TOPLINE: Legalization of recreational and medical cannabis is not associated with a reduction in opioid prescriptions or overall opioid overdose mortality, a new study suggested. However, investigators did find that recreational cannabis laws may be tied to a potential reduction in synthetic opioid deaths. METHODOLOGY: Investigators analyzed state-level data from the US Centers for Disease Control and Prevention and other databases (2006-2020) on the number of opioid prescriptions (per 100,000 persons). Prescription opioids included buprenorphine (except products to treat opioid use disorder), codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, and tramadol. Researchers used regression analyses to account for poverty rates and real gross domestic product and a generalized difference-in-differences method that accounted for staggered implementation of cannabis laws. TAKEAWAY: During the full study period, 13 states legalized recreational cannabis and 23 legalized medical cannabis. No statistically significant association was found between recreational cannabis laws and opioid prescriptions (3.08 fewer prescriptions per 100 persons; P = .17) or overall opioid overdose mortality (3.05 fewer deaths per 100,000; P = .24). The changes in outcomes associated with medical cannabis laws were larger in magnitude than those for recreational cannabis laws but also not statistically significant (3.54 additional prescriptions per 100 persons; P = .17 and 3.09 additional deaths per 100,000; P = .07). A potential reduction was found in synthetic opioid deaths associated specifically with states that had recreational cannabis laws (4.9 fewer deaths per 100,000; P = .04), but there were no differences in overdose deaths with other opioids. IN PRACTICE: "These results contrast with recent studies that suggested that recreational and medical cannabis legalization are associated with reductions in opioid prescriptions and medical cannabis legalization is associated with an increase in opioid mortality," the authors wrote. Note: This article originally appeared on Medscape

Sleep dysfunction affects symptom severity and communication among children with ASD or ADHD. Sleep problems mediated the relationship between symptom severity and communication difficulties among children with attention-deficit/hyperactivity disorder (ADHD) or with autism spectrum disorder (ASD), according to findings published in Autism Research. These results highlight the need to develop sleep interventions for these populations. Sleep problems are commonly reported among children with ADHD and ASD. However, it remains unclear how this disturbed sleep could potentially contribute to or exacerbate ADHD and ASD symptoms. Investigators from the Universitat de València in Spain hypothesized that children with ADHD and ASD would have more sleep problems than typically developing children and that these sleep problems and associated symptom severity would be associated with reduced communication skills among cases. The investigators recruited children (N=122) aged 7 to 12 years with ADHD (n=43) or ASD (n=47) from specialized psychoeducational care centers and matched (by age and intelligence quotient [IQ]) the cases with children who were developing typically (n=32). All study participants were assessed for sleep problems using the Sleep Disturbance Scale for Children (SDSC), for communication skills using the Children’s Communication Checklist second edition (CCC-2), and for symptom severity using a diagnostic interview for ADHD or the Autism Diagnostic Interview-Revised (ADI-R) instrument. The ADHD, ASD, and control groups comprised 90.7%, 89.3%, and 65.6% boys (P =.006); were 9.29, 9.37, and 8.75 years of age, on average; and their IQ was 98.94, 98.37, and 100.4, respectively. In a multivariate analysis, a significant main effect of group was observed for SDSC scores (F[12,214], 4.76; P <.001), in which there were significant group differences for all SDSC dimensions. In a post-hoc analysis, the ADHD and ASD groups differed significantly from the controls on all SDSC dimensions, except for sleep breathing disorders and sleep hyperhidrosis. Out of a total of 45 pairwise comparisons assessing the correlations between sleep problems, communication skills, and symptom severity, 37 significant correlations were observed among children with ADHD and 25 correlations were observed among children with ASD. Among children with ADHD and ASD, total sleep problem scores correlated (all P £.05) with structural communication (r, ADHD: 0.61; ASD: 0.33), pragmatic communication (r, ADHD: 0.55; ASD: 0.47), and symptoms severity (r, ADHD: 0.42; ASD: 0.32). In the multiple regression analyses, sleep problems and symptoms severity explained 44% of the variance in structural language and 35% of the variance in pragmatic language among children with ADHD. For children with ASD, sleep problems and symptoms severity explained 22% of the variance in structural communication dysfunction and 49% of the variance in pragmatic communication dysfunction. In the final models, for both groups, symptom severity, sleep problems, and communication skills were all significantly related with indirect effects of symptom severity on communication skills mediated through sleep problems. Study authors concluded, “The results of the mediation analysis indicate that in both groups, sleep problems mediate the relationship between symptoms and communication skills, so sleep difficulties have an indirect and partial effect on the communication challenges that these children experience.” Study limitations include the small sample size, imbalance in participant gender, and lack of participation of children with intellectual disabilities. This article originally appeared on Psychiatric Advisor

