Search Results

"The root of the word 'create' or 'creativity' essentially means 'to grow.' That is probably what lies at the heart of what patients really want; they want to grow in terms of their relationships, their abilities, their passions and interests, their health, and in terms of whatever dreams they want to achieve personally in their lives." Cognitive Behavioral Therapy SPECIAL REPORT: CREATIVITY & PSYCHIATRY THE BECK INSTITUTE Can creativity play a role in psychiatric treatment? Studies have shown that music and art therapy can be helpful for patients with schizophrenia, depression, dementia, and other mental disorders.1-4 Creativity can also enhance the therapeutic alliance.5 Norman Cotterell, PhD, senior clinician at the Beck Institute for Cognitive Behavior Therapy, is no stranger to leveraging creativity when supporting patients. His interest in the arts stem back to his school days, when he was in the drama club, the Princeton University Gospel Ensemble, and the Princeton Inn Theatre. To help clinicians cultivate creativity in clinical practice, Cotterell shared insights with Psychiatric Times. Psychiatric Times: It is often said that psychotherapy combines science and art. Where does the art come into play in your daily work with patients? Norman Cotterell, PhD: It comes on the fly. I’m usually thinking of ways I can help the patient get to where they want to go in life, and that is much more personal than science. I suppose the science comes into play in the empirically validated tools we have, but the art comes in terms of relating to a person one-on-one. PT: Do you think being a creative person helps clinicians better support patients? Cotterell: I have patients who come to me because I share their enthusiasm for art, music, literature, and theater. I share in the enthusiasm that they bring to whatever artistic pursuit they might have. I had a patient who thought visually and recorded her thoughts in pictures. If she could sketch out her negative thoughts, it wasn’t too much of a stretch to have her sketch her positive responses to those thoughts. She sketched responses that displayed her hopes, dreams, and aspirations. She sketched out the best that she saw in herself, the best that she saw in those around her, and the best that she saw in what the future might bring to her. Having her sketch that out in visual terms was incredibly powerful. Another patient of mine thought in terms of music. She created a mixtape that represented those hopes, dreams, and aspirations in musical form through other people’s work. There’s room for that. There’s room in sessions for clients to bring their creative, artistic pursuits into therapy. But it has to serve the nature of their goals for therapy; what they want to accomplish in life outside the session. PT: How can clinicians leverage metaphors, anecdotes, and humor to improve therapy and the patient-clinician alliance? Cotterell: Metaphors and anecdotes can be especially powerful, particularly in helping patients see that what can be an obstacle in one situation could be an opportunity in another. I sometimes use the example of [former] President Franklin D. Roosevelt. Many assume that being in a wheelchair would have been an obstacle to the presidency, but there is some indication it was an opportunity. Prior to polio, Roosevelt was a rich kid who was perceived as never having had to struggle a day in his life. After polio, he had something in common with people who were struggling through the Great Depression. So there is some thought that it increased his chances for the presidency, because he had something in common with voters who were struggling. I say to patients, “Well, you can’t walk. What can you do? You can lead your country in the highest office in the land.” Often, what can be an obstacle in one frame of mind can creatively be turned into an opportunity in another frame of mind. That might be what we do in therapy: turn obstacles into opportunities. We turn obstacles in terms of internal experiences, thoughts, feelings, sensations, and urges into opportunities to live life well. Humor is another powerful tool when used correctly. I have seen stand-up comedians in sessions, and they naturally think in humorous terms—for better or for worse. Often, the use of humor has a therapeutic impact. One patient told me that for him, doing stand-up comedy was tantamount to therapy. It’s just one form of language and one form of a coping strategy that helps patients. But it depends on the person. For some patients, humor is really important. It’s the way they speak, think, and cope. But some patients don’t have the same need or desire, so tread gently when it comes to humor. This is an area in which I would really let the patient take the lead, because individuals differ on what they find funny and on what kind of humor is therapeutic for them. PT: Can you give specific examples of creativity within the cognitive behavioral therapy (CBT) framework? Cotterell: The root of the word create or creativity essentially means “to grow.” That is probably what lies at the heart of what patients really want; they want to grow in terms of their relationships, their abilities, their passions and interests, their health, and in terms of whatever dreams they want to achieve personally in their lives. It is the old button-pushing question from David Burns: What kind of life would they be leading if they pushed a magic button and were totally, permanently healed? If they pushed the button and therapy was a smashing success, what would change on a day-to-day basis? What would they be doing? I have them create in their own minds a vision of that life. If they were healed, what would they do in the next 7 days? If they felt great about themselves, their world, their future; if their anxiety was no longer a problem; and if they were able to take steps toward what’s important and valuable and meaningful in their lives, then what would they do for the rest of today? Tomorrow morning? Tomorrow afternoon? Tomorrow night? The creative aspect is enabling the patient to create a vision of the kind of life they want. I suppose the tools that we provide serve as fertilizer to enable their dreams and aspirations to grow, and to enable them to move in the direction of the life they seek. PT: What specific CBT interventions are especially well suited for utilizing a creative approach? Cotterell: Action planning. Action plans could include what the patient wants to do in the next week for pleasure, what they want to do in the next week that could engage their mind, or what they want to do in the next week for connection. It could be building relationships with those they care about. It could be something that gives them a sense of meaning and purpose; something they do for growth, for love, and to contribute to the well-being of those around them. I have them create that vision for the next week, then we figure out what kinds of thoughts, urges, or sensations inside their body would get in the way of doing those things. The intervention within the session is finding creative ways to get around, get through, or travel with those thoughts, emotions, urges, or sensations that otherwise could serve as obstacles to the things they want to do to lead their life in a more fulfilling and more meaningful way.

