Keypoint: Dementia rates were lower than a comparison cohort of people with Parkinson disease. HealthDay News — Dementia rates are substantially higher among people with essential tremor than the general population, according to a study scheduled for presentation at the annual meeting of the American Academy of Neurology, to be held from April 13 to 18 in Denver. Elan Louis, M.D., from the University of Texas Southwestern Medical Center in Dallas, and colleagues examined the prevalence, incidence, and annual rates of mild cognitive impairment (MCI) and dementia among individuals with essential tremor. The analysis included 177 participants, with follow-up evaluations at 18, 36, 54, and 72 months (mean years of observation, 5.1). The researchers found that the cumulative prevalence of dementia and average annual conversion rate of MCI to dementia were 18.5 and 12.2 percent, respectively. These rates were nearly three times higher than in the general population and were approximately half the magnitude of a Parkinson disease comparison cohort. Similarly, the cumulative prevalence of MCI (26.6 percent) was almost double that seen in the general population, but less than that observed in patients with Parkinson disease. “While the majority of people with essential tremor will not develop dementia, our findings provide the basis for physicians to educate people with essential tremor and their families about the heightened risk, and any potential life changes likely to accompany this diagnosis,” Louis said in a statement. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Duration of depressive symptoms in preschool-aged children is positively correlated with daily impairment and distress. Study results published in The Journal of Child Psychology and Psychiatry found that among preschool-aged children, episodes of tantrums, sadness, tearfulness, and irritability needed to last an average total of more than 30 to 38 minutes per day to be considered psychometrically severe. Longer durations of these depressive behaviors were significantly correlated with increased daily impairment. Although depressive moods and behaviors (ie, sadness, irritability, and tearfulness) are developmentally normative for children, the length of time that children exhibit these behaviors may be a risk factor for depression and other clinically significant difficulties. However, it remains unclear what duration of time is considered “normative” for these episodes. To assess the daily duration of depressive mood behaviors, researchers recruited the parents and primary caregivers (N=900) of 3- to 5-year-old children at 2 sites in Maryland and California through flyer advertisements at local establishments and on social media. Participants completed a daily online diary for 14 days in which they described the duration of their child’s depressive moods and behaviors and how their mood affected the impairment and/or distress of the child and family. The diary items were adapted from the Early Childhood Inventory (ECI) and the impairment and distress items were adapted from the ECI and Preschool Age Psychiatric assessment (PAPA). On average, the children were 4.25 (SD, 0.79) years of age, attended 21.49 (SD, 16.88) hours of childcare per week, 48.0% were girls, and 62.8% were White. Most parents or guardians were married (87.8%), earned more than $100,000 annually (43.9%), and graduated college (78.3%). Although the original confirmatory factor analysis model did not fit the data, including the covariance between low energy or fatigue and change in activity level resulted in a well-fit model (c2, 77.23; P <.001). The researchers stratified the daily duration of behaviors and moods into 4 percentile categories: below the 50th percentile, between the 50th and 80th percentile, between the 81st and 95th percentile, and above the 95th percentile. The following cumulative durations of depressive behaviors/moods were considered psychometrically severe (either between the 81st and 95th percentile or above the 95th percentile): Tantrums: 30 minutes or greater Sadness: 32 minutes or greater Tearfulness: 35 minutes or greater Irritability: 38 minutes or greater Low interest or pleasure: 48 minutes or greater Low energy or fatigue: 59 minutes or greater Change in activity level: 101 minutes or greater The researchers observed significant correlations between depressive behavior duration and average daily impairment (r, 0.243; P <.001), all depressive behaviors and average daily impairment (r, 0.182; P <.001), and all depressive behaviors and overall distress for parent and child (r, 0.200; P <.001). A longer duration of depressive behaviors was also positively correlated with the child’s age (r, 0.122; P <.001) and negatively correlated with