Civil Commitment Rates Vary Dramatically Across States

Rates of civil commitment vary widely across the country, with nine states and the District of Columbia (D.C.) reporting significant increases from 2010 to 2022, according to a survey study published today in Psychiatric Services. No states showed a significant decrease.

Civil commitment, a legal process whereby individuals experiencing mental or substance use disorders are involuntarily detained in a psychiatric hospital for treatment, is governed by state laws, with substantial variation in how states collect and report civil commitment data. “This lack of standardization limits the ability to draw firm conclusions about national trends or about cross-state comparisons,” wrote Mustafa Karakus, Ph.D., of Westat, and colleagues.

Using systematic website searches and direct outreach to state mental health authorities (SMHAs) and court systems, the researchers obtained data on civil commitment rates between 2010 and 2022 for 32 states and D.C. Of the 18 states where no data was available, staff from seven SMHAs or state courts reported that no state office was currently tracking the number of civil commitments in their state. For the remaining 11 states, the online search yielded no data and the study team received no responses to outreach attempts.

Across the 32 states and D.C., there were an average of 213.84 involuntary civil commitments per 100,000 population. Rates ranged from 13.50 per 100,000 population in Tennessee to 875.98 per 100,000 in Florida. Rates reported by SMHAs were significantly higher than rates obtained from state court data.

“Such stark differences likely did not reflect true underlying differences in need or use of civil commitment but rather appeared to be largely driven by variation in how states collect, define, and manage their data on civil commitments,” Karakus and colleagues wrote.

The overall rate of civil commitment increased by an average of 3.78 per 100,000 population each year between 2010 and 2022; nine states plus D.C. were statistically above this average, led by Colorado with an annual increase of 16.01 civil commitments per 100,000 population.

The researchers said that the findings underscore the need for consistent and transparent reporting standards. “Improved data collection would also create opportunities to better understand contributing and explanatory factors and to identify best practices,” they wrote. “These practices include determining when and for whom civil commitment is most appropriate and designing care plans aimed at safely reducing lengths of stay and preventing involuntary inpatient readmission.” 

For related information, see the Psychiatric News article “States Paint Complex Picture of Civil Commitment for Dementia.”

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Injectable-Only Buprenorphine Initiation Shows Promise in Patients With Fentanyl Use

An injectable-only buprenorphine initiation protocol that doesn’t require cessation of fentanyl had a 75% rate of completion at an urban outreach clinic, according to a study appearing in JAMA Network Open.

“Our findings add to the sparse literature on rates of successful completion of existing and novel buprenorphine starting protocols outside of acute care settings for individuals using fentanyl,” wrote Richard C. Waters, M.D., M.Sc., of the Downtown Emergency Service Center in Seattle, and colleagues. “In the largest study of overlapping sublingual buprenorphine starts (also called low-dose initiations) in outpatient settings, 35% of individuals completed the protocol, with 22% retained at 28 days.”

Waters and colleagues recruited 95 adults who voluntarily sought treatment for moderate to severe opioid use disorder (OUD) with active fentanyl use at a treatment program in downtown Seattle; 79% of the adults were homeless or had a history of chronic homelessness. The patients agreed to try an investigational three-day buprenorphine initiation protocol involving only three overlapping injections, with no required prior sublingual dosing of the medication or cessation of fentanyl required. On day one, patients received a weekly 8 mg injection; on day two, a weekly 16 mg injection; and on day three, the choice of a monthly 128 mg or 300 mg injection.

Of the 95 patients included, 90% initiated the protocol and 75% eventually completed the protocol by receiving at least one monthly injection; the vast majority of completing participants (94%) chose the higher monthly dose (300 mg) injection option. In addition, 72% of participants who initiated the treatment were retained, defined as receiving a second monthly long-acting buprenorphine injection. Researchers found that an individual’s housing status did not impact their odds of completing the initiation protocol.

The researchers noted that their care program was low-threshold (requiring minimal demands on patients) and outreach-focused, which likely contributed to the high retention; thus, their results may not generalize to patients in other care settings. The study also lacked standardized assessments of withdrawal symptoms after each injection, some of which were severe.

“Future research should describe the patient experience and quantify the prevalence and magnitude of patient-reported opioid withdrawal symptoms experienced during this protocol,” the researchers wrote.

For more information, see the Psychiatric News story “Clinicians Find Low-Dose Regimens Ease Initiation of Buprenorphine.”

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Doctors Who Wear a Smartwatch May Experience Less Burnout, Greater Resilience

Physicians who wore a smartwatch with access to various health metrics such as step count and heart rate experienced reduced burnout and greater resilience compared with those who did not, according to a report published yesterday in JAMA Network Open.

Liselotte N. Dyrbye, M.D., of the University of Colorado School of Medicine, and colleagues at the Mayo Clinic recruited 184 physicians from their two respective institutions, including 83 residents or fellows. Of these, 92 were randomized to immediately receive a smartwatch that tracked heart rate, physical activity, respiratory rate, stress levels, and sleep patterns; the other 92 physicians received a smartwatch after six months.

All participants completed electronic surveys at baseline and every three months for a year to assess burnout, resilience, quality of life, depressive symptoms, stress, and sleepiness.

At six months, 35 of 85 physicians (41.2%) wearing the smartwatch reported burnout compared with 46 of 91 (50.5%) in the control arm. Average resilience scores at six months (measured with the 10-item Connor-Davidson Resilience Scale, which goes from 0 to 40) were 31.9 and 29.5 among physicians in the intervention and control arms, respectively. Adjusting for demographics, medical specialty, and work hours, the odds of burnout were reduced by 54% among physicians wearing a smartwatch compared with those who did not.

“Based on previously observed associations, the 54.0% reduction in the odds of overall burnout at six months observed in this study could lead to meaningfully lower rates of self-reported medical errors, malpractice litigation, and turnover and lost productivity, along with reduced associated costs to health systems and society,” the researchers wrote.

However, no statistically significant difference was seen in quality of life, depressive symptoms, stress, or sleepiness between the trial arms at six months, suggesting that wearing a smartwatch and having access to its collected data does not lead to global improvements in well-being. “Rather, wearing a smartwatch shows promise as an individual strategy to mitigate burnout and improve resilience, and it should be coupled with other individual and organizational efforts to address well-being more broadly,” Dyrbye and colleagues wrote.