Keypoint: Girls with ADHD appear to slow their response speed as a strategy to retain accurate response inhibition. Among children with attention-deficit/hyperactivity disorder (ADHD), response inhibition patterns vary by sex and are task-dependent, according to study results published in the Journal of Attention Disorders. Overall, boys with ADHD are more likely to display inhibition errors while girls have intact response inhibition, but slower response speeds. The behavioral symptoms of ADHD are thought to be related to impairments in cognitive control, such as deficits in inhibition control, interference control, and attention regulation. Recent evidence suggests that boys and girls with ADHD may exhibit different types of impairments. However, girls are often underrepresented in ADHD research given the higher prevalence among boys/men, so the potential sex differences in cognitive control remain unclear. To address this knowledge gap, researchers conducted a study to evaluate performance metrics of cognitive control across multiple tasks in both boys and girls with ADHD. The researchers recruited children aged 8 to 12 years (N=300) with a diagnosis of ADHD (n=201) and typically developing controls (n=99) in the United States. The study participants completed the go/no-go (GNG) task, stop signal task (SST), and flanker cognitive control task. The primary outcomes of interest were response speed, variability, and inhibition errors. On average, the girls (n=58) and boys (n=143) of the ADHD cohort were aged 10.2 (SD, 1.3) and 10.4 (SD, 1.4) years while the typically developing girls (n=37) and boys (n=62) were aged 10.1 (SD, 1.4) and 10.4 (SD, 1.2) years. Among the ADHD group, 48% of girls and 57% of boys used stimulant medications. Socioeconomic status was significantly lower among the ADHD group (P =.021) and baseline inattention scores for the ADHD cohort were significantly greater among girls (P <.001) relative to boys. For the GNG task, the researchers observed a significant effect of ADHD diagnosis for mean reaction time at go (P <.001), mean response variability in the ex-Gaussian part of reaction time (P <.001), and mean response variability in the Gaussian part of the trial (P =.014). Significant diagnosis-by-gender effects were observed for mean response variability in the Gaussian part of the trial (P =.015) and mean response speed in the Gaussian part of reaction time (P =.016). Together these differences indicate that across both groups, boys had more commission errors than girls while girls had quicker GNG response speeds than boys. Between groups, boys with ADHD had more errors than controls whereas girls with ADHD had a slower response speed than controls. Additionally, response variability was higher among children with ADHD than controls. For the SST task, the researchers observed a main effect of diagnosis for stop signal reaction time (P <.001), mean response variability in the ex-Gaussian part of reaction time (P <.001), mean stop signal delay (P =.016), mean reaction time at go (P =.020), and commission error rate (P =.042). These differences indicated that relative to controls, patients with ADHD had higher commission error rates, with slower go response speed for girls with ADHD and shorter stop signal delay among boys with ADHD. For the Flanker task, a main effect of diagnosis was observed for mean response variability in the Gaussian (P <.001) and ex-Gaussian (P <.001) parts of the trial and congruency effect error rate (P =.008). Overall, the patients with ADHD had greater flanker error rates than controls. Study authors concluded, “Results of this study indicate that boys and girls with ADHD engage in distinct task-dependent strategies during inhibition tasks whereas they show similar deficits in interference control and elevated [reaction time] variability.” Note: This article originally appeared on Psychiatry Advisor

- Access for pregnant women is a "public health and policy imperative," study author says OUD For mothers with opioid use disorder (OUD), the use of medication for their addiction such as buprenorphine or methadone during the prenatal period was associated with improved outcomes in infants, a cross-sectional study showed. Using data from a multistate Medicaid database on over 10,000 mother-infant dyads, prenatal use of medications for OUD was found to be associated with 20% higher odds of infants receiving six well-child visits (adjusted OR 1.20, 95% CI 1.11-1.31) and 20% lower odds of readmissions (aOR 0.80, 95% CI 0.70-0.91) during the first year of life, reported Mir M. Ali, PhD, of the Office of the Assistant Secretary for Planning and Evaluation at HHS, and co-authors. Prenatal medications for OUD use was inversely associated with any emergency department (ED) visits, but this result was not significant, they added. These findings were "consistent with the hypothesis that when pregnant individuals are engaged in OUD treatment, their infants are also likely to receive the appropriate levels of care," the authors wrote in a research letter published in JAMA Pediatricsopens in a new tab or window. "Additionally, we found that prenatal MOUD [medication for OUD] use was associated with lower odds of hospital readmissions after birth, a costly and potentially avoidable health service use that is common among infants with neonatal abstinence syndrome and signifies exacerbation of symptoms," they added, noting that "treatment during the prenatal period may have long-term implications for infant health by ameliorating the harm caused by untreated OUD." Co-author Stephen W. Patrick, MD, MPH, MSc, of the Vanderbilt Center for Child Health Policy and Vanderbilt University Medical Center in Nashville, Tennessee, told MedPage Today that this new research fills a gap in the existing literature. "We know that when pregnant people with opioid use disorder are treated with medications for opioid use disorder they are more likely to carry the pregnancy to term and their infants are less likely to be born low birth weight. However, we know little about the effect of maternal treatment on long-term outcomes," Patrick said. "As a practicing neonatologist, I care for opioid-exposed infants regularly and our research team conducts research which aims to understand how we can improve outcomes for both mothers and infants affected by the opioid crisis," he continued. "We have known for years that medications for opioid use disorder, like buprenorphine and methadone, decrease risk of overdose death and improve pregnancy outcomes. This study finds an important spillover effect with improvement in outcomes during the first year of life for infants of mothers treated with medications for opioid use disorder." Patrick also highlighted that access to medications for OUD for pregnant women is a "public health and policy imperative." "There are far too many barriers to treatment for pregnant women, which may be why we are seeing record levels of overdose deaths among pregnant women," he added. "There is an urgent need to expand access to improve outcomes for mothers and infants." Patrick said that he and his team are hoping to do future research that will help "better understand how interventions during pregnancy among individuals with opioid use disorder may improve outcomes beyond the neonatal period." For this study, Ali and colleagues analyzed data from 2012 to 2019 from the Merative MarketScan multistate Medicaid database, which captures data on 6 to 10 states per year. They included 10,352 mother-infant dyads (51.8% boys). More than half of mothers (55.3%) didn't receive MOUD at all. The mothers in the cohort had OUD and 9 months of continuous enrollment before giving birth, with 1 year of continuous enrollment after birth. About 40% were ages 25-29 at birth, and 25.6% were 30-34. Most of the women were white (83.3%), and 9.2% were Black. Ali and colleagues noted a few limitations to their study, including its observational nature, which cannot account for unobserved confounders, such as the mothers' access to transportation, social supports, or general home life stability. Additionally, since the analyzed Medicaid-covered mother-infant dyads were from only a few states, the same results might not apply to a national sample.

"The history of psychiatry is a history of fads in theory, diagnosis, and treatment. Such rapid shifts in conceptualization—such as the emergence of the concept of adult ADHD—almost always warrant informed critical examination." COMMENTARY As recently as 2 decades ago, the consensus view in American academic psychiatry was that attention-deficit/hyperactivity disorder (ADHD) rarely, if ever, persists into adulthood.1,2 For decades, ADHD was considered a disorder of childhood; adult cases were seen uncommonly and the diagnosis was rarely made. DSM-IV-TR, published in 2000, describes a condition existing in children and makes only scant reference to adults.3 Fast-forward to 2023, and adult ADHD is the diagnosis du jour; rates of diagnosis are skyrocketing at an alarming rate as are prescriptions for psychostimulants, the drugs that purportedly treat the condition. The history of psychiatry is a history of fads in theory, diagnosis, and treatment. Such rapid shifts in conceptualization—such as the emergence of the concept of adult ADHD—almost always warrant informed critical examination. In the case of a novel psychiatric disorder, it is either true that (1) psychopathologists and psychiatric nosologists have missed the disorder for more than a century, or (2) that the disorder is a case of disease mongering, when a condition that has never been observed is suddenly made popular overnight as a result of social, cultural, and economic reasons. We argue that the latter is true for adult ADHD. How did adult ADHD get its wheels? The rise in diagnosis of adult ADHD fully coincides with marketing by the pharmaceutical industry when Eli Lilly and Company got the first US Food and Drug Administration indication for this label with atomoxetine (Strattera) in 1996. Since that date, many academics have been promoting the concept of adult ADHD. The adult ADHD market has become a multibillion-dollar industry, with the rise of digital companies specializing in online diagnosis and treatment—some of which have come under legal scrutiny. Does ADHD Persist Into Adulthood? Findings from commonly cited retrospective studies suggest that approximately 50% to 60% of childhood ADHD persists into adulthood. These studies look backwards to attempt to determine which childhood cases continue into adulthood. However, these data are disproven by prospective studies, which repeatedly show that about 80% of children with ADHD do not continue to have that diagnosable condition, followed prospectively either into young adulthood or even for 33 years into their fourth decade of life (Figure).4,5 A total of 20% of cases persist, whereas 80% do not. In other words, most children with ADHD do not continue to meet the criteria for the diagnosis into adulthood. Construct Validity and Diagnostic Hierarchy When we argue that adult ADHD is not a scientifically valid diagnosis, we do not mean, of course, that the symptoms so attributed do not exist. Clearly, adult human beings can exhibit problems with attention, concentration, focus, memory, and related abilities. What we mean is that these symptoms have not been shown to be the result of a scientifically valid disease (adult ADHD) and are better explained by more classic and scientifically validated psychiatric conditions, namely diseases or abnormalities of mood, anxiety, and mood temperament. A