parental education (r, -0.181; P <.001), family income (r, -0.209; P <.001), and parental marital status (r, -0.172; P <.001). Parents of a Black (P =.038), multiracial (P <.001), or Hispanic (P =.009) child reported significantly longer duration of depressive behaviors than parents of a White child. Study authors concluded, “To our knowledge, this is the first study to delineate specific duration ranges for behaviors related to depression in preschool-aged children. These data can assist child practitioners in differentiating normative patterns from less normative mood problems to determine which children may be at risk.” Study limitations include the potential overlap between moods and behaviors, a lack of data on guilt, and possibly inaccurate estimates given the only once-daily behavior reporting. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Opioids during pregnancy increase the risk for spontaneous preterm birth. Prescription opioid exposure during pregnancy is positively associated with increased odds of spontaneous preterm birth in a dose-dependent manner. These findings, published in JAMA Network Open, emphasize the importance of prescribing the lowest necessary dose of opioids for pain management during pregnancy. For pregnant individuals, there are limited options beyond acetaminophen for managing moderate to severe pain during pregnancy due to the fetal risks associated with nonsteroidal anti-inflammatory drugs. Despite the high opioid prescription rates among pregnant individuals in the United States, the effect of short-term opioid exposure on perinatal outcomes remains inadequately characterized. To this aim, investigators conducted a retrospective, nested case-control study that examined pregnant patients enrolled in Tennessee Medicaid between 2007 and 2019. Eligible participants were comprised of pregnant individuals aged 15 to 44 years without a diagnosed opioid use disorder who gave birth to a single fetus at 24 weeks gestation or later. The primary exposure of interest was the total opioid morphine milligram equivalents (MMEs) filled within the 60 days preceding the delivery date. The investigators documented instances of spontaneous preterm birth and matched these cases with up to 10 controls by pregnancy commencement date, race, ethnicity, age at delivery within a 2-year range, and previous history of preterm birth. The investigators included 25,391 cases involving spontaneous preterm birth and 225,696 paired controls, for a pooled sample of 251,087 patients. On average, patients were 23 years of age and were mostly non-Hispanic White (cases, 58.1%; controls, 58.5%). Overall, 18,702 patients (7.4%) filled an opioid prescription in the 60 days before the index date. The investigators found that higher opioid MME doses were associated with increased odds of spontaneous preterm birth in a dose-dependent manner, as each doubling of MME was associated with a 4% increase in spontaneous preterm delivery risk (adjusted odds ratio [aOR], 1.04; 95% CI, 1.01-1.08). Elevated odds of preterm delivery began at 150 MME (aOR, 1.08; 95% CI, 1.03-1.14), and reached a 21% increased risk at 900 MME. The odds remained relatively consistent across different opioid types after accounting for confounding factors and opioid MME. These results indicate that even low doses of prescription opioids during pregnancy increase the risk for spontaneous preterm delivery. The investigators noted, “We also caution against the conclusion that lower doses especially those below 100 MME are safe; the confidence bands over the low dose range still include odds ratios that are consistent with meaningful harm.” In conclusion, study authors stated, “These findings support guidance to prescribe the lowest opioid dose necessary in pregnancy to manage pain.” Study limitations include potential residual confounding in the case-control design, reliance on opioid dispensing data, lack of nonprescription analgesics information, potential protopathic concerns, focus on births at 24 weeks or later, and representation from Medicaid-enrolled individuals limiting generalizability. Disclosures: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. Note: This article originally appeared on Psychiatry Advisor