For related information, see the Psychiatric News article “The Growing Problem of Administrative Burdens.”

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Human Therapist Outperforms AI at Delivering CBT

A human therapist consistently scored better and was rated as more effective in providing text-based cognitive behavioral therapy (CBT) than an artificial intelligence (AI) chatbot, according to a study published today in the American Journal of Psychotherapy.

“Because of the global shortage of mental health professionals, [AI] has emerged as a potential alternative for delivering CBT,” wrote Sebastian Acevedo, M.D., M.P.H., of Emory University School of Medicine, and colleagues. “Although AI has been integrated into electronic health records for diagnostic purposes, its ability to adhere to and execute CBT remains understudied.”

Acevedo and colleagues connected a psychiatrist experienced in CBT and OpenAI’s ChatGPT-3.5 with a role-playing patient. Both the psychiatrist and ChatGPT were provided with identical clinical scenarios and conducted 45-minute sessions with the patient. The psychiatrist interacted with the patient via Zoom’s chat function without video or audio.

Seventy-five mental health professionals (including psychiatrists, psychologists, and trainees from allied health fields) reviewed the transcripts without knowing that AI was involved and rated the effectiveness of the CBT using the Cognitive Therapy Rating Scale.

The psychiatrist outperformed ChatGPT across most domains, with 43% of reviewers rating the human therapist as very skillful compared with 16% who gave a similar rating to ChatGPT. More than half of the reviewers felt that the human therapist set an agenda that addressed the patient’s target problems, while only 28% felt the same about ChatGPT. Additionally, ChatGPT was more likely than the human therapist to ask insufficient questions or fail to ask follow-up questions. Thirty-six percent of reviewers thought the human therapist understood the patient’s internal reality, compared with 19% for ChatGPT.

In open-ended responses, the reviewers commented that, although ChatGPT demonstrated some signs of empathy, it felt generic, with some commenting that the therapist sounded like an AI program. Seven percent of reviewers also felt that the human therapist’s session was too rigid in adhering to the agenda and led to missed opportunities to address the patient’s needs.

“Although this study demonstrated that ChatGPT-3.5 can, to some extent, deliver structured therapy using CBT principles, it was unable to replicate the nuanced empathy and therapeutic alliance that a human therapist can establish,” the authors wrote, noting that other AI platforms with more advanced mechanisms may yield different results. “[I]ndividuals who use [ChatGPT] should be advised that they may experience limited benefits and that it is best suitable as an adjunct to human-delivered therapy rather than a stand-alone treatment.”

For related information, see the Psychiatric News Alert “Therapeutic Chatbot Shows Promise in Randomized Clinical Trial.”

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Smoking Cessation Associated With Recovery From Other SUDs

Quitting smoking increased the odds of recovery from other substance use disorders (SUDs) by 30%, according to a study published this week in JAMA Psychiatry.

“Although the health benefits of quitting smoking are well-known, smoking cessation has not been seen as a high priority in drug addiction treatment programs,” senior author Wilson Compton, M.D., of the National Institute on Drug Abuse (NIDA), said in a news release. “This finding bolsters support for including smoking cessation as part of addiction treatment.”

Compton, Michael Parks, Ph.D., and colleagues from NIDA used data from 2,652 adults with a history of SUDs who were enrolled in the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of adults in the United States. Participants were assessed annually over four years. During each assessment, participants reported on their smoking status (if they were current or former smokers) as well as their SUD symptoms and use in the past year.

Participants whose smoking status changed from current to former between assessments were 42% more likely to be in recovery from an SUD, meaning they had zero substance use or SUD symptoms in the past year. After adjusting for potential confounders, such as changes in mental health, the odds of SUD recovery after smoking cessation remained significantly higher, at 30%.

“We now have strong evidence from a national sample that quitting cigarette smoking predicts improved recovery from other substance use disorders,” NIDA Director Nora Volkow, M.D., said in the release. “It underscores the importance of addressing different addictions together, rather than in isolation.”

For related information, see the Psychiatric News article “Surgeon General Report Calls for Action on Smoking Inequities.”

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Depression Increased Risk for Asthma in Large U.S.-English Study

U.S. adults with depression had a 29% increased risk of developing asthma compared with those without depression, according to a genetic and observational study issued by BMC Psychiatry.

Other studies have shown a high comorbidity of depression and asthma, suggesting “a complex two-way relationship, potentially mediated by immune-inflammatory response, lifestyle-related behaviors, obesity, and neuroendocrine dysregulation,” wrote Tanao Ji, of the Medical School of Nantong University, in Nantong, China, and colleagues. “Despite these findings, a complete understanding of the relationship between depression and asthma remains elusive.”

Ji and colleagues analyzed data from 31,434 adults sourced from the U.S.-based National Health and Nutrition Examination Survey as well as 17,021 adults from the English Longitudinal Study of Ageing; all had completed depression assessments as well as a battery of other medical tests and had self-reported their asthma status. Researchers examined the correlations between depression and asthma, including performing two additional analyses to explore any genetic correlation using genome-wide association study summary statistics.

In the unadjusted analysis, researchers found that U.S. adults with depression were twice as likely to develop asthma compared with those without depression, while English adults had a 75% greater risk. The increased risk remained significant even after researchers adjusted for confounding variables, such as differences in demographics, smoking, drinking, body mass index (BMI), and serious chronic illnesses. Compared to non-asthmatic participants, people with asthma were more also likely to be female, not currently married, and to have lower family income. In addition, they tended to have higher BMI, smoking history, and a higher burden of medical comorbidities.

Further analysis revealed a positive genetic correlation between depression and asthma as well as a genetically predicted causal effect of depression on asthma, indicating that depression could be a potential risk factor for asthma. Researchers found significant interactions between smoking status in the United States, suggesting that “effective management of depression in individuals with a history of smoking in the United States may lead to a greater reduction in asthma risk compared to those without such a history.