major problem with the DSM system as currently constituted is that it fails to take into account the concept of diagnostic hierarchy, a fundamental diagnostic principle used across medicine. In sum, diagnostic hierarchy refers to the idea that not all diagnoses are created equal—that some are more important or more primary than others. Failure to adhere to the concept of diagnostic hierarchy has resulted in epidemics of polydiagnosis (assigning multiple diagnoses to the same patient) and polypharmacy (the use of multiple psychiatric medications, often across classes). What Causes the Symptoms Attributed to Adult ADHD? Plenty of other psychiatric disorders exist that can cause ADHD-like symptoms, and in current practice, individuals with these symptoms receive misdiagnoses of adult ADHD. For example, 84% of patients with symptoms meeting criteria for adult ADHD also have symptoms that meet criteria for mood illnesses.6 Using the concept of diagnostic hierarchy, poor attention is a symptom of depression, mania, and anxiety; thus, the occurrence of inattention while a patient has mood symptoms does not mean the patient has both an attention disorder and a mood disorder. This would be like saying every person with pneumonia also has a fever disorder. It is common to find that someone who thinks they have adult ADHD has another illness, such as a mood or anxiety condition, that causes the symptom of inattention. Another underappreciated consideration is the concept of mood temperament. Unlike the symptoms of major mood disorders, mood temperaments do not come and go; they are present all the time as part of one’s personality. Conditions such as cyclothymia, hyperthymia, and dysthymia involve constant presence of mild manic and/or depressive symptoms. Since these manic and/or depressive symptoms are present all the time, they can produce inattention, poor concentration, and poor executive function all the time. One of us (NG) recently published with colleagues the first study on the topic of misdiagnosis of mood temperament on ADHD.7 We found that 62% of patients who received a diagnosis of adult ADHD actually have an affective temperament, most commonly cyclothymia (42%). In patients treated with amphetamine, mood symptoms predictably worsened. Why Do the Drugs Work? A common claim is that since psychostimulants improve the cognition of individuals diagnosed with adult ADHD, then they must be treating an underlying disorder. But this is faulty logic. Psychostimulants improve cognition for everyone, including normal patients without psychiatric illness. It is because they have this general effect that they are so widely abused; it says nothing about the existence of adult ADHD. Concluding Thoughts The history of psychiatry teaches us that the field has been vulnerable to a host of diagnostic fads. Adult ADHD is the latest of such fads, and a careful review of the scientific literature reveals that the range of ADHD-like symptoms in adults is more accurately explained by other empirically validated psychiatric disorders. This has significant ramifications for therapy, given the wide use of psychostimulants in the treatment of these patients. The opinions expressed are those of the authors and do not necessarily reflect the opinions of Psychiatric Times. Dr Ruffalo is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. Dr Ghaemi is director of the Psychopharmacology Consultation Clinic at Tufts Medical Center and a professor of psychiatry at Tufts University School of Medicine. Related Articles Attention Deficit Hyperactivity Disorder (ADHD) Nonstimulants: A Better Option for ADHD? Paying Attention to ADHD Prescriptions in Your Community Amid Shortages, Federal Agencies Ask Drugmakers to Boost Output of ADHD Meds FDA OKs ADHD Generics; Flotation Therapy; Civilians Respond to Distress Calls ADHD Underappreciated in Older Adults

Young People Adolescence is supposed to be a time of carefree exploration of the world around us. In a perfect reality, teenagers should be worried about extracurriculars and college applications. Unfortunately, the environment our teenagers have inherited is plagued by constant technological distractions and premature exposure to mature subject matter. With relentless divisions and suffering seemingly unavoidable, it's no wonder many teens are experiencing significant mental health challenges and, subsequently, substance abuse as a means of self-medication. In fact, more than 1.5 million youth in the U.S. reported a substance use disorder just in the past year. My Story We could mull over my adverse childhood experiences and how, like many other young people, they contributed to my developing substance use disorder. But I’m more concerned with what I didn’t experience and how that shaped who I am today. I ended up abusing prescription drugs and being admitted to a residential drug abuse treatment center at 17 years old. After 11 months of isolation from reality, I returned to a world that no longer made sense. I didn't feel like a teenager anymore and had virtually nothing in common with the strangers I’d once called friends. While my classmates were shopping for prom dresses and filling out college applications, I was sitting in church basements with people twice my age discussing our ideas of a higher power and how we managed to avoid getting high that day. Despite feeling like an alien, I maintained my sobriety with the help of a strong recovery community in my area. But that is not always the case for many young people with mental health challenges. When resources that foster peer-to-peer connections are scarce and not easily accessible, young people must try to fit into a system that caters to only young children or adults. Programs focusing on youth navigating this critical time of self-discovery and coming of age are few and far between. My Work My lived experience has benefitted my current work of researching these rare programs and identifying models that are effective for young people experiencing mental health challenges. Although peer support is not a new concept in adult mental health treatment, the idea and use of youth peer support is a foreign concept across the board. Many of the youth programs that exist today tend to be restrictive or operate with antiquated models that result in a more clinical atmosphere. This often leads to young people feeling confined by or unable to relate to a program structure that simply was not made for them. We must highlight youth-led organizations that elevate youth voices and put peer-to-peer connections at center stage. Programs that use formal and informal peer services will ensure our young people are adequately prepared to succeed and offer respite for this population underrepresented in mental health services. Throughout my recovery, having few opportunities to interact with other young people caused me to face numerous “either/or” situations: I could focus on fostering relationships with the older, more experienced people in recovery, or I could choose to interact with people my age who were navigating the typical stages of adolescence without the experience of substance use or other mental health challenges. There were no established spaces that allowed those realms to intersect for young people. For instance, the premise of planning for my future was often contradicted by the recovery mantra of living “just for today” and left me overwhelmed and ill-prepared. When my classmates were discussing their ideas to change the world and make a difference, I felt constrained by my identity as a recovering addict because I rarely saw other people like me who were successfully navigating these spaces. It would be years before I learned that my experiences with mental health gave me a unique perspective and skill set to inspire hope and effect change. The following present-day youth-focused programs could have positively impacted my recovery journey. 1. Hope Academy High School High school can be a nightmarish experience for teens regardless of mental health challenges. Facilities dedicated to the academic and recovery needs of a student with substance use disorder almost seem like a fairytale for 17-year-old me. Returning to an environment full of people who understand the gravity of substance abuse and how it encompasses nearly every aspect of a person’s life can be extremely helpful. Institutions like Hope Academy High School in Indianapolis, Indiana, provide a standard curriculum under the umbrella of substance use recovery with a significant emphasis on peer support. This model ensures students receive a proper education and the necessary life skills for a young person navigating recovery. Hope Academy offers family therapy, after-school events, and hangouts that allow students to maintain an atmosphere of recovery outside their typical eight-hour school day. Attending a school like this might have lessened my feelings of shame and isolation by being close to peers already adjusting to our new way of life. 2. My Future Is EPIC My Future is EPIC follows a strengths-based, peer-led model focusing on goal-setting, life-planning, and self-advocacy for teens with substance use disorder. By emphasizing life planning, the program can address an area of concern for many teens, with and without substance use disorder, by identifying plausible, attainable goals and steps to achieve them. This component is crucial for young people who often struggle with conceptualizing their futures — especially since this is typically a pivotal stage for life planning and figuring out their identity. Education, employment, and healthy relationships are just a few areas addressed in this program’s model to help teens map out their future with the greatest chance for success. In addition to youth being program facilitators, My Future is EPIC relies heavily on youth peer-to-peer group sessions, allowing teens to connect with others on similar paths and see that these seemingly impossible life plans are achievable. 3. Lead A Change Project Another game-changing program that recognizes the unparalleled value of peer support is the Lead A Change Project, created by the Building Audacity organization. This project teaches young people ages 11–25 the basics of community organizing and implementation. Participants learn from their peers the vital processes of community building and program development, how to effectively communicate with local leaders, and get the chance to effect change in their communities. Building Audacity understands that involving youth voices in youth program development is crucial for them to be effective. By allowing youth to play pivotal roles in their future, programs like this are fostering a generation of people who can recognize a problem and bring about actual solutions for the betterment of themselves and their peers. Despite not having access to programs like these, I found a way to forge my path in the world of youth in recovery through advocacy and public speaking. But my journey might have been easier with access to peer programs. What began as a simple attempt at showing the world that young people also struggle blossomed into developing a platform that has allowed me to share my experience with others struggling with isolation, stigma, and feeling disadvantaged. I am encouraged by these programs that incorporate youth voices when seeking solutions to a system filled with gaps and disparity. By elevating the youth perspective and promoting formal and informal youth peer services, we can improve youth mental health care and implement preventive measures earlier in life.