Remote cognitive behavioral therapy (CBT) is just as effective as in-person CBT for a range of mental health and somatic disorders, a new review of more than 50 randomized clinical trials (RCTs) showed. The RCTs included more than 5000 patients receiving CBT for conditions such as mood, anxiety, and body dysmorphic disorders, as well as chronic pain, insomnia, and alcohol use disorder. "The World Health Organization has designated CBT as essential healthcare, but access remains an important barrier for many people in Canada. Our findings suggest that therapist-guided, remotely delivered CBT can be used to facilitate greater access to evidence-based care," lead investigator Jason Busse, PhD, McMaster University, Hamilton, Ontario, Canada, said in a press release. The findings were published online on March 18 in CMAJ. Access Problematic In Canada, CBT may be provided within existing government-funded healthcare services and by private providers such as registered psychotherapists, social worker, and psychologists who require out-of-pocket expenses. Access to evidence-based mental healthcare such as CBT can be challenging in a country as geographically large, and as sparsely populated, as Canada. To increase access, some of the provinces have funded internet-based CBT, but the efficacy of in-person vs remote CBT remains uncertain. The investigators searched the medical literature for RCTs that enrolled adult patients randomized to receive either therapist-guided remote or in-person CBT. The study included 52 RCTs with 5463 participants with a mean age of 43 years, and 3354 (61%) were female. A total of 17 studies focused on the treatment of anxiety and related disorders, 14 on depression and mood disorders, seven on insomnia, six on chronic pain or fatigue syndromes, five on body image or eating disorders, three on tinnitus, and one on alcohol use disorder. CBT was provided on an individual and group basis. Treatment duration ranged from 5 to 21 sessions, with the median follow-up of 180 days. Investigators found little to no difference in effectiveness between in-person and therapist-guided remote CBT on primary outcomes (standardized mean difference [SMD], −0.02; 95% CI, −0.11 to 0.07). Analysis using end scores also showed little to no difference in efficacy between in-person and remote CBT (SMD, −0.01; 95% CI, −0.11 to 0.08). Policy Implications The authors noted that remote CBT can potentially expand access to care as it is more convenient for patients and potentially more cost-effective. "Our finding that remote CBT is an effective alternative to in-person delivery has potential policy implications," they wrote. The researchers recommended Canadian provinces and territories increase funding to boost access to therapist-guided remote CBT, thereby expanding access to evidence-based care. Study limitations included the fact that most of the eligible RCTs reviewed in the analysis were conducted in high-income countries with middle-aged patients and followed them for a median 180 days, so generalizability of the findings to older patients living in lower-income patients or for longer follow-up periods was uncertain. The study was partially funded by the Canadian Institutes of Health Research. Disclosures were noted in the original article. This article originally appeared on Medscape

Keypoint: About 6% of individuals with a suicide attempt have never been diagnosed with a psychiatric disorder. Approximately 20% of adults with lifetime suicide attempts did not meet the criteria for a psychiatric disorder diagnosis before their first attempt, according to new research published in JAMA Psychiatry. Although suicidality is commonly associated with pre-existing psychiatric disorders or distress, not all individuals who die by suicide have an antecedent psychiatric disorder. The current study sought to explore lifetime suicide attempts among psychiatrically healthy individuals by investigating the prevalence of lifetime suicide attempts in healthy volunteers, examining the timing of such attempts relative to the onset of psychiatric conditions, and comparing rates across different demographics. Researchers leveraged data for this cross-sectional study from the National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III), which assessed diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and surveyed respondents on suicidal behavior. Among those reporting a lifetime suicide attempt, the researchers calculated attempt frequencies for both healthy volunteers and persons with lifetime psychiatric disorders. Of the 36,309 NESARC-III respondents, 66.8% (95% CI, 64.1%-69.4%) were women and 1948 (5.2%; 95% CI, 4.8%-5.6%) reported lifetime suicide attempts. For those with a history of suicide attempts, 128 (6.2%; 95% CI, 4.9%-7.4%) were healthy volunteers without a prior psychiatric diagnosis and 261 (13.4%; 95% CI, 11.6%-15.2%) made a first suicide attempt before the onset of a psychiatric disorder. As such, an estimated 19.6% of respondents reported a lifetime suicide attempt with no evidence of a psychiatric disorder prior to their attempt. While women were approximately twice as likely as men to report a lifetime suicide attempt (P <.001), the percentage of individuals with lifetime suicide attempts who were