“Drawing on data from large population-based samples, our findings may have meaningful implications for both public health and clinical implications,” the researchers continued. “These results point to the value of incorporating mental health screening into asthma prevention strategies and suggest that treating depression may contribute to improved asthma outcomes. Our evidence also lends support to multidisciplinary approaches that bridge psychiatry and respiratory medicine.”

For related information, see the Psychiatric News article “Allergies Linked to Increased Risk of Psychiatric Disorders.”

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Novel Candidate Outperforms Zolpidem for Treatment of Insomnia

Seltorexant, a novel selective orexin-2 receptor antagonist, helped adults with insomnia initiate and maintain sleep better than placebo—and for some measures, zolpidem—over a two-week clinical trial, according to a study issued today by JAMA Psychiatry.

“Insomnia disorder is the most common sleep disorder and is associated with increased risk of daytime sleepiness, accidents, depressive disorders, insulin resistance, and total health care expenditures, and decreased quality of life and work performance,” wrote Sofie Mesens, M.D. of Johnson & Johnson, and colleagues. However, the most prescribed medications for insomnia, benzodiazepine and sedative hypnotics such as zolpidem, can cause daytime drowsiness, dependence, tolerance, and, particularly in older people, increased risk of falls and cognitive impairment.

In this drugmaker-sponsored study, Mesens and colleagues recruited 364 adults aged 18 to 85 from six countries who scored ≥15 on the Insomnia Severity Index and had no psychiatric comorbidities. The participants were given either seltorexant (5 mg, 10 mg, or 20 mg), immediate release zolpidem (5 or 10 mg, depending on the local country’s prescribing guidelines), or placebo for 14 days. The participants received a baseline sleep assessment via polysomnography (PSG) prior to receiving their medication, with follow-up PSGs on the first and 13th night of their treatment.

Compared with placebo, participants taking seltorexant 10 mg or 20 mg reduced their sleep initiation time on night one by 36% and 49%, respectively, and reduced their time awake in the six hours after initially falling sleep by 32% and 40%, respectively. Participants taking seltorexant 20 mg also showed greater improvement in sleep initiation on night one than zolpidem. The improvements with seltorexant 10 mg and 20 mg remained on night 13 but diminished among participants taking zolpidem. On night 13, seltorexant 10 mg and 20 mg were both superior to zolpidem for sleep initiation, and seltorexant 20mg was superior at reducing wake onset.

Seltorexant was generally well tolerated, but five participants stopped taking it due to adverse cardiovascular or cerebrovascular events. Overall, treatment-emergent adverse events were lower in the combined seltorexant group (34%) than in the zolpidem group (43%).

“Limitations of this study included that the participants composed a subpopulation with insomnia (those without psychiatric comorbidities) and that fewer than 3% of the participants in this study were women of childbearing potential, who make up a substantial proportion of patients with insomnia,” the researchers wrote.

For related information, see the Psychiatric News articles, “Sleep for Positive Mental and Physical Health” and “To Lower Suicide Risk, Treat Troubled Sleep.”

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TMS May Enhance Language Therapy for Primary Progressive Aphasia

Transcranial magnetic stimulation (TMS) combined with language therapy may help slow the progression of primary progressive aphasia (PPA), a neurological condition that damages the parts of the brain that control speech and language, a study in JAMA Network Open suggests.

Lucia Fernandez-Romero, M.Sc., of the Universidad Complutense de Madrid, and colleagues enrolled 63 older adults who had PPA to receive either active TMS using an intermittent theta-burst TMS protocol or sham TMS for six months. All participants received language therapy immediately after each TMS session; the language therapy was adapted from lexical retrieval treatment, which consists of a sequence of tasks to guide the engagement, strengthening, and active use of central components of language processing. Participants were trained to learn five nouns per session that they were not able to name correctly on two occasions before language therapy began.

Participants received 10 TMS plus language therapy sessions during the first two weeks, followed by once per week for 22 weeks. Language skills were assessed at baseline, three months, and six months via the Mini Linguistic State Examination (MLSE), how well participants identified their trained nouns when they looked at pictures (confrontation naming), and how many words per minute they named in a spontaneous speech task.

At three months, participants in the active TMS group had higher MLSE scores and greater success at confrontation naming than those in the sham TMS group. At six months, MLSE scores improved slightly in both groups. However, confrontation naming declined slightly in the sham TMS group whereas it continued to improve in the active TMS group. At three months, participants in the active TMS group named about 65 words per minute on average, dropping to about 63 words per minute at six months, whereas participants in the sham group consistently named about 59 words per minute at both three and six months.

“Another important finding was the improvement in daily living activities and neuropsychiatric symptoms, suggesting that the therapy’s effects extend beyond trained language skills alone.,” the researchers wrote. “Given that individuals with PPA experience continual and inevitable progression of symptoms, these results suggest that TMS paired with evidence-based speech-language intervention may slow the progression of symptoms and associated brain changes.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Advances in Treatment of Frontotemporal Dementia.”

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Memory Decline Associated With Less Visual Exploration

Memory decline is associated with an underlying reduction in visual exploration and sampling, according to a study published today in PNAS.

Jordana S. Wynn, Ph.D., of the University of Victoria, Canada, and colleagues enrolled 106 volunteers spanning five groups of decreasing cognitive strength:

• 38 young adults ages 18 to 35
• 37 cognitively healthy older adults ages 60 to 85, scoring 26 or higher on the Montreal Cognitive Assessment (MoCA)
• 12 older adults ages 60 to 85 at risk of cognitive decline, scoring lower than 26 on the MoCA
• 15 adults ages 46 to 89 with diagnosed mild cognitive impairment
• Four adults (ages 30, 57, 64, and 66) with amnesia

All participants had normal or corrected vision and hearing and no history of psychiatric illness.

Participants completed two separate tests of naturalistic vision (though not everyone completed both tests). In the first, they viewed 120 unique images (on screen for five seconds) while their eye movements were carefully tracked. The second task was similar except that half the images were presented three times.

The researchers found that for both tasks, gaze patterns followed a linear trend across groups wherein young adults showed the most visual dispersion and the amnesic adults showed the least. In the first task, adults with greater cognitive impairment tended to look at the same areas of the screen regardless of the image. In the second task, cognitively healthy adults gazed at new parts of an image when it repeated, whereas those with decreased cognition tended to focus on the same image features when it repeated.

