2021.
• The percentage of patients who received medications without psychotherapy dropped significantly from 67.6% in 2018 to 62.1% in 2021.
• The percentage of patients who received both medications and psychotherapy remained relatively stable (20.8% in 2018 and 22.5% in 2021).

There was a particularly notable rise in the use of psychotherapy only among patients treated for schizophrenia or related disorders—rising from 1.3% in 2018 to 16.6% in 2021; this rise was balanced by a significant drop in the percentage of patients treated with both psychotherapy and medications.

Olfson and colleagues noted that the largest single-year increase in the use of psychotherapy occurred between 2018 and 2019, so factors unrelated to the COVID-19 pandemic and the rise of telemedicine contributed to this trend.

The authors also found interesting changes in which health professionals were providing psychotherapy.

“Psychiatrists provided psychotherapy to a decreasing percentage of all psychotherapy patients, which may have increased the need for psychiatrists to refer patients to and collaborate with non-physician psychotherapists,” Olfson said in a news release. “At the same time, social workers and counselors, but not psychologists, assumed a larger role in providing psychotherapy.”

Olfson said this shift in providers may increase further following a recent change in Medicare reimbursement policy that allows mental health counselors and licensed marital and family therapists to bill for psychotherapy.

For related information, see the Psychiatric News article “Wither, Psychotherapy?”

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Reduced Clozapine Monitoring During COVID Did Not Result in More Neutropenia or Discontinuation

Patients using clozapine for at least a year were not more likely to experience severe neutropenia or to discontinue the medication during the COVID-19 pandemic, when laboratory monitoring became less frequent, according to a report in Psychiatric Services.

Early in the pandemic, the Food and Drug Administration (FDA) removed penalties against health care professionals who were unable to meet the stringent laboratory monitoring requirements for clozapine. Then, in May 2020, an expert workgroup released a consensus statement suggesting that the frequency of monitoring could be reduced from every month to every three months for patients on continuous clozapine treatment for at least one year and no history of neutropenia.

(The FDA recently eliminated their requirements for clozapine prescribing but still recommend that clinicians monitor neutrophil levels according to prescribing information.)

Allison L. Little, Pharm.D., of the Corporal Michael J. Crescenz Department of Veterans Affairs (VA) Medical Center in Philadelphia, and colleagues analyzed data on 2,106 patients in the Veterans Health Administration who had been using clozapine for at least 12 months prior to March 2020; the study period was from March 1, 2020, to July 31, 2021. Clozapine discontinuation was determined to have occurred if the most recent clozapine prescription was coded as “discontinued” and no active prescriptions were listed in the medical record.

Little and colleagues also classified patients according to neutropenia status, with severe neutropenia defined as an absolute neutrophil count (ANC) of less than 500/μL. They further classified patients according to the length of their longest interval between laboratory monitoring: less than 30 days, 31 to 55 days, 56 to 90 days, 91 to 179 days, and greater than180 days.

On average, the longest ANC monitoring gap was 87.8 days, consistent with the consensus statement. No patients discontinued clozapine because of severe neutropenia. In fact, only one patient developed severe neutropenia, and after cessation and careful monitoring, that patient began a new trial of clozapine.

Moreover, the researchers found that longer intervals between ANC monitoring did not increase the rate of clozapine discontinuation. Overall, clozapine discontinuation for any reason occurred in 96 patients.

“More studies are needed to confirm the noninferiority of extended-interval laboratory monitoring for patients receiving clozapine,” the researchers wrote, but added that mental health providers should “consider these results to help bolster prescribing of this highly effective yet underutilized treatment option.”

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

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Valbenazine Significantly Improves Tardive Dyskinesia in Older Adults Over Long-Term

Adults ages 65 and older with tardive dyskinesia (TD) given valbenazine for up to 48 weeks experienced substantial and sustained improvements in symptoms while maintaining psychiatric stability, according to a post-hoc analysis of two clinical trials issued by the Journal of Clinical Psychiatry.

Valbenazine may be well suited for older patients with TD because it requires no titration to reach an effective, tolerable dose and is available as a sprinkle formulation that can be mixed with soft foods, noted Martha Sajatovic, M.D., of Case Western Reserve University School of Medicine in Cleveland, and colleagues. The researchers wrote that they undertook the study to address the “relative paucity of information on valbenazine efficacy and safety in relation to increasing age” among individuals 65 and older. The study was funded by valbenazine drugmaker Neurocrine Biosciences.