Key Points Question: Which categories and trajectories of psychopathological and behavioral symptoms are associated with suicidal thoughts in adolescence after accounting for comorbid symptoms? Findings: In this cohort study of 2780 adolescents, the clustering pattern of trajectories varied depending on the categories of psychopathological and behavioral symptoms. After adjusting for each symptom trajectory and confounders, adolescents with persistent withdrawn symptoms and those with increasing somatic symptoms had a significantly higher risk of suicidal thoughts than adolescents without these symptoms. Meaning: These findings suggest that to prevent adolescent suicide, it is important to pay attention to the risk of social withdrawal and somatic symptoms, particularly when these symptoms persist or increase in longitudinal follow-up. Abstract Importance: The suicidal risk of psychopathology in adolescence is suggested to differ based on its longitudinal trajectory, but the comorbidity of these symptom trajectories has not been well examined. This study comprehensively clustered trajectories of multiple psychopathological and behavioral symptoms and examined their associations with suicidal thoughts in adolescence. Objective: To determine which categories and trajectories of psychopathological and behavioral symptoms are associated with suicidal thoughts in adolescence, accounting for comorbid symptoms. Design, Setting, and Participants: This population-based cohort study in Japan used data from the Tokyo Teen Cohort (TTC) study, which was established in 2012 and is currently ongoing. Data from 3 waves of surveys conducted at ages 10, 12, and 16 years from October 2012 to September 2021 were used. Of the adolescents in the cohort, participants with at least 2 evaluations of psychopathological and behavioral symptoms were included. Data were analyzed from December 2022 to March 2023. Exposure: Latent class growth analysis was used to cluster the trajectory of each psychopathological and behavioral symptom. Main Outcomes and Measures: The associations between symptom trajectories and suicidal thoughts at age 16 were examined. Suicidal thoughts were assessed using a self-report questionnaire. Psychopathological and behavioral symptoms were assessed using the 8 subscale scores of the caregiver-report Child Behavior Checklist. Results: This study included 2780 adolescents (1306 female participants [47.0%]). Of the 1920 adolescents with data on suicidal thoughts, 158 (8.2%) had suicidal thoughts. The median (IQR) age was 10.2 (10.0-10.3) years at the first evaluation, 11.9 (11.8-12.1) years at the second evaluation, and 16.3 (16.1-16.5) years at the last evaluation. The clustering pattern of trajectories varied depending on symptom categories. After adjusting for each symptom trajectory and confounders, adolescents with persistent high withdrawn symptoms (odds ratio [OR], 1.88; 95% CI, 1.10-3.21) and those with increasing somatic symptoms (OR, 1.97; 95% CI, 1.16-3.34) had a significantly higher risk of suicidal thoughts than adolescents without these symptoms. There was no interaction between these symptom trajectories and the risk of suicidal thoughts. Conclusions and Relevance: This cohort study found that persistent withdrawn symptoms and increasing somatic symptoms during early to midadolescence were associated with an increased risk of suicidal thoughts in midadolescence, even after accounting for comorbid symptoms and confounders. Attention should be paid to the suicidal risk associated with these symptoms, particularly when they persist or increase in the longitudinal follow-up. Introduction The importance of adolescent mental health has been increasingly recognized, and the World Health Organization has recommended mental health promotive and preventive interventions for all adolescents. However, about 10% to 20% of adolescents experience suicidal thoughts, and adolescent suicidal thoughts predict suicide attempts. Suicide remains one of the leading causes of death among adolescents worldwide, highlighting the need for further prevention. Psychopathology is a major risk factor for adolescent suicide, and many psychiatric disorders emerge during adolescence. Psychological autopsies, retrospective psychiatric evaluations of individuals who died by suicide, have shown that mood disorder (51%-76%) and substance use disorder (26%-62%) are 2 common diagnoses. Recent cohort studies have suggested that the risk of suicidal behaviors in adolescents with psychopathological and behavioral symptoms depends on the longitudinal trajectories of these symptoms. For example, depressive symptoms that persist from adolescence into adulthood, rather than being limited to adolescence, are associated with a higher risk of self-harm with suicidal thoughts in adulthood. It has also been proposed that boys with hyperactivity or inattention symptoms that persist moderately or highly from childhood to adolescence are at a greater risk of suicidal thoughts and attempts during adolescence than those with fewer symptoms trajectory. However, these previous studies have only examined the association of suicidal behaviors with a single category of symptoms. Most adolescent psychopathological and behavioral symptoms are developmentally fluid and nonspecific to any psychiatric diagnosis. As a result, comorbidity is common and 20% to 50% of adolescents with psychiatric symptoms have more than 1 category of symptoms. Despite this, no studies that we know of have investigated the association of suicidal behaviors with trajectories of multiple psychopathological and behavioral symptoms. Therefore, it remains unknown which categories and trajectories of symptoms are associated with a higher risk of suicidal behaviors when dealing with comorbid symptoms. This study aims to comprehensively examine the trajectories of multiple psychopathological and behavioral symptoms and clarify which symptom trajectories are associated with suicidal thoughts. Methods Sample We used data from the Tokyo Teen Cohort (TTC) study.22 TTC is a prospective birth cohort study of the general population that aims to examine mental and physical development during adolescence. Participants in the study were children born between September 2002 and August 2004 in 3 municipalities in Tokyo, Japan (Setagaya-ku, Mitaka-shi, and Chofu-shi). In the baseline survey, participants were randomly selected from the 18 830 eligible children using resident registers, as described elsewhere.22 See eMethods 1 in Supplement 1 for the flowchart of participant selection. A total of 3171 adolescents at age 10 years, 3007 at age 12 years (follow-up rate, 94.8%), and 2616 at age 16 years (follow-up rate, 82.5%) participated in the study. This study used data from 3 waves of data collection at ages 10, 12, and 16 years conducted from October 2012 to September 2021. Trained examiners visited participants’ homes at each time point and administered self-report questionnaires to the child and caregiver. At the first visit, written informed consent was obtained from the parents. Participants with available Child Behavior Checklist (CBCL) scores from at least 2 time points were included in this study. TTC is a joint study by the Tokyo Metropolitan Institute of Medical Science, the University of Tokyo, and the Graduate University for Advanced Studies, and was approved by the ethics committees at each institution. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Suicidal Thoughts Participants were asked in the self-report questionnaire, “Do you currently think that you should not be alive?” when they were age 16. This question was adapted to capture passive suicidal thoughts that emerge in the early stages of the suicide spectrum.23,24 The answer choices were: no, somewhat no, somewhat yes, and yes. We dichotomized the participants into those without suicidal thoughts (answered no and somewhat no) and those with suicidal thoughts (answered yes and somewhat yes). Psychopathological and Behavioral Symptoms Psychopathological and behavioral symptoms were measured using the Japanese version of the CBCL 4 to 1825 at 3 time points when participants were aged 10, 12, and 16 years. CBCL is an internationally used clinical and research instrument for comprehensively assessing children’s problems, which has also been validated in Japanese.26 The primary caregivers answered each item on a scale of 0 (not true), 1 (somewhat or sometimes true), or 2 (very true or often true). This study used the following 8 subscale scores: withdrawn (score range 0-18), somatic complaints (0-18), anxious depressed (0-28), social problems (0-16), thought problems (0-14), attention problems (0-22), delinquent behavior (0-26), and aggressive behavior (0-40). See eMethods 2 in Supplement 1 for the items included in each subscale. Confounders