“[E]ye movements can reveal population differences in memory function, even in the absence of explicit task demands,” Wynn and colleagues wrote. “Our results provide compelling evidence that naturalistic gaze patterns can serve as a sensitive marker of cognitive decline.”

For related information, see the Psychiatric News article “Visual Diagnostics Become More Accessible.”

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Suicidal and Self-Harm Behaviors Common Among Transgender and Nonbinary People

Nearly one-third of transgender and nonbinary people will attempt suicide at least once in their lives, according to a comprehensive review published this week in JAMA Psychiatry. 

“Quantifying the mental health burden facing trans and nonbinary people is an important step with important implications for both delivery of care and shaping health care policy,” wrote Kirsten J. Hainey, M.P.H., of the University of Glasgow in Scotland, and colleagues.

Hainey and colleagues conducted an umbrella review that investigated the prevalence of mental health and neurodevelopmental conditions in trans and nonbinary people ages 18 and older. They included 24 reviews and meta-analyses that analyzed 754 primary studies published between 1983 and 2022.

The most common issues addressed in the reviews were suicide related. The lifetime prevalence of suicidal ideation among transgender and nonbinary people was 50%, the lifetime prevalence of suicide attempt was 29%, and the lifetime prevalence of non-suicidal self-injury was 47%. Compared with cisgender people, trans and nonbinary people were about 3.5 times as likely to experience any of these above events. There was little difference between trans men and trans women for lifetime prevalence of suicidal ideation or attempts.

Additionally, trans and nonbinary people were more likely than cisgender individuals to experience an eating disorder, experience post-traumatic stress disorder, and be diagnosed with autism. The prevalence of autism ranged widely in the included reviews, which the authors suggested may be due to changes in diagnostic criteria and awareness across the review time frame.

The review identified what the authors referred to as “critical evidence gaps.” Robust prevalence estimates were missing for common disorders such as depression and anxiety, for example. These gaps “should be urgently addressed to ensure [trans and nonbinary people’s] mental health needs can be addressed by evidence-informed policy and practice.”

For related information, see the Psychiatric News article “Executive Orders Have Chilling Effect on Transgender Community.”

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Low and High Testosterone Associated With PTSD Symptoms in Males and Females

In both males and females, low levels of testosterone may be a risk factor for future posttraumatic stress disorder (PTSD) symptoms, according to a study published yesterday in Translational Psychiatry. Elevated testosterone was also associated with PTSD symptom risk, while individuals in the middle had the lowest risk.

“Our findings are consistent with previous work that has shown testosterone to have anxiolytic and antidepressant effects in men,” wrote Hanyang Shen, M.P.H., M.Sc., of Stanford University, and colleagues. “In women, there is also some evidence that testosterone can have anxiolytic and antidepressant effects, but high levels may also lead to new onset mood episodes.”

The researchers made use of the vast UK Biobank repository, which contains medical, genetic, social, lifestyle, and environmental data on more than 500,000 middle-aged adults. Their sample included 62,565 males (average age 57) and 67,906 females (average age 55) who completed a mental health questionnaire mailed out in 2016 and had previously provided blood samples; the researchers excluded individuals whose baseline testosterone was at the extreme low or high end of normal human range. The mental health questionnaire included six questions on PTSD symptoms derived from the PTSD Checklist for DSM-5.

Male and female participants were then divided into 10 groups (deciles) based on total testosterone (TT) levels, with group one (lowest levels) serving as the reference. Shen and colleagues found that relative to group one, all other groups had lower PTSD symptom scores, after adjusting for other variables. The scores exhibited a U-shaped pattern, with decile seven associated with the fewest PTSD symptoms in both males (TT range of 12.54 to 13.50 nmol/L) and females (TT range of 1.11 to 1.25 nmol/L).

Among both males and females, stronger associations between testosterone levels and future PTSD symptoms were seen in adults with a BMI of 30 or higher.

“Analyzing data from 130,471 participants, this study is over 60 times larger than the largest previous investigation of the relationship between testosterone and future PTSD symptoms, affording the testing of more nuanced models than previously investigated,” the researchers wrote. “[M]ore studies exploring how BMI, and other body composition measures that more directly distinguish body fat from muscle, modify the impact of testosterone on psychiatric disorders need to be conducted to further unveil this mechanism.”

For related information, see the Psychiatric News article “Can Hormonal Treatments Help Your Patients?”

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Global Functioning Tests, Six-Month Follow-Up Important for Clinical High-Risk Patients

Assessing symptoms as well as global functioning among young people at clinical high risk of psychosis and following them for at least six months may provide the most accurate view of their clinical outlook, suggested a study issued by JAMA Network Open yesterday.

Most individuals at clinical high risk for psychosis do not transition to psychosis, noted Johanna Seitz-Holland, M.D., Ph.D., of Harvard Medical School, and colleagues. “Early identification of individuals likely to remit could optimize treatment allocation, including clinical trial participation, and understanding remission-related factors may inform preventive strategies and interventions.”

Seitz-Holland and colleagues analyzed data from 614 individuals ages 12 to 30 at clinical high risk of psychosis who participated in the North American Prodromal Longitudinal Study between February 2015 and November 2018, had positive symptoms at baseline, and completed at least one follow-up assessment. The researchers assessed remission at seven follow-up visits over two years using two different methods: measuring positive symptoms only and measuring positive symptoms and global functioning. Individuals who reached remission and continued to meet remission criteria at all subsequent visits were classified as stable.

Participants were more likely to be classified as in remission at any one visit when receiving a symptoms-only assessment compared with a symptoms-and-function assessment (34% versus 21%, respectively). Similarly, remitters were more likely to be classified as stable under the symptoms-only definition compared with symptoms-and-function (54% versus 47%, respectively).

The researchers noted that the chance of staying in remission rose significantly once a person had more than one previous visit recorded in remission. They also found that higher functioning and fewer positive symptoms at baseline were associated with remission; however, other variables such as age, sex at birth, race, use of antipsychotics, use of antidepressants, cognitive performance, and trauma history were not.