“Weight” a minute! Researchers investigated the impact of body mass index on the clinical features of bipolar disorder in the STEP-BD study. CASE VIGNETTE “Mr Lee” is a 32-year-old male with a history of bipolar I disorder, with depression during his most recent episode. The onset of his mood disorder was at age 21 years. He failed previous trials of valproic acid and aripiprazole. He has a history of 2 suicide attempts by overdose on medications. He was also previously treated with a course of electroconvulsive therapy (ECT). He has been taking lithium 900 mg daily for the past 5 years. During this time, he has not had any episodes of mania, but he does have chronic mild depressive symptoms. He has a history of comorbid obesity and type 2 diabetes, but he does not have hypertension or hyperlipidemia. His current body mass index (BMI) is 38. At an outpatient visit, Mr Lee expresses a desire to try to exercise by walking while his son plays at a local park. He asks about the potential mental health benefits of exercise. As his psychiatrist, how would you respond? Bipolar disorder is associated with a 2- to 3-fold increased risk of premature mortality, with an average reduced lifespan of 9 to 17 years.1 Obesity rates in the United States are increasing,2 and individuals with mood disorders, including bipolar disorder, are at increased risk.3,4 Suicide mortality in the United States is also increasing,5 although evidence for an association between obesity and suicidal behavior is inconsistent. There is also evidence that increased low-grade inflammation, associated with higher BMI, may be associated with a more severe course of illness in patients with bipolar disorder. The Current Study Kadriu and colleagues8 aimed to assess whether higher BMI affected disease course and severity, symptom severity, and disease burden (medical and psychiatric comorbidity) in patients with bipolar disorder from the 7-year, longitudinal Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. Participants met DSM-IV criteria for bipolar disorder, cyclothymia, or schizoaffective disorder, bipolar type. Psychiatric comorbidities, including anxiety disorders, substance use disorders, eating disorders, and attention-deficit/hyperactivity disorder were also permitted. Participants were treated in a naturalistic setting. Study investigators included 2790 outpatients with data on height and weight. Data were also available on current mood, medical and psychiatric comorbidities, medication use, adverse effects, substance use, stressors, care utilization, history of ECT, history of suicide attempt, bipolarity index, the Montgomery-Åsberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). Participants were grouped into 7 categories by BMI: underweight (<18.5), thin (18.5-20), normal (20 to 25), overweight (25 to 30), class I obesity (30 to 35), class II obesity (35 to 40), and class III obesity (>40). The investigators used a network-based approach (Watts-Strogatz) to assess the influence of BMI on comorbidities. Relationships between BMI and psychosocial variables were assessed with logistic regression. The association between BMI and mood symptoms was assessed with linear regression. The mean participant age was 40 years, and 54% of participants were female. The average BMI was 28.4 ± 6.4 (median 27.2). Sex was significantly different across BMI categories (females were more likely to be underweight, and males were more likely to be obese.) Overweight and obese patients had a significantly higher bipolarity index. History of previous ECT treatment was also significantly different across BMI categories (lowest prevalence in the BMI <20 groups). There was a significant relationship between higher BMI and history of suicide attempt, with the highest prevalence in individuals with class III obesity. There was evidence of a bimodal distribution for BMI and the number of hospitalizations during the study, although the findings did not reach statistical significance. There was no significant difference in depressive episodes across BMI categories. However, manic episodes, bipolar II disorder diagnosis, panic disorder, social phobia, and posttraumatic stress disorder all differed significantly by BMI groups. Graph theory demonstrated a robust linear increase in comorbidities with increasing BMI. Trajectory clustering analysis indicated that higher BMIs were associated with worsening trajectory of core depressive symptoms. Study Conclusions In the STEP-BD study, the investigators found that BMI was associated with greater symptom severity, a greater number of psychiatric and medical comorbidities, a history of ECT, and a worsening trajectory of core depressive symptoms. The investigators noted factors such as obesity, hypothalamic pituitary adrenal (HPA) axis activation, and inflammation as potential mechanisms underlying these associations. Study strengths included the large sample size, real-world data, long-term continuity of care, and rigorous statistical analyses. Study limitations included the use cross-sectional data (which delimits inferences about causality), the exploratory nature of some of the analyses, the inability to account for fluctuations in weight over the course of the study, that all study sites were in the United States, that BMI cannot delineate subcutaneous versus visceral adiposity, and the absence of data on waist circumference or waist-to-hip ratio. The Bottom Line The study findings suggest that higher BMI adversely affects disease course and severity in individuals with bipolar disorder. Therefore, this measure is germane to the clinical care of this patient population. Note: This article originally appeared on Psychiatric Times

Increased hazard ratios were seen for all-cause mortality and mortality due to natural and unnatural causes. HealthDay News — Individuals with obsessive compulsive disorder (OCD) have an increased risk for all-cause mortality, according to a study published online Jan. 17 in The BMJ. Lorena Fernández de la Cruz, Ph.D., from the Karolinska Institute in Stockholm, and colleagues conducted a population-based matched cohort and sibling cohort study to estimate the risk for all-cause and cause-specific mortality in people with OCD. The population-based cohort included 61,378 people with OCD and 613,780 unaffected people matched on sex, birth year, and county of residence; the sibling cohort included 34,085 people with OCD and 47,874 unaffected full siblings. The cohorts were followed for a median of 8.1 years. During the study period, 4,787 people with OCD and 30,619 unaffected people died (crude mortality rates, 8.1 and 5.1 per 1,000 person-years, respectively). The researchers found that people with OCD had an increased risk for all-cause mortality and mortality due to natural causes and unnatural causes (hazard ratios, 1.82, 1.31, and 3.30, respectively) in hazard models adjusted for birth year, sex, county, migrant status, and sociodemographic variables. In the OCD cohort, higher natural causes of death included those due to endocrine, nutritional, and metabolic diseases; mental and behavioral disorders; and diseases of the nervous, circulatory, respiratory, digestive, and genitourinary systems; conversely, the risk for death due to neoplasms was lower. Of unnatural causes, the highest hazard ratio was seen for suicide followed by accidents. “Better surveillance, prevention, and early intervention strategies should be implemented to reduce the risk of fatal outcomes in people with OCD,” the authors write. Several authors disclosed ties to the pharmaceutical, publishing, and medical technology industries. This article originally appeared on Psychiatry Advisor