healthy volunteers or lacked a psychiatric disorder prior to attempts did not significantly vary by sex. However, women were significantly more likely than men to make a suicide attempt in the same year as the onset of a psychiatric disorder (P <.001), while men were more likely to experience an attempt following the onset of a psychiatric disorder (P <.001). These study findings indicate that an estimated 6.2% of individuals in the United States who attempted suicide were healthy volunteers, and this percentage increased to 19.6% when including those whose suicide attempts occurred before the onset of a psychiatric disorder diagnosis. Study authors concluded, “This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations.” Study limitations include the reliance on self-reported information and a lack of data on psychiatric diagnoses that were not assessed in the NESARC-III survey. Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of author disclosures. This article originally appeared on Psychiatry Advisor

Keypoint: A daily 60-mg dose of atogepant significantly reduced mean monthly migraine days in patients with episodic migraine. A daily 60-mg dose of atogepant taken over the course of 12 weeks reduced mean monthly migraine days in adult patients with episodic migraine who failed 2-4 classes conventional treatments, according to study results published in The Lancet Neurology. Researchers conducted a randomized, double-blind, placebo-controlled, phase 3b trial (ELEVATE; ClinicalTrials.gov identifier: NCT04740827) to evaluate the safety, tolerability, and efficacy of daily atogepant in adult patients with episodic migraine who did not respond to 2-4 classes of conventional oral preventative treatments. The primary outcome of interest was change from baseline in mean monthly migraine days across the 12-week treatment period. Secondary outcomes included change from baseline in mean monthly headache days and medication use across the same treatment period. Both the primary and secondary endpoints were analyzed using a mixed model for repeated measures. Adult patients were eligible for the study if they had a history of migraine for at least 1 year and migraine onset prior to age 50. Patients included in the study also had 4-14 monthly migraine days and documented failures by 2-4 classes of oral migraine preventative treatments, 1 of which was propranolol or metoprolol, topiramate, flunarizine, or amitriptyline. Between March 2021 and August 2022, patients (N=315; 89% women; 96% White) were randomly assigned 1:1 to receive either 60 mg of oral atogepant (n=157) or placebo (n=158) daily during the treatment period. Of these 315 patients, 313 received treatment (atogepant, 156 vs placebo, 157) and were included in the safety population. The most common previous preventative treatment failures were topiramate (55%) and amitriptyline (53%). Most patients had been failed by 2 classes of treatment (56%), followed by those who had been failed by 3 (35%), and finally those who had been failed by 4 (9%). Compared with placebo, atogepant significantly reduced the mean monthly migraine days across the treatment period. The least squares mean changes from baseline in mean monthly migraine days across the treatment period was -1.9 (standard error [SE], 0.4) with placebo vs -4.2 (SE, 0.4) with atogepant. The least squares mean difference from placebo was -2.4 days with atogepant (95% CI, -3.2 to -1.5; adjusted P <.0001). Atogepant also demonstrated more significant improvements for all secondary efficacy endpoints. In the atogepant group, 78 (51%) patients had a reduction of at least 50% in mean monthly migraine days over the treatment period vs 28 (18%) patients in the placebo group (odds ratio [OR], 4.8; 95% CI, 2.9-8.1; adjusted P <.0001). The least squares mean difference for change from baseline in mean monthly headache days was -2.2 (95% CI, -3.1 to -1.3; adjusted P <.0001), indicating the superior performance of atogepant. Similarly, the least squares mean difference for change from baseline in mean monthly acute medication use days was-2.6 (95% CI, -3.4 to -1.9; adjusted P <.0001), again favoring atogepant. Treatment-emergent adverse events (TEAEs) were reported by 81 (52%) patients in the atogepant group vs 84 (54%) patients in the placebo group. Constipation, COVID-19, nausea, and nasopharyngitis were the most commonly reported TEAEs across both the placebo and atogepant groups (3% vs 10%; 10% vs 8%; 3% vs 7%; 8% vs 5%, respectively). Most TEAEs were mildly or moderately severe. Study limitations included a relatively brief treatment period, as well as the exclusion of patients who had been failed by more than 4 treatment classes and those with chronic migraine. “Future studies should consider examining the efficacy, tolerability, and safety of atogepant in patients with chronic migraine and for whom two to four previous preventive treatment classes have failed,” the researchers concluded. Disclosure: Multiple study authors declared affiliations with biotech, pharmaceutical, and or/device companies. Please see the original reference for a full list of disclosures. This article originally appeared on Neurology Advisor