“Regardless of the definition used, only one-half of remitters were stable, indicating that remission is a dynamic state and that vulnerability can persist even after functional remission,” the researchers noted. “Our findings tentatively support a stable remission definition based on at least 6 months of sustained remission…. Hence, continued follow-up and facilitated reengagement with clinical services after remission are essential.”

For related information, see the Psychiatric News articles "Predicting Psychosis: Field Moves From Assessment of Clinical Risk to Search for Biomarkers" and "Youth at High Risk for Psychosis: What Happens to Those Who Don’t Become Psychotic?"

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Poor Sleep Linked to Self-Harm in Adolescents

Poor sleep may raise the risk of self-harm in adolescents, a study in the Journal of Child Psychology and Psychiatry has found.

Michaela Pawley, Ph.D., of the University of Warwick in the United Kingdom, and colleagues analyzed data from 10,477 participants in the Millennium Cohort Study, an ongoing multidisciplinary study that has been following people in the U.K. who were born between 2000 and 2002. When the participants were 14, they were asked:

• What time they went to sleep and woke up on school and non-school days (sleep duration)
• How long it usually took them to fall asleep during the last four weeks (sleep onset latency)
• How often they had woken up and had trouble falling back asleep in the last four weeks (night awakenings)

The researchers also calculated participants’ social jet lag—the difference between their sleep midpoint on non-school days and school days.

The participants were asked about self-harm when they were 14 and again when they were 17.

Pawley and colleagues found that shorter sleep duration on school days, longer sleep onset latency, and more frequent night awakenings were significantly associated with self-harm at 14 and 17, whereas weekend sleep duration and social jet lag were not.

The researchers noted several possible explanations for the association between poor sleep and self-harm. First, the cumulative effect of short sleep duration during the week contributes to chronic sleep deprivation, which has adverse effects on mood and physical health. Second, long sleep onset latency may reflect underlying attentional difficulties such as mental sluggishness, distractibility, and/or excess daydreaming—which are also self-harm risk factors.

Night awakening, meanwhile, “may be considered a unique predictor in our study due to its influence on both micro- and macro-sleep architecture,” the researchers wrote. “Individuals who awaken frequently throughout the night may struggle to obtain enough REM sleep, developing deficits in emotion regulation and [the] ability to implement healthy emotional responses.”

Pawley and colleagues said that cognitive-behavioral therapy for insomnia (CBT-I) may address the three risky sleep problems they identified. However, they added that current etiologic models of insomnia were derived from adults and that little is known about the interplay of factors associated with adolescent sleep problems. In turn, it is unknown whether those factors would influence the effectiveness of CBT-I in adolescents.

For related information, see the Psychiatric News articles “Sleep Problems in Late Childhood, Early Adolescence Linked to Psychiatric Symptoms” and “Novel Therapies Aim to Boost Teen Sleep and Mood.”

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Intervention Targeting Food and Fullness Cues Found Effective for Binge Eating Disorder

A behavioral intervention targeting an individual’s sensitivity to food-based cues may be effective for people with binge eating disorder, according to study findings published today in JAMA Network Open.

In a clinical trial, the intervention known as regulation of cues plus behavioral weight loss (ROC+BWL) outperformed cognitive behavioral therapy (CBT) in reducing weight and binge eating risk.

For the trial, Kerri N. Boutelle, Ph.D., of the University of California, San Diego, and colleagues randomized 129 veterans (59% male) to receive five months of either ROC+BWL or CBT. ROC+BWL targets multiple mechanisms of binge eating by training individuals to understand appetitive cues, inhibit the urge to eat when not physically hungry, and tolerate food cravings. CBT focused on normalizing eating patterns as well as addressing problematic thoughts related to eating behavior, body shape, and self-esteem. Both treatments were provided in weekly 90-minute group sessions and set a goal of engaging in at least 250 minutes of physical activity per week.

At the end of the treatment period, veterans who received ROC+BWL reported fewer binge eating episodes, slightly greater weight loss, and reduced caloric intake compared with those receiving CBT. The benefits of ROC+BWL were more pronounced in veterans who had full-syndrome binge eating disorder at the start of the trial (at least 12 binge eating episodes in the previous three months). Binge eating frequency remained lower in the ROC+BWL group at a six-month follow-up, though average weight rebounded to match the CBT group.

“ROC+BWL targets both appetitive traits and reduction in energy intake, which could provide multiple distinct skills to manage urges to binge eat and overeat and provide a more durable treatment,” Boutelle and colleagues wrote. “Although this investigation provides initial support for the use of ROC+BWL as an alternative model to treat binge eating among veterans, more research is needed on the effects on weight and on these treatments among community samples, and longer-term studies are needed, as well as studies that include ROC alone.”

For related information, see the American Journal of Psychiatry article “Cognitive Behavioral Therapy and Lisdexamfetamine, Alone and Combined, for Binge-Eating Disorder With Obesity."

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Emotion Regulation Therapy Is Effective for Teens and Young Adults With Autism

The 2024 National Survey on Drug Use and Health is here—with encouraging news, but some missing details. Read more on the findings at Newswire.

An intervention focused on emotion regulation can help autistic teens and young adults significantly reduce their daily impairments to living, reports a study in the Journal of the American Academy of Child and Adolescent Psychiatry.

“Clinically elevated emotion dysregulation, difficulty monitoring and modifying emotional arousal and reactivity, is 2-4 times more likely among autistic people than non-autistic peers,” wrote Susan W. White, Ph.D., of the University of Alabama, and colleagues. “… [E]motion dysregulation may be particularly interfering during transition to adulthood, acknowledged to be a primary barrier to desired social, employment, and educational outcomes.”

What’s more, as emotion dysregulation is associated with many psychiatric disorders, a therapy focused on this problem might be less intimidating to non-autism specialists, the authors continued.

White and colleagues randomized 109 adolescents and young adults (ages 12 to 22) with autism to receive one of two therapies. Fifty-seven participants received Emotion Awareness and Skills Enhancement (EASE), a 16-module program rooted in mindfulness that teaches individuals to become more aware of and better regulate their emotions. The other 52 participants received an active control in which therapists could perform a range of evidence-based interventions over 16 weeks, such as cognitive behavioral therapy or social skills intervention, as long as they didn’t include any core elements of EASE.