Does psychiatry’s future lean towards online practice? Telepsychiatry is a form of telemedicine that uses telephone or video conferencing tools to provide psychiatric services. As with in-person psychiatric treatment, telepsychiatry providers can evaluate and diagnose, provide therapy, and prescribe medication. On the one hand, I fully agree with Dr Varas that something is lost when we are not meeting in the same room with our patients. As I stated in my article, however, I think that telepsychiatry will increasingly be the way of the future, especially with younger generations of patients and therapists, along with continued advances in technology. Dr. Reddy believes that telepsych allows patients that are in remote areas of the country of state the access to quality doctors. People feel more comfortable taking about sensitive issues in their own environment. It eliminates the white coat syndrome. The no show rate is dramatically improved as it is much more flexible than commuting at least 30 minutes to 1 hour for an appointment, then seeing the doctor then being stuck in traffic. In this fast paced word, we don't have much time. The advantage of telepsych is we don't have to do a physical examination on patients, which is unlike many other fields who are transitioning into telehealth. I see patients from 7 hours away which would have been impossible with the benefits of telepsychiatry. I can see patients all over Missouri and Kansas City which is a major advantage as they are often burned out by their local providers and want a clean state. Now a days it's common to psychiatrists to practice in multiple states to reach more patients. I hope to expand with more Midwest states in the near especially with the patient population i see which is highly vulnerable. Dr Vilash Reddy is the owner of One Life Psychiatry. As a child/adult/addiction psychiatrist, he has a holistic approach mental health, through the use of medication, therapy, and alternative remedies.  His main focus he believes is vitally important is to educate and empower patients that are struggling with mental illness. He places a strong emphasis on understanding the patient way before prescribing random medicines which why he often the 2nd, 3rd, etc opinion.

Recent research highlights the potential role of an atypical antipsychotic to treat anxiety, a prevalent and undertreated symptom in bipolar I disorder (BPD). Notably, investigators said, the drug comes without the typical metabolic side effects, including weight gain, associated with this drug class. A post hoc analysis of pooled data from two trials comparing two different doses of cariprazine (Vraylar) to placebo showed it was consistently effective not only in alleviating bipolar depression but also in improving symptoms of anxiety. "Since this was a post hoc analysis, one has to be careful about not overstating the findings," study investigator Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, Toronto, Ontario, Canada, and head of the Mood Disorders Psychopharmacology Unit, told Medscape Medical News. "But what we can say is that anxiety has been an under-researched, undertreated symptom dimension in BPD, and these findings about cariprazine are very promising," said McIntyre, chair and executive director of the Brain and Cognition Discovery Foundation, Toronto, Canada. The analysis was published in International Clinical Psychopharmacology and was presented as a poster at the 2023 Neuroscience Education Institute, Colorado Springs, Colorado. Ubiquitous, Common, Hazardous Anxiety in BPD is "ubiquitous, common, and hazardous," McIntyre said. "We talk so much about depression and mania as cardinal presentations, but someone could make a case that in that trifecta, we're missing anxiety." In patients with BPD and anxiety, "the index episode is much more difficult to treat, there's a longer time to remission, lower rates of recovery, and a shorter time to recurrence," noted McIntyre, chair of the board of the Depression and Bipolar Support Alliance. Anxiety also may "represent a portent of other things that can add more to the trouble, like alcohol, illicit drugs, or cannabis use — especially now that cannabis is no longer illegal," McIntyre said. Unfortunately, he said, "there hasn't been an organized, systematic approach to developing a therapy for anxiety in BPD." Rather, patients are prescribed benzodiazepines, gabapentinoids, or selective serotonin reuptake inhibitors, all of which have limitations, he added. Some atypical antipsychotics such as quetiapine have been shown to be helpful with anxiety but "have a lot of baggage and side effects — especially sedation, somnolence, weight gain, and metabolic problems," McIntyre noted. Cariprazine is a dopamine D3-preferring D3/D2 partial agonist, a serotonin 5-HT1A receptor partial agonist, and 5-HT2B receptor antagonist, which has shown anxiolytic-like activity in rodent models. It was approved by the US Food and Drug Administration to treat mania, depression, and mixed episodes of BPD in 2015 and BPD in 2019. McIntyre and his team believed there was an opportunity in the completed randomized controlled trials of cariprazine in BPD to conduct a post hoc analysis of its impact on anxiety. 'Cornerstone Mood Stabilizer' The researchers pooled data from two phase 3, randomized, double-blind, placebo-controlled studies in adults with BPD experiencing a current major depressive episode. The pooled intention-to-treat population consisted of 952 patients with BPD (mean age, ~43 years; 62% female) randomized to receive either 1.5 mg/d, 3 mg/d of cariprazine, or placebo. Patients were divided into two subsets: Lower or higher anxiety (defined as a Hamilton Anxiety Rating Scale [HAM-A] total score of < 18 and ≥ 18, respectively). Patients also completed the Montgomery-Åsberg Rating Scale (MADRS). A third of the patients received a placebo, a third received the 1.5 mg/d dose, and a third received the 3 mg/d dose. Demographic and baseline characteristics were similar between the subsets. Results showed there was a statistically significant change in HAM-A total score for cariprazine 1.5 mg/d (P = .0027). The investigators also found a statistically significant change in MADRS total score change for cariprazine 1.5 mg (P = .0200) in the higher anxiety subset. The rate of remission was significantly greater for cariprazine 1.5 mg/d in the higher and lower anxiety subsets (P = .0172 and P = .0004, respectively). In addition, the change in HAM-A total score change was statistically significant for cariprazine 1.5 mg/d in the higher anxiety subgroup (P = .0105) and the 3 mg/d dose in the lower anxiety subgroup (P = .0441). McIntyre hopes these findings can be replicated in other trials. "Clinically, I find that many patients who take cariprazine don't require as many benzodiazepines or other medications for anxiety, and it's one of