Sajatovic and colleagues pooled data from 304 individuals (55 of whom were 65 or older) who had participated in one of two 48-week studies of valbenazine—one an open-label study and the other a blinded-dosing study comparing 40 mg or 80 mg dosing. Participants were assessed with two clinician-rated assessments, the Abnormal Involuntary Movement Scale (AIMS) and Clinical Global Impression of Change-Tardive Dyskinesia (CGI-TD), at baseline and at various points over 48 weeks.

Overall, 40% of older participants experienced a meaningful response to valbenazine (≥50% improvement in AIMS) at eight weeks, which rose to 65% at 24 weeks and 82% at 48 weeks; the improvements in older adults were comparable to those seen in younger participants. Similar strong and comparable improvements were seen with CGI-TD scores; in fact, at week 48, older adults were significantly more likely to have a CGI-TD score ≤2 than younger participants (93% versus 77% respectively).

There was no statistical difference in the prevalence of adverse events between younger and older participants, though a significantly higher percentage of older participants discontinued medication due to an adverse event compared with the younger subgroup (26% versus 13%, respectively). The most common adverse events were urinary tract infection, drowsiness, and headache.

“This article reports on data indicating that once-daily valbenazine is effective and well-tolerated in the ≥65-year age group,” the researchers wrote. “Given the projected rates of population aging in the U.S. and globally, along with the increased risk of TD with older age and historic under representation of adults aged ≥65 years in clinical trials, these results address an important gap in TD research.”

For more information, see the Psychiatric News article “Tardive Dyskinesia: Assessing and Treating a Debilitating Side Effect of Prolonged Antipsychotic Exposure.”

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Psychological Distress Lower in Black Immigrants Than Native-Born Black Americans

Black adults born in the United States are more likely to experience moderate-to-severe psychological distress than Black adults born abroad, according to a study published in JAMA Network Open.

“Black or African American individuals have often been examined as a monolithic group,” wrote Maryam Elhabashy, B.A., and colleagues at the National Institute on Minority Health and Health Disparities. Yet, in 2022, “11.8% of Black or African American individuals were non–US-born, and the proportion is projected to be 13.0% in 2035 and 16.6% in 2060. This necessitates more research that considers the diversity in this population.”

The researchers examined responses from 49,820 Black adults (58% female) who completed the National Health Interview Survey between 2005 and 2018; of these respondents, 43,885 were born in the United States. Part of the survey included the Kessler Psychological Distress Scale, which features six questions about how often respondents have felt sad, nervous, restless, hopeless, worthless, or that everything was an effort in the past 30 days.

Overall, 22.6% of U.S.-born Black adults reported moderate-to-severe psychological distress (a score of 5 or higher on the Kessler Scale), compared with 17.4% of those not born in the U.S. Non–U.S.-born individuals who were married or living with a partner had the lowest probability of experiencing psychological distress, while other types of marital status had no effect. In contrast, being married or living with a partner did not reduce the risk of psychological distress in U.S.-born individuals, but being divorced or separated did raise the risk.

Alcohol and health insurance also had different impacts depending on nativity; U.S.-born individuals, but not those born abroad, had less risk of psychological distress if they were never drinkers or insured.

Across both groups, being unemployed, having less than a college education, living below the poverty income threshold, or being a current/former smoker raised the risk of psychological distress, though the first two items were more potent in U.S-born individuals while the latter two were more potent in non–U.S.-born individuals.

Elhabashy and colleagues said that poverty may be an important factor for non–U.S.-born individuals due to additional financial obligations such as remittances and the stress of maintaining household well-being in two countries. “On the other hand, unemployment and education as factors among U.S.-born individuals may be associated with systemic racism and the diminished return of educational attainment on Black adults’ subjective health.”

For related information, see the American Journal of Psychiatry article “Differences in Social Determinants of Health Underlie Racial/Ethnic Disparities in Psychological Health and Well-Being: Study of 11,143 Older Adults.”

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Antidepressants Effective, Safe for Patients After Heart Attacks

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

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

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

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

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

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

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

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Long Sleep Duration Linked to Poorer Cognitive Performance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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New Drug Shows Promise for Helping Patients Quit Smoking

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

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

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

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

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

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

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

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

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Less Time Outside Linked to Anxiety Symptoms in Early Childhood

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

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

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

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

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

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

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

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