After 16 weeks, youth in the EASE group had significantly greater improvements in symptoms related to emotion regulation than the active control group. Overall, 63% of EASE participants showed strong improvements in their daily functioning, compared with 44% receiving the active control. Though the difference was not statistically significant, “these findings are noteworthy given the robust nature of the [control], in which clients received personalized treatment designed to meet the person’s specific needs,” the authors wrote.

EASE participants also showed statistically significant improvements in internalizing and externalizing symptoms from baseline, whereas only the latter improved in the active control group. EASE also demonstrated superiority on the therapist side, receiving higher ratings on patient engagement and building a therapeutic alliance than the active control group.

For related information, see the Psychiatric News article "As Number of Adults With Autism Rise, Need For Better Services Apparent."

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Antipsychotics May Reduce Risk of Catatonia Relapse

Nearly half of individuals who develop catatonia—a neuropsychiatric syndrome marked by abnormal speech and movements—will experience a relapse within a few years, according to a study published yesterday in JAMA Psychiatry. Providing antipsychotics at discharge can reduce relapse risk.

“Notably, the underlying psychiatric diagnosis (psychotic vs affective disorder) and baseline sociodemographic or clinical factors were not associated with meaningful differences in relapse rates … reinforcing catatonia as a distinct syndrome,” wrote Harsh Pathak, M.D., at the National Institute of Mental Health & Neuro Sciences in Bengaluru, India, and colleagues.

The researchers examined medical records of 303 patients who were treated for catatonia at a neuropsychiatric center in India between January 2014 and December 2017 and came back for at least one follow-up visit by December 2020. Of this group, 191 patients had an underlying psychosis spectrum disorder, while 112 had an affective disorder.

Overall, 48.8% of the patients experienced catatonia relapse, with most events occurring within the first two years after the initial episode. The only baseline difference between patients who relapsed and those who didn’t was that those who relapsed had a longer first episode of their underlying psychiatric illness (average of 109 versus 53 days). Other clinical or demographic factors, including patient age, psychiatric illness type, and history of catatonia, were similar between groups.

With regard to treatment protocols, the researchers found that patients who received an antipsychotic prescription at discharge had a 41% reduced risk of relapse compared with those who did not; this reduced risk was present in patients with or without a prior history of catatonia. There was also some indication that providing inpatient acute treatment rather than outpatient treatment could reduce relapse risk.

The findings emphasize “the need for early maintenance treatment and the recurrent nature of catatonia,” Pathak and colleagues wrote. “While lorazepam remains effective for acute episodes, antipsychotics may play a key role in relapse prevention. While the study focused on delineating whether factors at baseline could help estimate the risk of catatonia relapse, future research incorporating follow-up variables could further enhance understanding of catatonia’s long-term course.”

For related information, see the Psychiatric News article “Comprehensive Catatonia Guideline Released.”

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Modest Uptick in Teen Use of ADHD Medications Hasn’t Boosted Misuse

Recent years’ increased prescribing of stimulants for attention-deficit/hyperactivity disorder (ADHD) in adolescents has not led to rising abuse, according to a study issued yesterday by JAMA.

“These findings are consistent with declines in peer-to-peer diversion among adolescents following COVID-related school closures and findings from adult studies,” said Sean Esteban McCabe, Ph.D., of the University of Michigan, and colleagues.

McCabe and colleagues analyzed responses from 259,623 youth in eighth, 10th, and 12th grade from the national Monitoring the Future survey between 2005 and 2023. Respondents reported on whether they had ever taken or were now taking prescription stimulants for ADHD; nonstimulant medications were excluded. Respondents also answered questions about lifetime and past 30-day use of these medications “without a doctor telling you to take them.”

Researchers noted that following a sharp drop in teens’ medical stimulant use at the start of the pandemic, such use peaked in 2022 at 9.3%. However, over the 18-year study period, teens’ medical use of prescription stimulants for ADHD increased only modestly. While teens’ nonmedical use of the medications was more prevalent than medical use at the study outset (10.03% versus 8.11%, respectively), nonmedical use decreased significantly over time, reaching a low of 4.69% in 2023. Meanwhile, lifetime prevalence of combination medical/nonmedical use of the medications also dropped over time, from 2.05% in 2005 to 1.37% in 2023.

Compared with adolescents in eighth grade, those in 10th and 12th grade had higher misuse of stimulants but greater declines in such use over time. Among adolescents who reported stimulant misuse, about half used stimulants one to two times, one-quarter used them three to nine times, and the remainder used them more than 10 times.

Limitations of the study include lack of information about dose and lack of representation of homeschooled or truant youth, the researchers wrote.

“Despite concerns about increased stimulant prescribing, findings indicate no associated increase in nonmedical prescription stimulant use at this time, although longitudinal research and continued monitoring is necessary,” the researchers wrote. “These findings enable clinicians and policymakers to consider population-level trends in … use patterns when weighing the risks and benefits of prescription stimulants.”

For more information, see the Psychiatric Services article (from McCabe and colleagues) “Attention-Deficit Hyperactivity Disorder Stimulant Therapy and Prescription Drug Misuse During Transition to Young Adulthood.”

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Neuropsychiatric Side Effects More Common in Beta Blockers Than Other Antihypertensives

People who take beta blockers may have a higher risk of neuropsychiatric adverse events compared with patients who take other blood pressure medications, a study in the Journal of Psychopharmacology suggests.

Lujain Ez Eddin, B.S., of Western University in Canada, and colleagues used the FDA Adverse Event Reporting System (FAERS) database to compare reported side effects of beta blockers (atenolol, propranolol, carvedilol, metoprolol) with those of lisinopril (an angiotensin-converting enzyme inhibitor) and losartan (an angiotensin II receptor blocker) between 2004 and 2023. The researchers conducted a broad analysis for nervous system and psychiatric events along with a comparison of nine specific adverse events commonly reported in these two categories: dizziness, nightmares, insomnia, confusional state, altered mental status, hallucinations, disorientation, delirium, and somnolence.