Confounder selection was based on a disjunctive cause criterion, in which a variable that is the cause of either exposure or outcome is treated as a confounder.27 Based on previous studies on risk factors of psychopathology and suicidal thoughts,7,9,10,28,29 the following variables were treated as confounders: sex, annual household income, separation from primary caregiver, bereavement from family members, mental health problems of mother or father, alcohol consumption of mother or father, being bullied, and lifetime experience of suicidal thoughts. Lifetime experience of suicidal thoughts was assessed at age 12 years, and the other variables were assessed at age 10 years. See eMethods 3 in Supplement 1 for the details on the measures. Statistical Analysis Latent Class Growth Analysis To cluster psychopathological and behavioral symptom trajectories, we used latent class growth analysis (LCGA) on the 8 subscale scores of the CBCL, using Mplus version 8.8 (Muthén and Muthén).30 The scores were standardized and missing values were handled using the full information maximum likelihood method under the assumption of missing at random (eTable 1 in Supplement 1). Our model assumed linear change between time points, with constant residual variance over classes and time. More complex models did not converge. Models were created by optimization with the expectation maximization algorithm with 1000 random starting values. We increased the number of classes up to 6. Maximum likelihood with robust standard errors was used as the estimator. Model selection was primarily based on the Lo-Mendell-Rubin test (significance level set at 2-sided P < .05), which determines if the k-class model is superior to the k-1 class model. Akaike information criterion, bayesian information criterion (BIC), sample size adjusted BIC, entropy, size of the smallest class, and average posterior probability of assignment were also considered. To make interpretation easier, trajectory patterns were given names. We followed the Guidelines for Reporting on Latent Trajectory Studies (eAppendix 1 in Supplement 1). Logistic Regression Analysis To examine the association between symptom trajectories clustered by LCGA and suicidal thoughts, we performed logistic regression analysis on participants who had available data on suicidal thoughts. We fitted 4 models. Model 1 was a univariable logistic regression analysis examining the association of each symptom trajectory with suicidal thoughts. Model 2 was a multivariable logistic regression analysis including only symptoms that were statistically significant in Model 1. Model 3 added confounders to model 2. Model 4 was a multivariable logistic regression analysis including symptoms that were statistically significant in model 3, their interaction term, and confounders. Although we did not set any hypotheses in advance, we examined interaction to clarify if each symptom trajectory that was significant in model 3 was independently associated with suicidal thoughts. For the logistic regression analyses, we treated the trajectory subgroup with the largest proportion of each symptom as the reference. Missing values were handled using multiple imputation methods with the mice package.31 The imputation procedure included explanatory variables, outcome variables, and covariates. We created 100 data sets and combined them according to Rubin rules. The above analyses were performed using R version 4.2.1 (R Project for Statistical Computing). The significance level was set at P < .05. To confirm the validity of the outcome dichotomization, we performed a sensitivity analysis where only participants who answered yes were considered to have suicidal thoughts. Additionally, we examined the cross-sectional association between symptoms and suicidal thoughts by using standardized CBCL subscale scores at age 16 years instead of symptom trajectories in the logistic regression analysis. Data were analyzed from December 2022 to March 2023. Results A total of 2780 adolescents (1306 female participants [47.0%]) were included in this study. Of the 1920 adolescents with data on suicidal thoughts, 158 (8.2%) had suicidal thoughts. The median (IQR) age was 10.2 (10.0-10.3) years at the first evaluation, 11.9 (11.8-12.1) years at the second evaluation, and 16.3 (16.1-16.5) years at the last evaluation. The annual household income of the participants was ¥0 to ¥2.99 million for 4.4% (117 of 2677), ¥3 to ¥5.99 million for 24.6% (660 of 2677), ¥6 to ¥9.99 million for 40.5% (1085 of 2677), and more than ¥10 million for 30.4% (815 of 2677). A total of 35% (970 of 2771) of adolescents had experienced bereavement from family members. Mental health problems were reported for 4.8% (123 of 2561) of mothers and 3.5% (91 of 2573) of fathers. There were no significant differences in demographic characteristics and mean score of psychopathological and behavioral symptoms between the included and excluded adolescents (eTable 2 in Supplement 1). See eFigure 1 in Supplement 1 for the correlation between CBCL subscale scores. The CBCL subscale scores had missing values ranging from 6 to 38 (0.2%-1.4%) at age 10 years, 123-144 (4.4%-5.2%) at age 12 years, and 548-567 (19.7%-20.4%) at age 16 years. The rate of missing data on suicidal thoughts was 30.9% (860 of 2780). (Table 1) The symptom trajectories of the 8 CBCL subscale scores were clustered using LCGA (Figure). See eTable 3 in Supplement 1 for fit statistics and the estimated means of the models and the observed individual trajectories (eFigure 2 in Supplement 1). In the logistic regression analysis, we included data from 1920 participants whose data on suicidal thoughts were available. Among the symptom trajectories, thought problems with the 1-class solution were not included in the models. The low subgroup was used as a reference for all symptoms. In model 1, all symptoms except delinquent behavior were significantly associated with suicidal thoughts. In model 2, persistent high withdrawn (odds ratio [OR], 1.75; 95% CI, 1.05-2.90) and increasing somatic complaints (OR, 2.24; 95% CI, 1.37-3.36) were significantly associated with suicidal thoughts after adjusting for other symptom trajectories. In model 3, persistent high withdrawn (OR, 1.88; 95% CI, 1.10-3.21) and increasing somatic complaints (OR, 1.97, 95% CI, 1.16-3.34) remained significantly associated with suicidal thoughts after adjusting for other symptom trajectories and confounders. The prevalence of suicidal thoughts in adolescents with persistent high withdrawn was more than twice as high as those with low withdrawn (46 of 281 [16.4%] vs 112 of 1630 [6.9%], respectively). The prevalence of suicidal thoughts in adolescents with increasing somatic complaints was approximately 3 times as high as those with low somatic complaints (35 of 169 [20.7%] vs 123 of 1751 [7.0%], respectively) (eTable 4 in Supplement 1). In model 4, the interaction between persistent high withdrawn and increasing somatic complaints was not significant, while the association between these symptom trajectories and suicidal thoughts remained significant (Table 2). The variance inflation factors of the variables used in the models were all less than 2.0 (eTable 5 in Supplement 1), suggesting that multicollinearity was minimal. The results of the likelihood ratio test examining the overall effect of each symptom trajectory group are shown in eTable 6 in Supplement 1. In a sensitivity analysis of the outcome dichotomization, the results were similar to the main analyses (eAppendix 2 in Supplement 1). Additional analysis on the cross-sectional association between symptoms and suicidal thoughts at age 16 years revealed that, after adjusting for each symptom score and confounders, withdrawn (OR, 1.57; 95% CI, 1.28-1.92) and social problems (OR, 0.69; 95% CI, 0.51-0.93) had a significant cross-sectional association with suicidal thoughts, but not somatic complaints (OR, 1.10; 95% CI, 0.96-1.25) (eAppendix 3 in Supplement 1). Discussion This is the first study we know of to comprehensively cluster the longitudinal trajectory of adolescent psychopathological and behavioral symptoms and examine their associations with suicidal thoughts in midadolescence. The clustering patterns of trajectories varied depending on the symptom categories. Among these symptom trajectories, persistent high withdrawn symptoms and increasing somatic symptoms were associated with an increased risk of suicidal thoughts in midadolescence. There was no interaction effect between these 2 trajectories on the risk of suicidal thoughts. Persistent high withdrawn symptoms were shown to be associated with an elevated risk of suicidal thoughts in midadolescence, consistent with previous studies.32,33 Since the cross-sectional association between withdrawn symptoms and suicidal thoughts was also significant, caution