Keypoint: Treatment with 2 doses of CYB003 led to robust and sustained improvements in depression symptoms at 4 months. The Food and Drug Administration (FDA) has granted Breakthrough Therapy designation to CYB003, a proprietary deuterated psilocybin analog for the adjunctive treatment of major depressive disorder (MDD). The designation was based on data from a phase 2 trial (ClinicalTrials.gov Identifier: NCT05385783) that evaluated the psychedelic-based therapeutic in patients with moderate to severe MDD. Findings showed treatment with 2 doses of CYB003 (12 mg or 16 mg) led to robust and sustained improvements in depression symptoms at 4 months. In both dosing cohorts, the mean reduction from baseline in the Montgomery–Asberg Depression Rating Scale (MADRS) score was approximately 22 points from baseline. In the 16 mg group, roughly 75% of patients were considered responders, defined as at least a 50% improvement in MADRS score, after 2 doses. Remission rates (defined as MADRS score ≤ 10) were reported to be 60% and 75% in the 12 mg and 16 mg cohorts, respectively, following 2 doses. “The sustained reduction in depression symptoms at the four-month mark after just 2 doses of CYB003 is a critical milestone that demonstrates the durability of the response, following the rapid improvement in symptoms,” said Amir Inamdar, MBBS, DNB (Psych), MFPM, Chief Medical Officer of Cybin. “Unlike currently approved adjunctive treatments which require chronic, daily dosing, CYB003 allows for intermittent dosing without the challenges of withdrawing patients from their existing medications.” With regard to safety, no drug-related serious adverse events were reported in the study. Suicidal ideation or behavior were not observed during the trial period. “Considering these positive findings, we are eager to progress the program and bring relief and treatment alternatives to the millions of people who can benefit,” added Inamdar. The Company stated that a phase 3 trial is expected to begin in mid-2024. This article originally appeared on MPR

PSYCHIATRIC VIEWS ON THE DAILY NEWS But I do see a way. There is a narrow way through.” - Paul Atreides in “Dune” “All the world is a narrow bridge, and most important is not to be overwhelmed by fear.” - Rabbi Nachman of Breslov One of the definitions of a prophet is one who foretells future events correctly. We have had a few such possibilities lately. One is the featured character Paul Atreides in the movie “Dune.” As a possible Messiah, and with the help of the psychedelic spice, he foresees various future scenarios involving planetary war. The Free Press began a weekly series on past prophets in the United States. First, on March 2, featured Marshall McLuhan of “the medium is the message” fame. Decades ago, he seemed to foresee our internet age and its profound rewiring of our society and brains. Next, on March 11, was Bayard Rustin, the civil rights advocate and ally of the Rev. Dr Martin Luther King Jr. He predicted that psychologically traumatizing White individuals to increase their guilt would be likely to backfire, as perhaps may be now happening with diversity, equity, & inclusion consultants. March 16 featured D.A. Henderson who, back in 2006, warned against a global shutdown in an epidemic because it would lead to economic and social disruption. Even though I was way off in predicting how long the COVID-19 pandemic would last, as discussed in my last column, these portraits of prophets inspired me to responsibly see how I did so far in a series of predictions starting just about a year ago. One might assume that since psychiatrists have some expertise in understanding human behavior, that our prediction ability would increase. Therefore, in ensuing columns, I will try to fairly cover my previous predictions about psychiatry and artificial intelligence, psychedelics, politics, naming, social psychopathologies, indigenous individuals, eulogies, and predictions. My prediction is that I will complete them on April 1, April Fool’s Day 2024. Wouldn’t that be fitting? Note: This article originally appeared on Psychiatry Times