Overall, beta blockers were associated with higher reported odds of both nervous system events and psychiatric events compared with lisinopril (2.08 and 1.68 times more likely, respectively) and losartan (1.29 and 1.53 times more likely, respectively). Of the specific events studied, beta blockers had significantly higher reports for dizziness, nightmares, insomnia, hallucinations, disorientation, and somnolence, but not confusion, delirium, and altered mental status.

Among the beta blockers, propranolol—a fat-soluble medication that is sometimes used off-label in the treatment of akathisia and certain anxiety disorders—had the highest reported odds of several of these neuropsychiatric events compared with both lisinopril and losartan.

“Taken together, these findings support prior studies suggesting that lipophilic [beta] blockers, such as propranolol, can more easily cross the blood–brain barrier, increasing the likelihood of neuropsychiatric adverse effects,” the researchers wrote. “In addition, it is possible that beta blockers could increase the risk of neuropsychiatric [events] through mechanisms other than their beta blocker properties, such as by altering neurotransmitter levels or other pathways.”

The researchers noted that FAERS data are subject to underreporting, which could lead to a bias in the findings, especially for milder or less recognized adverse events. On the other hand, notoriety bias, in which certain drugs or events are disproportionately reported due to heightened awareness or publicity, could result in overreporting.

For related information, see the Psychiatric News article “Beta Blockers Associated With Decreased Violence.”

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Individuals With Persistent Grief Have Higher Mortality Risk

Individuals with intense and sustained grief following the death of a relative use more mental health services and are more likely to die within 10 years compared with peers experiencing low levels of grief, according to a study published in Frontiers in Public Health.

Mette Kjærgaard Nielsen, M.D., Ph.D., of the Research Unit for General Practice in Aarhus, Denmark, and colleagues examined the health outcomes of 1,735 adults who had initially been contacted in 2012; at that time, all the individuals had a close relative (such as a spouse or parent) with a terminal illness. Using the Prolonged Grief-13 (PG-13) scale, participants had filled out measures of their grief symptoms at baseline and again six months and three years after their loved one’s death. Nielsen and colleagues used Danish health registry data to track participants’ use of mental health services (talk therapy and/or psychotherapy) and psychotropic medication for up to 10 years or their death.

Based on PG-13 scores over three years, participants were placed in five grief categories: consistently low (n=670), initially moderate then decreasing (526), initially high then decreasing (310), late onset (122), and consistently high (107).

Compared with individuals in the consistently low grief group, those in the consistently high group were 2.9 times as likely to use mental health services, 5.6 times as likely to receive an antidepressant prescription, and 2.6 times as likely to receive an anxiolytic or sedative prescription. Individuals with initially high grief were also more likely to receive antidepressants, anxiolytics, or sedatives than the consistently low group, but did not have additional mental health service use. Further, the researchers found that individuals in the consistently high grief group were nearly twice as likely to die during the follow-up period as those in the consistently low group.

“The present study establishes that individuals most likely to receive excess health care services beyond three years after bereavement were those with high levels of persistent grief symptoms,” Nielsen and colleagues wrote. “Hence, the available services seem to be directed at those with the most severe symptoms. However, the persistent need for mental health service over a long-term period could indicate that the existing interventions may not be sufficient to address the needs of bereaved relatives.”

For additional information, see the Psychiatric News Special Report “Prolonged Grief Disorder—What You Need to Know.”

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Advocacy Through Storytelling APA is concerned about potential Fiscal Year 2026 funding cuts to several federal programs that will have a significant impact on the mental health and substance use community. We ask that you complete this form to submit a personal story about how these cuts will affect you, your patients or your community. APA is looking to leverage your stories as part of our overall advocacy efforts on the Hill and within the media.

Just 7,000 Steps a Day Lowers Risk of Depression, Dementia, Mortality

People who walked more were less likely to die of any cause or contract a number of serious health outcomes, including depression and dementia, according to a new meta-analysis published by The Lancet Public Health.

The past decade “has seen a rapid advancement in the evidence surrounding step counts,” wrote Ding Ding, Ph.D., M.P.H., at the University of Sydney, in Sydney, New South Wales, Australia, and colleagues. “[Studies] consistently found that higher daily step counts are associated with better health outcomes. However, most reviews focused on all-cause mortality and cardiovascular disease, leaving gaps in our understanding of the associations between step counts and other health outcomes, such as cancer and cognitive function.”

Ding and colleagues identified 57 studies published between January 2014 and February 2025 involving adults who used devices to assess their daily step counts. Results were correlated to participants’ health outcomes.

Compared with 2,000 steps per day, 7,000 steps per day was associated with a 22% lower risk of depressive symptoms and a 38% lower risk of dementia. In addition, the higher step count was also associated with a 47% lower risk of all-cause mortality, a 37% lower risk of cancer mortality, a 25% lower risk of cardiovascular disease incidence, and a 14% lower risk of type 2 diabetes. Researchers also found that even modest step counts of 4,000 steps per day were linked to better health compared with 2,000 steps per day.

The limitations of this meta-analysis included the small number of studies available for many outcomes, a lack of age-specific data, and the fact that most data were derived over several days, which might not align with long-term step counts recorded by consumer wearables over months or years.

“Although 10,000 steps per day—an unofficial target for decades without a clear evidence base—was associated with substantially lower risks for all-cause mortality, cardiovascular disease incidence, cancer mortality, dementia, and depressive symptoms than 7,000 steps per day, the incremental improvement … was small, and there was no statistical difference between 7,000 steps per day and a higher step count for all the other outcomes,” the researchers wrote. “Therefore, 7000 steps per day might be a more realistic and achievable recommendation.”

For related information, see the Psychiatric News article “Higher Daily Step Counts Yield Fewer Depression Symptoms Among Adults.”

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Stigma Toward Patients With SUDs Persists Among Clinicians

More than 30% of physicians and dentists said they prefer not to work with patients with an opioid use or stimulant use disorder, a significantly higher rate than reported for other conditions that carry stigma such as HIV (9%), depression (9%), or even alcohol use disorder (17%), according to a study published yesterday in Addiction.  