is needed in interpreting the importance of the persistent trajectory itself. Although social withdrawal is complicated by many psychiatric disorders, including anxiety and phobic disorder and major depression,34 we found an independent association between withdrawn symptoms and suicidal thoughts. Social withdrawal is known to be associated with social isolation,35 and social isolation is associated with suicidal thoughts during adolescence.36,37 Therefore, the loss of protective social connections9,38 may explain the independent association between withdrawn symptoms and suicidal thoughts. Increasing somatic symptoms were also found to be independently associated with suicidal thoughts in midadolescence, consistent with a systematic review on pain in adolescence which showed a significant association between pain and suicidality even after adjusting for depression.39 A previous cohort study also showed that the number of somatic symptoms in midadolescence was associated with the risk of suicide-related behaviors in adulthood.40 The increasing trajectory of somatic symptoms should be important because the cross-sectional association with suicidal thoughts was not significant. About 4 absolute CBCL subscale scores increased between age 10 and 16 years (eTable 7 in Supplement 1). Somatic symptoms in this study were probably functional, as indicated by the annotation without known medical cause on the CBCL questionnaires. Headache, fatigue, and stomachache were the most frequent symptoms and often coexisted among participants in this study (eFigure 3 in Supplement 1), which is consistent with the previous study.41 While there are many factors contributing to functional somatic symptoms,42 one hypothesis is somatization, which refers to the physical manifestation of psychological distress, particularly prevalent in cultures that inhibit emotional expression.43 In addition, pain and suicidality have been suggested to share common psychological mechanisms such as future orientation, psychological flexibility, and mental imagery in adults.44 These psychological processes may contribute to the independent association between somatic symptoms and suicidal thoughts found in this study. We clustered the trajectory of anxious and depressive symptoms from early to midadolescence into 4 subgroups (high, increasing, decreasing, and low), which accords with previous studies.45-47 Only the trajectory of increasing anxious and depressive symptoms showed a higher risk of suicidal thoughts, which is also consistent with a previous study.15 However, the association between anxious depressive symptoms and suicidal thoughts became nonsignificant after adjusting for other symptoms and confounders. This result seems to be inconsistent with a previous cross-sectional study in which depression, among various risk factors including CBCL subscales, was found to predict suicidal thoughts and behaviors.48 The longitudinal nature of our study may partly explain this disparity, as we clustered anxious depressive symptoms into subgroups with different trajectories. Social problems unexpectedly were implied to have a protective effect against suicidal thoughts after adjusting for other symptoms and confounders in the cross-sectional analysis (eAppendix 3 in Supplement 1). One possible explanation is that approximately half of the items of the CBCL social problems were associated with childish social relationships (eg, prefers being with younger kids). These symptoms might reflect a certain social connection with others, which could be protective against social isolation, and consequently prevent suicidal thoughts. Attention problems and aggressive behaviors also showed an association with suicidal thoughts in the univariable logistic regression analysis, but this association became nonsignificant after adjusting for other symptoms and confounders. Given the comorbidity of these symptoms with other symptoms during adolescence,34,41,49,50 one interpretation of our result is that social withdrawal and somatic complaints are associated with relatively higher psychological distress than other symptoms. Another possibility is that adolescent psychological distress is more likely to be expressed somatically or behaviorally rather than emotionally, but further investigation is needed to confirm this. As a clinical implication, attention should be paid to withdrawn and somatic symptoms to prevent adolescent suicide. The coexistence of these symptoms increases the risk of suicidal thoughts additively, as their interaction term was not significant. Based on the hypothetical mechanisms by which social withdrawal and somatic symptoms independently associate with suicidal thoughts, social connections and psychological support may be important in the care of adolescents with these symptoms. This is valuable for a wide range of people involved in adolescent health, as social withdrawal and common somatic symptoms are often more noticeable than emotional symptoms such as depression. Although social withdrawal and somatic symptoms may not receive sufficient clinical attention,51,52 our findings showed their crucial role in suicide prevention, particularly when they persist or increase in the longitudinal follow-up. Strength and Limitations One strength of this study was its longitudinal and comprehensive data collection with a high follow-up rate. By following up with participants for over 6 years, we were able to reveal the multiple trajectories of adolescent psychopathological and behavioral symptoms. Additionally, we could confirm the external validity of clustering by comparing our results with previous studies on anxious and depressive symptoms. However, there were several limitations to our study. First, due to the limited time points of data collection, the LCGA only converged with a strong assumption, thus the applied model might be too simple. For example, we were unable to include thought problems in the logistic regression analysis due to the 1-class solution. Future studies with more time points could reveal more complex trajectories. Second, we did not evaluate some important variables such as genetics,53 adverse childhood experiences,54 and information about social gender.55 Furthermore, the confounders were evaluated at age 10 years, thus the time-varying effects of the confounders remained unclear. Additionally, baseline suicidal thoughts were assessed at age 12 years instead of age 10 years due to data availability. Third, we did not use a validated tool that captures the full range of suicidal thoughts and behaviors; instead we assessed passive suicidal thoughts using a single questionnaire to reduce the psychological burden of participants. Additionally, the psychopathological and behavioral symptoms were reported by caregivers rather than self-reported. However, this approach is somewhat justified because most adolescents with suicidal thoughts are reluctant to seek help. Conclusions In this cohort study, we found that persistent high withdrawn symptoms and increasing somatic symptoms during early to midadolescence were associated with an elevated risk of suicidal thoughts in midadolescence, even after accounting for comorbid psychopathological and behavioral symptoms and confounders. A wide range of people involved in adolescent health should pay attention to the suicidal risk associated with these symptoms and consider the possibility of providing psychosocial support, particularly when the symptoms persist or increase in the longitudinal follow-up. Note: This article originally appeared on JAMA Network Open