the better-tolerated medications without metabolic complications or weight gain, so it's become a cornerstone mood stabilizer," he said. Polypharmacy Avoided Another recent study retrospectively analyzed medical records of close to 40 adult patients with BPD I who were receiving treatment with aripiprazole for bipolar depression and then switched to cariprazine. "We wanted to conduct a study in depressed patients who had gained weight on aripiprazole and then directly switched to cariprazine. It improved their mood and helped mitigate weight gain, thereby avoiding polypharmacy of additional antidepressants and weight loss agents," study investigator Maxwell Zachary Price, a medical student at Hackensack Meridian School of Medicine, Nutley, New Jersey, told Medscape Medical News. "In our general outpatient psychiatry practice, we've treated many adult patients with oral aripiprazole for maintenance of BPD," the study's senior investigator, Richard Price, MD, clinical assistant professor of psychiatry at Weill Cornell Medical College, New York City, added. Aripiprazole is associated with weight gain. Moreover, aripiprazole "hasn't shown efficacy in managing BPD," he said. Most patients in Price's practice are insured through Medicaid, which mandates treatment with aripiprazole before covering cariprazine. "We noticed their weight had been creeping up over the years, and they also were experiencing depressive symptoms," he said. The requirement to initiate treatment with aripiprazole before switching to cariprazine offered Price an opportunity to compare the two agents in this real-world setting by retrospectively reviewing the charts of 37 patients with BPD (23 females and 14 males who made the switch). The patients had been taking aripiprazole for a mean duration of 94.9 weeks and had experienced a mean increase in body weight of 16.1% ± 12.3% on aripiprazole before switching. Patients who were taking 2 mg-10 mg of aripiprazole were switched to 1.5 mg of cariprazine, while those taking ≥ 15 mg of aripiprazole were switched to 3 mg of cariprazine. "Patients tolerated the switch well and maintained stability during the transition," and "no patients discontinued cariprazine during the study," Price said. After a mean duration of 36.7 weeks (range, 1-127 weeks), the patients showed a decrease in Clinical Global Impression-Bipolar Severity of Illness Scale score from a mean of 5.0 ± 0.9 to a mean of 2.8 ± 0.7 (t = −12.75, P < .00001). The patients' weight dropped from a mean of 90.3± 21.5 kg on aripiprazole to a mean of 83.9 ± 19.2 kg on cariprazine (t = −4.22, P < .001). Two patients experienced initial nausea that resolved by taking the medication with food, and two experienced initial restlessness that resolved with dosage reduction. "We found that the patients were lighter in mood, body habitus and weight, and less agitated and their mental alertness and concentration improved as well," said Price. He hopes that further research in randomized blinded trials will corroborate the findings. Hypothesis-Generating Research Joseph Cerimele, MD, MPH, associate professor of psychiatry and behavioral sciences, University of Washington, Division of Population Health, UW Medicine, Seattle, Washington, said the research findings are "hypothesis-generating." Ciremele, who wasn't involved with either study, said many clinicians and researchers are trying to tailor treatment options to match patient characteristics, and these studies and other similar research, "help us all ask questions related to concurrent symptoms in bipolar depression." However, the post hoc analysis was a secondary analysis of an efficacy trial where individuals with concurrent anxiety disorders were excluded. "So, a next step might be to evaluate this and other treatments in individuals with BPD and concurrent anxiety disorders," he said. The study by Jain et al was funded by AbbVie. McIntyre had received research grant support from CIHR/GACD/National Natural Science Foundation of China and the Milken Institute; speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics Inc., Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome Therapeutics, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular Therapies, NewBridge Pharmaceuticals, Viatris, Abbvie, and Atai Life Sciences. McIntyre is the CEO of Braxia Scientific Corp. His coauthors' disclosures are listed in the original paper. Richard Price had received honoraria from AbbVie, Alkermes, Allergan, Intra-Cellular Therapies, Janssen, Jazz, Lundbeck, Neuronetics, Otsuka, and Supernus. Maxwell Price and Cerimele reported no relevant financial relationships. Note: This article originally appeared on Medscape

Conscientiousness, extraversion, and a positive outlook were associated with a lower risk of developing dementia. Psychosocial factors, including personality traits and subjective well-being, were strong predictors of dementia diagnosis but were not predictors of neuropathology at autopsy, according to the findings of a meta-analysis published in the journal Alzheimer’s & Dementia. The big 5 personality traits (conscientiousness, extraversion, openness to experience, neuroticism, and agreeableness) and subjective well-being measures have been associated with dementia, but there is limited concise evidence regarding these risk factors and dementia pathology. To assess the relationship between psychosocial factors and brain pathology, researchers from Northwestern University in the United States searched publication databases for studies that included data about the big 5 and subjective well-being as well as pathology outcomes. A total of 8 longitudinal samples comprising 44,531 (aged 49-81 at baseline; 26%-61% women) patients who were followed up to 21 years were included in this analysis. An increased likelihood of a dementia diagnosis was related with neuroticism (b, 0.11; 95% CI, 0.07-0.15) and negative affect (b, 0.13; 95% CI, 0.003-0.24) whereas dementia was less likely among individuals with conscientiousness (b, -0.15; 95% CI, -0.19 to -0.11), positive affect (b, -0.07; 95% CI, -0.14 to -0.01), extraversion (b, -0.05; 95% CI, -0.09 to -0.009), and openness to experience (b, -0.05; 95% CI, -0.11 to 0.000). Dementia was not related with agreeableness (b, -0.04; 95% CI, -0.09 to 0.01) or satisfaction with life (b, -0.08; 95% CI, -0.16 to 0.006). Across studies, however, there was no consistent association between psychological characteristics and measures of neuropathology. Overall, 3.7% of estimates reached significance using data from individual samples but no significant signals were replicated across samples. In a moderation analysis, 3.2% of assessments reached significance. Of these significant signals, 7.38% of moderators were significant for clinical dementia and 