Carrigan Parish, Ph.D., D.D.S., of Columbia Mailman School of Public Health, and colleagues surveyed 1,240 primary care physicians, emergency medicine physicians, and dentists (mean age 53 years, 60% male, 68% white). Stigma was assessed using the Medical Condition Regard Scale, an 11-item scale through which respondents reported the degree to which they found patients with a particular medical condition enjoyable, treatable, and worthy of medical resources. The conditions included type II diabetes, depression, HIV, alcohol use disorder (AUD), opioid use disorder (OUD), and stimulant use disorder.

Respondents were consistently more likely to endorse negative responses regarding patients with substance use disorders (SUDs) than other conditions. Among SUDs, the greatest stigma scores were toward patients with stimulant use disorder, followed by OUD, then AUD. Further:

• Respondents were less likely to feel able to provide effective care to patients with SUDs than other conditions. For example, 22% believed there is little they can do to help patients with stimulant use disorders, compared with 7% who said the same for HIV or depression.
• More than half of respondents reported feeling compassion toward patients with diabetes (51.5%), HIV (57.6%), and depression (57.6%), while significantly fewer said the same for patients with AUD (37.6%), OUD (33.4%), and stimulant use disorders (27.7%).
• Emergency medical physicians had the highest stigma scores toward patients with SUDs, particularly stimulant use disorders. Yet they were the most likely to report providing treatment to these patients.

“While we’ve made progress in expanding access to evidence-based SUD treatment, stigma remains a profound barrier—often embedded in the clinical encounter itself,” Parish said in a news release. “Our findings show that many providers still feel uncomfortable treating patients with substance use disorders, and that hesitancy leads directly to missed opportunities for care. In particular, emergency departments often serve as the first—and sometimes only—point of care for people with [SUDs]. We need to leverage those moments, not miss them.”

For related information, see the Psychiatric News articles “Discrimination Persistent Barrier to Care for OUD Patients” and “Physician Reluctance to Intervene in SUD Tied to Lack of Institutional Support.”

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Advocacy through storytelling APA is concerned about potential Fiscal Year 2026 funding cuts to several federal programs that will have a significant impact on the mental health and substance use community. We ask that you complete this form to submit a personal story about how these cuts will affect you, your patients or your community. APA is looking to leverage your stories as part of our overall advocacy efforts on the Hill and within the media.

Remote CBT Effectively Addresses Pain

Cognitive behavioral therapy for chronic pain (CBT-CP) delivered either by a remote health coach or via a self-guided online program can reduce pain severity among patients, according to a study published today in JAMA.

Cognitive behavioral therapy is a widely accepted and effective nonpharmacologic treatment for chronic pain, but is limited by a paucity of trained clinicians, especially in non-urban areas, wrote Lynn DeBar, Ph.D., M.P.H., of the Kaiser Permanente Center for Health Research, and colleagues. “Remote treatment is promising for lowering costs; overcoming patient, clinician, and system barriers; and having greater safety compared with pharmacologic pain treatments.”

DeBar and colleagues recruited 2,331 participants (mean age of 59, 74% women, 75% White, 44% rural) with high-impact musculoskeletal pain. Participants were randomly assigned to one of three groups: The first group received eight one-on-one sessions of CBT-CP with a health coach delivered over phone or video conference; the second group self-completed an eight-session, online CBT-CP program; and the third group received usual care, plus a mailed copy of a pain-management resource guide.

Before and after the intervention, participants completed the 11-item version of the Brief Pain Inventory–Short Form to determine their pain severity. A 30% or greater reduction in someone’s pain inventory score post-intervention was considered a clinically meaningful improvement.

After completing the intervention, 32% of participants in the health coach group and 26.6% of participants in the online intervention group reported meaningful pain improvements, compared with 20.8% in the usual care group. While participants in the health coach group were statistically more likely than those in the self-guided group to show meaningful improvement in their pain severity, the benefit of CBT-CP over usual care was sustained over 12 months in both groups.

The findings “suggest that centralizing delivery of the CBT-CP based programs via telephone/videoconferencing and online interventions is effective, with potential for widespread dissemination into clinical care and health care organizations nationwide,” the authors concluded.

For related information, see the Psychiatric News article "Integrated Behavioral Approaches Show Promise in Treating Pain."

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COVID Pandemic Accelerated Brain Aging, Even Among Uninfected

The COVID-19 pandemic accelerated brain aging by several months, even among individuals who did not get infected with the virus, according to a study published today in Nature Communications.

“The neuroinvasion of SARS-CoV-2 is well established, with virus persistence detected up to 230 days post-infection,” wrote Ali-Reza Mohammadi-Nejad, Ph.D., of the University of Nottingham, England, and colleagues. “Understanding the pandemic’s effects on brain health, considering infection status and socio-demographic factors, is crucial for addressing its long-term health consequences and broader public health implications.”

The researchers made use of extensive brain imaging data available in the UK Biobank to develop and train a brain-age prediction tool. The tool was then used to assess changes in brain age in 996 middle-aged and older adults (average age of 59) without chronic disease who received two MRI scans about three years apart. Of these, 564 adults received both scans before the onset of the pandemic in March 2020 (control group), while the remaining 432 received their second scan after pandemic onset (pandemic group).

The researchers next calculated the brain age gap (BAG)—the difference between an individual’s chronological age and brain age—for all the adults at both time points. While the two groups were evenly matched at baseline, at the follow-up scan, the average BAG for the pandemic group was 5.5 months greater than for the control group. Accelerated brain aging was more pronounced in males, older adults, and individuals with sociodemographic deprivation (lower scores on employment, education, and/or housing indices).

However, while brain age accelerated across the pandemic group broadly, only those individuals who reported being infected with the coronavirus experienced reductions in cognitive measures such as mental flexibility and processing speed at the second time point compared with the control group, with more pronounced changes again observed in older adults.

“Our findings provide valuable insight into how the COVID-19 pandemic affected brain health, demonstrating that the general pandemic effects alone, without infection, exerted a substantial detrimental effect on brain health, augmented by bio-social factors (age, health, and social inequalities),” Mohammadi-Nejad and colleagues wrote.

For more information, see the Psychiatric News article “Measurements of Brain Age May Help Target Therapy.”

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