Mirtazapine, biperiden, and vitamin B6 have the greatest efficacy for antipsychotic-induced akathisia (AIA) treatment, according to a systematic review and network meta-analysis published in JAMA Network Open. Vitamin B6 demonstrated the best efficacy and tolerance profile. Antipsychotics are the first-line treatment for patients with schizophrenia spectrum and psychotic disorders. However, some patients taking antipsychotics will experience AIA, a disorder characterized by restlessness and continuous, excessive movement. Patients with AIA are often at increased risk for suicidality and treatment nonadherence. Currently, the primary recommendation for treating AIA is to modify the patient’s current antipsychotic regimen (ie, consider monotherapy, reduce dose, switch to a different antipsychotic), which is not always clinically feasible. Therefore, investigators conducted a systematic review and meta-analysis to determine the efficacy of various drugs for treating AIA. The investigators searched publication databases for randomized clinical trials (RCTs) that compared adjunctive drugs for AIA relative to placebo, had at least 10 patients, used a validated akathisia score, and had no additional drugs administered during the study period. The primary outcome measured was the reduction in akathisia score, with secondary outcomes including tolerance (number of adverse effects) and acceptability (number of dropouts due to tolerance issues). The investigators included 15 double-blind RCTs for a pooled sample size of 492 patients. The RCTs consisted of 10 parallel group trials (66.7%), 323 crossover trials (20.0%), and 3 multi-arm studies (20.0%). Across studies, the medications that were analyzed included propranolol, mirtazapine, mianserin, vitamin B6, biperiden, cyproheptadine, clonazepam, and zolmitriptan. The investigators observed that multiple medications outperformed placebo for the treatment of AIA. These medications include: Mirtazapine (standardized mean difference [SMD], −1.20; 95% CI, −1.83 to −0.58) Biperiden (SMD, −1.01; 95% CI, −1.69 to −0.34) Vitamin B6 (SMD, −0.92; 95% CI, −1.57 to −0.26) Trazodone, (SMD, −0.84; 95% CI, −1.54 to −0.14) Mianserin (SMD, −0.81; 95% CI, −1.44 to −0.19) Propranolol (SMD, −0.78; 95% CI, −1.35 to −0.22) Conversely, cyproheptadine, clonazepam, zolmitriptan, and valproate had similar efficacy to placebo. For acceptability and tolerability, some patients reported transient sedation with mianserin, drowsiness and dizziness with trazodone and mirtazapine, hypersalivation and depression with valproate, dry mouth and sedation with biperiden and valproate, and hypotension with propranolol. Additionally, although mirtazapine, biperiden, and vitamin B6 exhibited moderate to large effect sizes with comparable efficacy, mirtazapine may be poorly tolerated due to its sedative effects and potential for weight gain. This study represents the first network meta-analysis that examines the efficacy associated with adjunctive drugs for the treatment of AIA. The investigators concluded, “Vitamin B6 may have the most favorable efficacy and tolerability profile, followed by mirtazapine and biperiden, for the treatment of antipsychotic-induced akathisia.” These findings may be limited by the low statistical power in the subgroup analysis, potential underestimation of the efficacy of propranolol, and variability in the inclusion of benzodiazepines and anticholinergics across studies. Note: This article originally appeared on Psychiatry Advisor

Vortioxetine significantly improved depressive symptoms, cognitive performance, daily and global functioning, and quality of life at 12 weeks in patients with depression and early dementia. A 12-week course of vortioxetine can improve cognition, overall functioning, and quality of life in older patients with major depressive disorder (MDD) and comorbid early-stage dementia, according to study findings published in the Journal of Affective Disorders. Depression and dementia are common in older adults and can often present as comorbid conditions. Vortioxetine is an antidepressant that has shown to improve cognitive performance and quality of life in patients with MDD. Researchers conducted MEMORY (ClinicalTrials.gov Identifier: NCT04294654), a multicenter, open-label effectiveness Phase IV study, to assess the effectiveness of vortioxetine in improving mood and cognition in patients with MDD and early-stage dementia. The study included 16 psychiatric sites from 5 countries: Estonia, France, Italy, Poland and Spain. Data was collected from February 2020 through July 2022. It is likely that the procognitive effects of vortioxetine will be most marked in patients with dementia when used early in the course of the disease … The stages of this study were a 2-week screening period, a 12-week open-label flexible dose treatment period, and a 4 week-safety follow up period or study withdrawal. The researchers included patients aged 55 to 85 with a recurrent MDD diagnosis and documented early-stage dementia diagnosed at least 6 months before screening and after the onset of MDD. The researchers also required patients to have an MDD onset before the age of 55 and the patients included had to be experiencing a current depressive episode less than 6 months in duration. Patients taking other antidepressant medications other than vortioxetine were excluded from the study. Other patients excluded from treatment were those with a vitamin B12 or folate deficiency, those who had a significant suicide risk, and those who had a different psychiatric disorder aside from dementia. The primary endpoint was a change in Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to week 12. A total of 82 patients aged 55 to 85 (mean age, 70.3) were included in the study. Over half of participants were women (66%) and most patients were White (95%). The average duration of the current depressive episode was 12.5 weeks. There was a significant improvement in the MADRS total score observed for patients at all study periods (P <.0001). The least-squares average change in MADRS score from baseline was -12.4 (standard error [SE], 0.78) at week 12. Cognitive performance was improved among patients as shown by the DSST total score change from baseline (4.9; SE, 0.9; P <.0001). There were also significant improvements in daily function, which was assessed by the IADL polytomous score at week 12 (-0.86; P =.009). The researchers observed significant improvements in health-related quality of life (HRQoL) from baseline to week 12, with a least-squares mean percentage BASQID total score of 10.2 (SE, 1.25). Overall disease severity and impact on global functioning showed improvements at week 4 and 12 (P <.0001 for both). “It is likely that the procognitive effects of vortioxetine will be most marked in patients with dementia when used early in the course of the disease, before significant irreversible damage to signal firing capacity and neurotransmitter function has occurred,” the researchers wrote. Study limitations included the lack of a control population and its open-label design. Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. References:Christensen MC, Schmidt SN, Grande I. Effectiveness of vortioxetine in patients with major depressive disorder and early-stage dementia: the MEMORY study. J Affect Disord. Published online June 12, 2023. doi:10.1016/j.jad.2023.06.024 Source: Neurocognitive Disorders; Allison Nguyen July 18, 2023

Trial results underscore the importance of early diagnosis and treatment in patients with Alzheimer's disease. An experimental drug for the treatment of Alzheimer disease slows the progression of the disease in patients with mild impairment by 60%, according to new trial data. In the trial, which involved more than 1700 patients, the drug, donanemab, slowed the progression of problems with thinking and memory by around a third. However, the rate rose to 60% when the drug was started in patients who were only mildly impaired. The results were less robust in patients who were older and in the later stages of Alzheimer disease. This shows that “earlier detection and diagnosis can really change the trajectory of this disease,” according to Anne White, president of neuroscience at Eli Lilly and Company, developer of donanemab.1 Like Leqembi (lecanemab)—which received traditional approval by the US Food & Drug Administration (FDA) for the treatment of Alzheimer disease on July 62—donanemab is an intravenous antibody that was designed to eliminate deposits of beta amyloid from the brain. Lilly has announced that it expects the FDA to decide whether to grant donanemab approval by the end of 2023.1 References 1. Beasley D. Lilly drug slows Alzheimer’s by 60% for mildly impaired patients in trial. Reuters. July 17, 2023. Accessed July 17, 2023. https://www.reuters.com/business/healthcare-pharmaceuticals/lilly-drug-slows-alzheimers-by-60-mildly-impaired-patients-alzheimers-group-says-2023-07-17/ 2. FDA converts novel Alzheimer’s disease treatment to traditional approval. US Food and Drug Administration. News release. July 6, 2023. Accessed July 17, 2023. https://www.fda.gov/news-events/press-announcements/fda-converts-novel-alzheimers-disease-treatment-traditional-approval New Directions for Alzheimer and Dementia Treatment Peter J. Whitehouse, MD, PhD Decades of efforts to find effective medical treatments for dementia and Alzheimers disease have largely failed. Would a public health approach be more effective? Medical approaches to treating dementia and Alzheimer disease have been mostly unsuccessful. In this Mental Health Minute, Peter J. Whitehouse, MD, PhD, recommends that clinicians go beyond biomedical approaches. Instead, he advocates a suite of public health approaches, based on the research in his latest book, American Dementia: Brain Health in an Unhealthy Society. Dr Whitehouse is professor of Neurology and Psychiatry at Case Western Reserve University, and professor of Medicine at the University of Toronto. Along with Daniel R. George, PhD, MSc, of American Dementia: Brain Health in an Unhealthy Society.