Keypoint: Psilocybin poisoning exposures started to significantly increase starting in 2019 for adolescents and in 2020 for adults. From 2018 to 2022, psilocybin poisoning calls have tripled for adolescents and doubled for young adults, as reported in the Journal of Adolescent Health. The psychoactive agent in hallucinogenic mushrooms, psilocybin, can cause intense psychedelic hallucinations, euphoria, and altered perception of space and time. Although psilocybin is designated as a Schedule I substance in the US, multiple cities and states have taken steps to decriminalize psilocybin. To evaluate trends in adolescent and young adult exposures to psilocybin in the US, investigators from the University of Virginia School of Medicine sourced data for this study from the National Poison Data System (NPDS). The investigators identified cases between 2013 and 2022 in which individuals (N=4055) aged 13 to 25 years were exposed to psilocybin. The investigators also collected the available demographic data, level of healthcare received, reason for exposure, and medical outcome. Among reported psilocybin exposures, 2372 cases involved adolescents and 1683 involved young adults. Most psilocybin poisoning calls involved boys or men (74.8% to 75.1%), most events involved intentional abuse (78.3% to 81.1%), and 65.8% were single-substance exposure events. The number of psilocybin-related cases was relatively stable between 2013 and 2018. However, the number of cases started to significantly increase starting in 2019 for adolescents and in 2020 for adults (both P <.001). By 2022, cases had more than tripled among adolescents (P <.0001) and more than doubled among young adults (P <.0001) compared with 2018. From 2013 to 2022, the number of cases more than doubled among men and boys (246 to 545; P <.0001) and almost tripled among women and girls (73 to 213; P <.0001). In single substance cases, 72.3% of adolescents and 72.1% of adults received medical attention and the event resulted in a moderate effect on 47.1% of adolescents and 45.3% of adults. The most common effects included hallucinations or delusions (36.6%), agitation (27.6%), tachycardia (20.2%), and confusion (16.0%). In addition, seizures were reported in 1.8% of cases. In multiple exposure cases, the most common co-occurring substances were marijuana among adolescents and alcohol among adults. Two deaths occurred in cases that involved fentanyl and hallucinogenic amphetamine, in which psilocybin was determined to be the secondary cause of death in both cases. These findings indicate that psilocybin poisoning exposures have significantly increased in recent years among adolescents and young adults in the US. Study authors concluded, “As psilocybin might become more available, continued surveillance is critical to inform lawmakers and guide public policy.” The primary limitation of this study is that reporting to poison control is voluntary and only includes cases that rise to the level requiring medical attention, so rates of psilocybin use in this study are likely an under-representation of real-world use. Note: This article originally appeared on Psychiatry Advisor

Adverse childhood experiences (ACEs) are associated with a significantly increased risk for adult depressive, anxiety, and stress-related disorders, new data from a large registry study of twins showed. Researchers found that each additional adverse event placed children at a 52% greater risk for a psychiatric disorder as an adult, with sexual abuse associated with the greatest risk. The findings showed that the association held even after controlling for shared genetic and environmental factors. The results suggested that "interventions targeting ACEs, including primary prevention and enhanced access to evidence-based trauma therapies to individuals who experienced ACEs, may be associated with reduced risk of future psychopathology," the investigators, with first author Hilda Björk Daníelsdóttir, MSc, of the University of Iceland, Reykjavik, Iceland, wrote. The findings were published online on March 6 in JAMA Psychiatry. Dose-Dependent Effect Previous research has shown a robust link between childhood abuse and an increased risk for psychiatric disorders in adulthood, but evidence of this association in studies that adjust for familial confounding is "completely lacking," the investigators wrote. To learn more about how genetic factors may affect the relationship between ACEs and later psychiatric diagnoses, the investigators used data from the nationwide Swedish Twin Registry, which includes data on more than 25,000 identical and nonidentical twins. The twin registry is linked to the Swedish National Patient Registry, which includes information on inpatient or outpatient psychiatric diagnoses after age 19. The twins responded to a large web-based questionnaire about past-week depressive symptoms as a measure of current mental health and distinct types of ACEs including family violence, emotional