0.92% were significant for neuropathology. For example, a significant interaction between conscientiousness and age was observed on the likelihood of dementia (b, 0.005; 95% CI, 0.002-0.008). The researchers tested whether conscientiousness interacted with a dementia diagnosis to affect the likelihood of neuropathology. They identified no significant association overall (b, 0.10; 95% CI, -0.08 to 0.28) but found that individuals with higher conscientiousness had different Braak stage overall than their clinical dementia diagnosis would indicate. The major limitation of this study was the lack of access to data about neuropathology markers, in which half of samples did not have complete autopsies. “[O]ur results suggest a protective effect of openness to experience, positive affect, and satisfaction with life for incident dementia diagnosis, though effects were less consistent across datasets. Although the Big Five and aspects of [subjective well-being] were not associated with neuropathology at autopsy, moderator analyses reveal some evidence that these psychological factors may also act as predispositions that influence neuropathology.” Note: This article originally appeared on Neurology Advisor

For adults with ADHD, DBT as a treatment strategy demonstrated superior acceptability to clinical management with placebo. A randomized controlled study published in Psychotherapy and Psychosomatics found that dialectical behavior therapy (DBT) demonstrated acceptability as a treatment strategy for adults with attention-deficit/hyperactivity disorder (ADHD), even in the long term. However, future interventions should target treatment adherence to maximize clinical outcomes. When ADHD persists in adulthood, symptoms can affect educational attainment and social and occupational functioning. Adults with ADHD have reported that cognitive behavioral therapy (CBT) and DBT are useful interventions, but few studies have focused on acceptability and adherence to treatment. The Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS; ISRCTN54096201) was a 4-arm study conducted between 2007 and 2013 that compared DBT-based group therapy plus methylphenidate (GBT+MPH) with DBT-based group therapy plus placebo (GBT+PLB), clinical management plus methylphenidate (CM+MPH), and clinical management plus placebo (CM+PLB). The DBT intervention comprised 12 weekly sessions followed by 10 monthly sessions lasting 120 minutes that covered mindfulness, behavior analysis, emotional regulation, impulse control, stress management, and self-respect modules, among others. The clinical management intervention was delivered in 15- to 20-minute individual sessions following the same schedule as DBT and involved supportive counseling to encourage patients to develop coping skills. For this study, researchers evaluated self-reported efficacy of the treatment and adherence, measured by session attendance. The researchers randomly assigned participants to receive GBT+MPH (n=107), GBT+PLB (n=109), CM+MPH (n=110), and CM+PLB (n=107). These cohorts comprised 47.7%, 45.9%, 50.9%, and 54.2% women; were 34.9, 35.6, 35.6, and 34.9 years of age on average; 62.6%, 51.4%, 53.6%, and 62.6% had combined ADHD; and 50.5%, 53.2%, 50%, and 52.3% had used medication treatments for their ADHD, respectively. At week 52, the researchers found that the overall self-reported effectiveness of treatment was significantly greater for CM+MPH than CM+PLB (P <.001), for GPT+PLB than CM+PLB (P <.001), and for GPT+MPH than CM+PLB (P <.001). The patients who received methylphenidate reported significant effects from medication compared with placebo recipients at weeks 52 and 130 (all P £.019). Notably, recipients of DBT with or without active pharmacotherapy reported significant effects from the therapy intervention compared with CM+PLB at week 52 (both P £.002). Among the DBT recipients, self-reported use of skills was associated with significant improvements in Clinical Global Impression (CGI) scores (P <.001), Conners’ Adult ADHD Rating Scale (CAARS) total scores (P <.05), and CAARS ADHD index scores (P <.05). However, the researchers observed no significant group differences in subjective adherence to or effectiveness of overall skills between the GPT+MPH and GPT+PLB groups (all P ³.061). Additionally, the number of unexcused absences from treatment sessions was higher for GPT+PLB than CM+MPH (P =.013) and CM+PLB (P =.028). Consequently, the researchers found that the number of unexcused absences was negatively correlated with the use of skills overall (r = -0.212) and the use of mindfulness (r = -0.194), emotional regulation (r = -0.174), impulse control (r = -0.181), and relationship/self-esteem (r = -0.173) skills. Study authors concluded, “These findings suggest that improving adherence to therapy skills could enhance treatment response.” These study findings may be limited, as the patients who were lost to follow-up were younger and had more severe illness than those who remained in the study. This article originally appeared on Psychiatric Times

What is ADHD and Adults Care with a Specialist Psychiatrist? Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. Symptoms of ADHD include inattention (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) and impulsivity (hasty acts that occur in the moment without thought). ADHD is considered a chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships, and daily functioning (Harpin, 2005). ADHD can lead to poor self-esteem and social function in children when not appropriately treated (Harpin et al., 2016). Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism possibly stemming from higher levels of criticism throughout life (Beaton, et al., 2022). Of note, ADHD presentation and assessment in adults differs; this page focuses on children. An estimated 8.4% of children and 2.5% of adults have ADHD (Danielson, 2018; Simon, et al., 2009). ADHD is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. It is more commonly diagnosed among boys than girls given differences in how the symptoms present. However, this does not mean that boys are more likely to have ADHD. Boys tend to present with hyperactivity and other externalizing symptoms whereas girls tend to have inactivity. Symptoms and Diagnosis Many children may have difficulties sitting still, waiting their turn, paying attention, being fidgety, and acting impulsively. However, children who meet diagnostic criteria for ADHD, differ in that their symptoms of hyperactivity, impulsivity, organization, and/or inattention are noticeably greater than expected for their age or developmental level. These symptoms lead to significant suffering and cause problems at home, at school or work, and in relationships. The observed symptoms are not the result of an individual being defiant or not being able to understand tasks or instructions. There are three main types of ADHD: Predominantly inattentive presentation. Predominantly hyperactive/impulsive presentation. Combined presentation. A diagnosis is based on the presence of persistent symptoms that have occurred over a period of time and are noticeable over the past six months. While ADHD can be diagnosed at any age, this disorder begins in childhood. When considering the diagnosis, the symptoms must be present before the individual is 12 years old and must have caused difficulties in more than one setting. For instance, the symptoms can not only occur at home. Inattentive type Inattentive refers to challenges with staying on task, focusing, and organization. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Doesn’t pay close attention to details or makes careless mistakes in school or job tasks. Has problems staying focused on tasks or activities, such as during lectures, conversations or long reading. Does not seem to listen when spoken to (i.e., seems to be elsewhere). Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties (may start tasks but quickly loses focus). Has problems organizing tasks and work (for instance, does not manage time well; has messy, disorganized work; misses deadlines). Avoids or dislikes tasks that require sustained mental effort, such as preparing reports and completing forms. Often loses things needed for tasks or daily life, such as school papers, books, keys, wallet, cell phone and eyeglasses. Is easily distracted. Forgets daily tasks, such as doing chores and running errands. Older teens and adults may forget to return phone calls, pay bills and keep appointments. Hyperactive/impulsive type Hyperactivity refers to excessive movement such as fidgeting, excessive energy, not sitting still, and being talkative. Impulsivity refers to decisions or actions taken without thinking through the consequences. For a diagnosis of this type of ADHD, six (or five for individuals who are 17 years old or older) of the following symptoms occur frequently: Fidgets with or taps hands or feet, or squirms in seat. Not able to stay seated (in classroom, workplace). Runs about or climbs where it is inappropriate. Unable to play or do leisure activities quietly. Always “on the go,” as if driven by a motor. Talks too much. Blurts out an answer before a question has been finished (for instance may finish people’s sentences, can’t wait to speak in conversations). Has difficulty waiting for his or her turn, such as while waiting in line. Interrupts or intrudes on others (for instance, cuts into conversations, games or activities, or starts using other people’s things without permission). Older teens and adults may take over what others are doing. Combined type This type of ADHD is diagnosed when both criteria for both inattentive and hyperactive/impulse types are met. ADHD is typically diagnosed by mental health providers or primary care providers. A psychiatric evaluation will include a description of symptoms from the patient and caregivers, completion of scales and questionnaires by patient, caregivers and teachers, complete psychiatric and medical history, family history, and information regarding education, environment, and upbringing. It may also include a referral for medical evaluation to rule out other medical conditions. It is important to note that several conditions can mimic ADHD such as learning disorders, mood disorders, anxiety, substance use, head injuries, thyroid conditions, and use of some medications such as steroids (Austerman, 2015). ADHD may also co-exist with other mental health conditions, such as oppositional defiant disorder or conduct disorder, anxiety disorders, and learning disorders (Austerman, 2015). Thus, a full psychiatric evaluation is very important. There are no specific blood tests or routine imaging for ADHD diagnosis. Sometimes, patients may be referred for additional psychological testing (such as neuropsychological or psychoeducational testing) or may undergo computer-based tests to assess the severity of symptoms. The Causes of ADHD Scientists have not yet identified the specific causes of ADHD. While there is growing evidence that genetics contribute to ADHD and several genes have been linked to the disorder, no specific gene or gene combination has been identified as the cause of the disorder. However, it is important to note that relatives of individuals with ADHD are often also affected. There is evidence of anatomical differences in the brains of children with ADHD in comparison to other children without the condition. For instance, children with ADHD have reduced grey and white brain matter volume and demonstrate different brain region activation during certain tasks (Pliszka, 2007). Further studies have indicated that the frontal lobes, caudate nucleus, and cerebellar vermis of the brain are affected in ADHD (Tripp & Wickens, 2009). Several non-genetic factors have also been linked to the disorder such as low birth weight, premature birth, exposure to toxins (alcohol, smoking, lead, etc.) during pregnancy, and extreme stress during pregnancy. ADHD Treatment ADHD treatment usually encompasses a combination of therapy and medication intervention. In preschool-age and younger children, the recommended first-line approach includes behavioral strategies in the form of parent management training and school intervention. Parent-Child Interaction Therapy (PCIT) is an evidence-based therapy modality to help young children with ADHD and oppositional defiant disorder. According to current guidelines, psychostimulants (amphetamines and methylphenidate) are first-line pharmacological treatments for the management of ADHD (Pliszka, 2007). In preschool-aged patients with ADHD, amphetamines are the only FDA-approved medication, although guidelines suggest that methylphenidate rather than amphetamines may be helpful if behavioral interventions prove insufficient. Alpha agonists (clonidine and guanfacine) and the selective norepinephrine reuptake inhibitor, atomoxetine, are the other FDA-approved options for treating ADHD. There are newer FDA-approved medications for ADHD treatment, including Jornay (methylphenidate extended-release) which is taken at night and starts the medication effect the next morning, Xelstrym (dextroamphetamine) which is an amphetamine patch, Qelbree (viloxazine) which is a non-stimulant, Adhansia (methylphenidate hydrochloride), Dyanavel (amphetamine extended-release oral suspension), Mydayis (mixed salts amphetamine product), and Cotempla (methylphenidate extended-release orally disintegrating tablets). Many children and families can alternate between various medication options depending on the efficacy of treatment and tolerability