From TIME: “By the latest federal estimates, about one in eight U.S. adults now takes an antidepressant and one in five has recently received some kind of mental-health care, an increase of almost 15 million people in treatment since 2002. Even in the recent past—from 2019 to 2022—use of mental-health services jumped by almost 40% among millions of U.S. adults with commercial insurance, according to a recent study in JAMA Health Forum. But something isn’t adding up. Even as more people flock to therapy, U.S. mental health is getting worse by multiple metrics. Suicide rates have risen by about 30% since 2000. Almost a third of U.S. adults now report symptoms of either depression or anxiety, roughly three times as many as in 2019, and about one in 25 adults has a ‘serious mental illness’ like bipolar disorder or schizophrenia. As of late 2022, just 31% of U.S. adults considered their mental health ‘excellent,’ down from 43% two decades earlier. Dr. Robert Trestman, chair of the American Psychiatric Association’s (APA) Council on Healthcare Systems and Financing, says there are multiple factors at play, some positive and some negative. On the ‘positive’ side, more people are comfortable seeking care as mental health goes mainstream and becomes less-stigmatized, increasing the total number of people getting diagnosed with and treated for mental-health issues. Less positively, Trestman says, more people seem to be struggling in the wake of societal disruptions like the pandemic and the Great Recession, driving up demand on an already-taxed system such that some people can’t get the support they want or need. Some experts, however, believe the issue goes deeper than inadequate access, down to the very foundations of modern psychiatry. As they see it, the issue isn’t only that demand is outpacing supply; it’s that the supply was never very good to begin with, leaning on therapies and medications that only skim the surface of a vast ocean of need.” Full Article

TOPLINE: Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer's disease (AD) or AD-related dementias (ADRD), data from a large prospective study of US veterans show. METHODOLOGY: Investigators analyzed data from 35,200 US veterans aged ≥ 55 years diagnosed with major depressive disorder from January 1, 2000, to June 1, 2022, and followed them for ≤ 20 years to track subsequent AD/ADRD diagnoses. Health information was pulled from electronic health records of the Veterans Health Administration (VHA) Corporate Data Warehouse, and veterans had to be at the VHA for ≥ 1 year before diagnosis. Participants were considered to be exposed to an antidepressant when a prescription lasted ≥ 3 months. TAKEAWAY: A total of 32,500 individuals were diagnosed with MDD. The mean age was 65 years, and 91% were men. 17,000 patients received antidepressants for a median duration of 4 years. Median follow-up time was 3.2 years. There was no significant association between antidepressant exposure and the risk for AD/ADRD (events = 1056; hazard ratio, 0.93; 95% CI, 0.80-1.08) vs no exposure. In a subgroup analysis, investigators found no significant link between different classes of antidepressants and dementia risk. These included selective serotonin reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors. Investigators emphasized the need for further research, particularly in populations with a larger representation of female patients. IN PRACTICE: "A possibility for the conflicting results in retrospective studies is that the heightened risk identified in participants on antidepressants may be attributed to depression itself, rather than the result of a potential pharmacological action. So, this and other clinical confounding factors need to be taken into account," the investigators noted. SOURCE: The study was led by Jaime Ramos-Cejudo, PhD, VA Boston Healthcare System, Boston. It was published online May 8 in Alzheimer's & Dementia. LIMITATIONS: The cohort's relatively young age limited the number of dementia cases captured. Data from supplemental insurance, including Medicare, were not included, potentially limiting outcome capture. DISCLOSURES: The study was supported by the National Institutes of Health and the National Alzheimer's Coordinating Center. The authors declared no conflicts of interest. Note: This article originally appeared on Medscape

Keypoint: Adults who identify as LGBTQ+ report more ACEs and are more likely to report chronic pain than adults who do not identify as LGBTQ+. In adults who identify as lesbian, gay, bisexual, transgender, queer, etc. (LGBTQ+), high scores for adverse childhood experiences (ACEs) were associated with higher average pain scores in the last 6 months and higher ratings of perceived pain, according to study results published in Anesthesia and Analgesia. Childhood adversity is associated with chronic pain in adults. Adults who identify as LGBTQ+ report more ACEs and are more likely to report chronic pain than adults who do not identify as LGBTQ+. However, little is known about the link between chronic pain and childhood adversity in the LGTBQ+ community, despite their disproportionate burden of chronic disease. To address chronic pain effectively in those who identify as LGBTQ+, researchers sought to understand the link between childhood adversity and chronic pain, especially in the transgender and gender-diverse individuals. The researchers at the University of California conducted a cross-sectional study of adults aged 18 years or older, who identified as LGBTQ+, and reported chronic pain. To conduct the study, surveys were electronically distributed from August 2022 to November 2022 through the email listservs and social media platforms of LGBTQ+ organizations. Demographic information was collected from the surveys and the validated Chronic Pain Questionnaire as well as a validated instrument that measured childhood adversity via the ACE score was incorporated. The researchers considered ACE scores of 4 or more to be high. The researchers analyzed responses from 136 participants. The study group’s mean age was 29 ± 7.4 years, and the group’s mean pain rating in the last 6 months was 5.9 of 10. For 80% of participants, their worst pain was rated at least 7 of 10. Around half the group (47%), had high ACE scores, which were associated with greater 6-month average pain scores and higher ratings of perceived current pain. The mean 6-month pain score for the group was 6.27±1.79, and the mean difference was -2.22 (95% CI, -1.2 to 0.0; P =.028). Their rating of perceived current pain was 4.53±2.16, and the mean difference was -2.78 (95% CI, -1.9 to -0.3; P =.007). The study also found that the 75 transgender and gender diverse participants in the study had higher ACE scores than those who were cisgender. More specifically, the median absolute difference between gender identity groups in this measure was 1 (95% CI, 0.0-2.0; P =.004). In addition, the current pain scores of transgender and gender diverse adults were 3.9±1.8 compared with 3.0±1.9 for cisgender adults (95% CI, 0.0-0.3; P =.009). The researchers reported nearly 38% of study participants had a history of sexual trauma, which was associated with chronic pelvic pain (effect size estimate, 0.21; P =.016). Having a history of forced sexual touch or touch encounters was associated with having received a diagnosis of fibromyalgia. Additionally, for having a history of forced sexual touch, the effect size estimate for fibromyalgia was 0.31 (P =.008), and for having a history of touch encounters, the effect size estimate for fibromyalgia was 0.31 (P =.037). Study limitations include the study’s cross-sectional design, the limited diversity of the study participants and the lack of computer savvy participants. Study results cannot be generalized to other racial groups or to those who were not computer savvy. “Childhood adversity and chronic pain’s dose-dependent relationship among our LGBTQ+ sample indicates a need to explore trauma’s role in perceived pain,” the researchers concluded. “Given sexual trauma’s association with pain location and diagnosis, type of trauma may also be crucial in understanding chronic pain development,” they added, “[B]y understanding the link between childhood adversity and chronic pain, health care providers can ensure to especially screen vulnerable populations, such as LGBTQ+ patients, for ACEs.” Note: This article originally appeared on Clinical Pain Advisor