abuse or neglect, physical neglect, physical abuse, sexual abuse, rape, and hate crime. Three birth cohorts from the twin registry were surveyed between 2005 and 2016 and followed up in the national registry from age 19 until the end of 2016. Among the sample of 25,000 twin pairs (15,000 female; mean age at assessment, 29 years), 9750 (39%) participants reported exposure to at least one ACE, while 2000 (8%) reported exposure to three or more ACEs. Most respondents — 61% — reported no ACE exposure. More than 2300 participants received a psychiatric diagnosis as an adult. The incidence of any psychiatric disorder increased from 503 individuals (6.4%) among participants without any ACEs to 993 individuals (24.6%) among those reporting three or more. At the cohort level, a greater number of ACEs was associated with increased odds of any psychiatric disorder in a dose-dependent manner, the investigators noted (odds ratio [OR], 1.52; 95% CI, 1.48-1.57). Untangling Genes and Environment To determine how much of the increased risk for adult mental illness is due to ACEs and how much can be attributed to genetics and environment, the researchers focused on twin pairs where one had exposure to one type of ACEs and the other did not. This analysis revealed that the association remained but was attenuated. In identical twins, the effect of each ACE raised the odds of having a psychiatric condition by 20% (1.20; 95% CI, 1.02-1.40), and for nonidentical twins, the odds increased by 29% (1.29; 95% CI, 1.14-1.47). The weakening of the risk "suggests that familial confounding contributed to the association between ACEs and adult mental health outcomes," the authors wrote. Of all the ACEs, sexual abuse carried the highest risk for adult psychiatric disorders. Children who were exposed to sexual abuse, compared with those who were not, had up to a 200% higher risk for any psychiatric disorder in the following comparisons: Full cohort (OR, 3.09; 95% CI, 2.68-3.56), dizygotic twin pairs (OR, 2.10; 95% CI, 1.33-3.32), and monozygotic twin pairs (1.80; 95% CI, 1.04-3.11). "Our results demonstrated that familial factors contributed to a lesser extent to the association between sexual abuse and adult psychiatric disorders," the authors wrote. One major limitation of the study was that ACEs were based on retrospective report and thus may be subject to recall bias. Also, the findings cannot be generalized to other countries or cultures. The study was funded by the European Research Council, the Icelandic Center for Research, and the European Union Horizon 2020. Disclosures are noted in the original article. Note: This article originally appeared on Medscape

Keypoint: A reduced risk was seen for venous thromboembolism, arterial thrombosis/thromboembolism, and heart failure. HealthDay News — COVID-19 vaccination is associated with a reduced risk for post-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection cardiac and thromboembolic outcomes, according to a study published online March 12 in Heart. Núria Mercadé-Besora, from the University of Oxford, and colleagues conducted a staggered cohort study based on national vaccination campaigns using electronic health records from the United Kingdom, Spain, and Estonia to examine the association between COVID-19 vaccination and the risk for post-COVID-19 cardiac and thromboembolic complications. Outcomes included heart failure, venous thromboembolism (VTE), and arterial thrombosis/thromboembolism (ATE) recorded at 0 to 30, 31 to 90, 91 to 180, and 181 to 365 days after SARS-CoV-2 infection. The analyses included 10.17 million vaccinated and 10.39 million unvaccinated individuals. The researchers found that vaccination was associated with reduced risks for acute and postacute COVID-19 VTE, ATE, and heart failure, with meta-analytic subhazard ratios of 0.22, 0.53, and 0.45 and 0.53, 0.72, and 0.61 for 0 to 30 days and 91 to 180 days after SARS-CoV-2 infection, respectively. “Vaccination against SARS-CoV-2 substantially reduced the risk of acute post-COVID-19 thromboembolic and cardiac complications, probably through a reduction in the risk of SARS-CoV-2 infection and the severity of COVID-19 disease due to vaccine-induced immunity,” the authors write. Note: This article originally appeared on Psychiatry Advisor