of the medication. The goal of treatment is to improve symptoms to restore functioning at home and at school. ADHD and School-Aged Children Teachers and school staff can provide parents and doctors with information to help evaluate behavior and learning problems and can assist with behavioral training. However, school staff cannot diagnose ADHD, make decisions about treatment or require that a student take medication to attend school. Only parents and guardians can make those decisions with the child’s health care clinician. Students whose ADHD impairs their learning may qualify for special education under the Individuals with Disabilities Education Act or for a Section 504 plan (for children who do not require special education) under the Rehabilitation Act of 1973. Children with ADHD can benefit from study skills instruction, changes to the classroom setup, alternative teaching techniques and a modified curriculum Source: Comprehensive Guide for Advocating for 504 vs IDEA ADHD and Adults Many children diagnosed with ADHD will continue to meet criteria for the disorder later in life and may show impairments requiring ongoing treatment (Pliszka, 2007). However, sometimes a diagnosis of ADHD is missed during childhood. Many adults with ADHD do not realize they have the disorder. A comprehensive evaluation typically includes a review of past and current symptoms, a medical exam and history, and use of adult rating scales or checklists. Adults with ADHD are treated with medication, psychotherapy or a combination. Behavior management strategies, such as ways to minimize distractions and increase structure and organization, and support from immediate family members can also be helpful. ADHD is a protected disability under the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). This means that institutions receiving federal funding cannot discriminate against those with disabilities. Individuals whose symptoms of ADHD cause impairment in the work setting may qualify for reasonable work accommodations under ADA. Related Conditions Autism spectrum disorder Disruptive, impulse control and conduct disorders Social communication disorder Specific learning disorder Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 2013.

US suicide rates reached an all-time high in 2022. Here’s how effective implementation of 988 can help address the problem. 988 - Q&A According to the US Centers for Disease Control and Prevention (CDC), suicide rates reached an all-time high in 2022.1 Psychiatric Times® sat down with Margie Balfour, MD, PhD, of Connections Health Solutions to discuss the 988 Suicide & Crisis Lifeline, its importance in addressing mental health crises, and how hospitals and health care facilities can get involved. Psychiatric Times: Given the alarming increase in suicide rates, 988 has gained significant attention. Can you elaborate on the importance of the 988 initiative and how it can contribute to addressing the current mental health crisis? Margie Balfour, MD, PhD: 988 is a critical piece of our nation’s suicide prevention efforts. 988’s predecessor is the National Suicide Prevention Lifeline—a network of over 200 call centers across the United States that was linked by a common 1-800 number since 2006—and the research on Lifeline call centers shows that callers have reduced thoughts of suicide and feelings of hopelessness after calling.2 988 expands access to this important intervention by linking it to an easy-to-remember, 3-digit number and creating the ability for the public to access it via text and chat. Compared to a year ago, the number of people contacting the Lifeline via text increased nearly tenfold.3 Furthermore, the implementation of 988 has catalyzed an expansion of crisis services overall with increased funding for mobile crisis teams and crisis stabilization facilities.4 The bottom line is that more people have easier access to these life-saving services, and access will continue to increase as these new services grow. PT: A recent National Alliance on Mental Illness (NAMI) poll1 indicates strong public support for federal funding in mental health care, particularly for 988. How can this widespread support translate into meaningful changes in mental health policy and funding priorities? What specific actions or strategies do you believe can help policymakers address the urgent needs outlined in the poll? MB: The broad public and bipartisan support for crisis care is remarkable and creates an opportunity for a once-in-a-generation expansion of crisis services.4 We are in a similar position as the emergency medical services field was in the 1970 to ‘80s following the first 911 call in 1968, and now we cannot imagine life without ambulances, emergency rooms (ERs), etc. States across the nation are building the comparable services for behavioral health emergencies—mobile crisis teams, crisis stabilization facilities, etc. However, thus far most of this work is being financed by Substance Abuse and Mental Health Services Administration (SAMHSA) funds, Medicaid, and other state and local funds, and there are significant disparities in insurance coverage for behavioral health versus medical emergencies.5 More than 220 million Americans with Medicare or private insurance do not have coverage for mobile crisis or crisis stabilization facilities. Ambulances cannot get paid for taking people to a crisis center instead of emergency rooms. These services need parity coverage. We also need to develop clear definitions and standards to describe different types of crisis stabilization facilities,6 similar to how emergency medical systems have trauma center classification (Level 1, Level 2, etc) so that communities can plan crisis systems that can take care of everyone in need. PT: How do you foresee advancements in mental health research contributing to suicide prevention and improved services? Are there specific areas of research or innovation that you find particularly promising in addressing the complex challenges associated with mental health and suicide prevention? MB: I think peer support from people who have lived experience with suicidal thoughts and other behavioral health challenges can be enormously helpful, and there is increasing interest in research to help us better understand how it is helpful, in what situations, for which populations, etc. We also need research to better understand, from a systems perspective, how different crisis services affect outcomes and cost so we can be sure we are building and funding the systems communities need. PT: How are hospitals and health care facilities preparing for the implementation of 988? What challenges and opportunities do you foresee in this transition, and how can health care organizations collaborate to ensure a seamless and