COMMENTARY The diagnosis of attention-deficit/hyperactivity disorder (ADHD) continues to be the focus of controversy in psychiatric literature.1 I would like to begin by critically examining the “H” in “hyperactivity,” as suggested by S. Nassir Ghaemi, MD. I concur with Dr Ghaemi that distractibility and “hyperactivity” are not part of the same psychological problem. Since 1991, when I started to observe the behaviors of children diagnosed with ADHD, I have noticed that “hyperactivity” is associated with either a mood disease or anxiety.I have hundreds of cases documented in 3 books,3-5 and as of today, I have not found 1 case in which the increased activity, physical or psychological, is associated with a diagnosis of ADHD. On the contrary, the reported “hyperactivity” has been a manifestation of obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), social anxiety, bipolar illness, autism, and a few other diseases. On the other hand, as my mentor and friend Ronald W. Pies, MD, likes to say, “the body can have as many illnesses as it pleases.”6 The key difference between having several concurrent diseases and an unjustified diagnosis is that in the first scenario, every medical entity has symptoms of its own. The following vignette is an example of a frequently encountered diagnostic confusion. Case Example “Kevin” is a preadolescent Caucasian boy raised by his grandmother. From early childhood, he was exposed to physical neglect, and he also witnessed the assassination of his father, who was described as a violent person and addicted to street drugs. While in foster care, Kevin was sexually molested and again suffered emotional and physical neglect. He has severe anger issues, but his grandmother says he is very smart and can do his schoolwork, if he wants to. Several psychiatrists and psychotherapists have diagnosed him with PTSD, bipolar disorder, autism, bulimia, and insomnia. Lastly, a school counselor had Kevin and his grandmother complete a Vanderbilt questionnaire and determined that Kevin has ADHD. Discussion It seems obvious that a person like Kevin would have impaired attention in the classroom, but the questionable habit of elevating symptoms to the status of a diagnostic category misled the school clinician to diagnose ADHD, leading to other serious consequences from giving psychostimulants to a child misdiagnosed with ADHD, but suffering from mood and/or anxiety disorders. I should emphasize that Kay Redfield-Jamison, PhD, said once in an interview, “There are few things worse than putting a child with bipolar illness on stimulants.”7 And then, there is what I would call institutional fallacy. Here is 1 example: Six respected researchers from a prestigious university published their findings in an esteemed psychiatric journal.8 The writing is impeccable, and the conclusions appear to be sound, but when you read between the lines, something is not right. In the first paragraph, they say, “For example, in a study of robust open-label dosing with lisdexamfetamine, 40% of adults with ADHD were considered to have unresolved and clinically significant impairment in essential elements of executive behavior. Therefore, there is a significant need for new ADHD interventions.” Notice that the investigators assume that all the participants in the study quoted by them have ADHD. Furthermore, how can a drug weaker than lisdexamfetamine (Vyvanse) have a significant effect on an individual with an impaired attention span when conventional amphetamines failed to improve symptoms? If you wonder why I question the accuracy of the diagnosis in that study,9 I must say that I do so in any ADHD publication, and I have an abundance of evidence to sustain my view (see references). However, the investigators of this second study are heavyweights in the field who I respect and admire. Over several decades, I have encountered thousands of children (and adults with a childhood history) who were labeled conduct disorder and/or oppositional-defiant plus ADHD, when in fact they had OCD, social anxiety, PTSD, bipolar disorder, or even schizophrenia. It may be hard to believe, but I treated 2 children who for several years were receiving methylphenidate while having constant auditory hallucinations. Not surprisingly, they were adopted by nice families, and the evaluating physicians assumed that the legal guardian in front of them was the child’s birth mother. Another component of “institutional fallacy” is the pervasive belief that ADHD is a frequent comorbidity with other diagnoses. If we agree that ADHD is a diagnosis of exclusion, we then need to ask for the science behind the validity of those co-occurrent illnesses. As Dr Ghaemi and the late professor Hagop Akiskal, MD,10 stated multiple times, we should diagnose ADHD only when other explanations for an impaired attention span have been ruled out. I propose that we reclaim science and discard false assumptions, including that sleep disruption, moodiness, aggressive or defiant behaviors, autistic obsessions, etc, are inherent components of the ADHD syndrome. Instead, we should be digging deeper to determine if non-ADHD disorders better explain these features. Note: This article originally appeared on Psychiatry Times