effective response to mental health crises? MB: Hospitals can start right now by incorporating 988 and local crisis resources into their discharge planning. Instead of sending patients out of the ER with instructions to call 911 if they have a future crisis, tell them to call 988. If they do have to call 911, educate them on how to ask for an officer with mental health training. Learn about local community resources. Is there a mobile crisis team? Is there a crisis stabilization center they can go to besides the ER? They can also get involved in planning the future crisis system. Every state received planning grants as part of the 988 implementation, and pretty much every community has some kind of group working on this. This is a great opportunity for hospitals to look at what happens to patients with behavioral health emergencies in their system. What happens in the outpatient primary care clinic if someone is suicidal? Instead of calling 911/police, can you work out an arrangement to call 988 or have a mobile crisis team come instead? Some hospitals are building crisis stabilization units attached to their ER or supporting community initiatives to build a freestanding facility. Note: This article originally appeared on Psychiatric Times

Symptoms of anxiety and depression increased in adults living in trigger states that immediately banned abortions after the US Supreme Court Dobbs decision overturned Roe v. Wade, which revoked a woman’s constitutional right to an abortion, new research shows. This could be due to a variety of factors, investigators led by Benjamin Thornburg, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, noted. These include fear about the imminent risk of being denied an abortion, uncertainty around future limitations on abortion and other related rights such as contraception, worry over the ability to receive lifesaving medical care during pregnancy, and a general sense of violation and powerlessness related to loss of the right to reproductive autonomy. The study was published online on January 23, 2024, in JAMA. Mental Health Harm In June 2022, the US Supreme Court overturned Roe vs Wade, removing federal protections for abortion rights. Thirteen states had "trigger laws" that immediately banned or severely restricted abortion — raising concerns this could negatively affect mental health. The researchers used data from the Household Pulse Survey to estimate changes in anxiety and depression symptoms after vs before the Dobbs decision in nearly 160,000 adults living in 13 states with trigger laws compared with roughly 559,000 adults living in 37 states without trigger laws. The mean age of respondents was 48 years, and 51% were women. Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 (PHQ-4). In trigger states, the mean PHQ-4 score at baseline (before Dobbs) was 3.51 (out of 12) and increased to 3.81 after the Dobbs decision. In nontrigger states, the mean PHQ-4 score at baseline was 3.31 and increased to 3.49 after Dobbs. Living in a trigger state was associated with a small but statistically significant worsening (0.11-point; P < .001) in anxiety/depression symptoms following the Dobbs decision vs living in a nontrigger state, the investigators report. Women aged 18-45 years faced greater worsening of anxiety and depression symptoms following Dobbs in trigger vs nontrigger states, whereas men of a similar age experienced minimal or negligible changes. Implications for Care In an accompanying editorial, Julie Steinberg, PhD, with University of Maryland in College Park, notes the study results provide "emerging evidence that at an individual level taking away reproductive autonomy (by not having legal access to an abortion) may increase symptoms of anxiety and depression in all people and particularly females of reproductive age." These results add to findings from two other studies that examined abortion restrictions and mental health outcomes. Both found that limiting access to abortion was associated with more mental health symptoms among females of reproductive age than among others," Steinberg pointed out. "Together these findings highlight the need for clinicians who practice in states where abortion is banned to be aware that female patients of reproductive age may be experiencing significantly more distress than before the Dobbs decision," Steinberg added. The study received no specific funding. The authors had no relevant conflicts of interest. Steinberg reported serving as a paid expert scientist on abortion and mental health in seven cases challenging abortion policies. Note: This article originally appeared on Medscape

NIH researchers found widespread differences in the brains of children with anxiety disorders that improved after treatment. Researchers at the National Institutes of Health have found overactivation in many brain regions, including the frontal and parietal lobes and the amygdala, in unmedicated children with anxiety disorders. They also showed that treatment with cognitive behavioral therapy (CBT) led to improvements in clinical symptoms and brain functioning. The findings illuminate the brain mechanisms underlying the acute effects of CBT to treat one of the most common mental disorders. The study, published in the American Journal of Psychiatry, was led by researchers at NIH’s National Institute of Mental Health (NIMH). “We know that CBT is effective. These findings help us understand how CBT works, a critical first step in improving clinical outcomes,” said senior author Melissa Brotman, Ph.D., Chief of the Neuroscience and Novel Therapeutics Unit in the NIMH Intramural Research Program. Sixty-nine unmedicated children diagnosed with an anxiety disorder underwent 12 weeks of CBT following an established protocol. CBT, which involves changing dysfunctional thoughts and behaviors through gradual exposure to anxiety-provoking stimuli, is the current gold standard for treating anxiety disorders in children. The researchers used clinician-rated measures to examine the change in children’s anxiety symptoms and clinical functioning from pre- to post-treatment. They also used task-based fMRI to look at whole-brain changes before and after treatment and compare those to brain activity in 62 similarly aged children without anxiety. Children with anxiety showed greater activity in many brain regions, including cortical areas in the frontal and parietal lobes, which are important for cognitive and regulatory functions, such as attention and emotion regulation. The researchers also observed elevated activity in deeper limbic areas like the amygdala, which are essential for generating strong emotions, such as anxiety and fear. Following three months of CBT treatment, children with anxiety showed a clinically significant decrease in anxiety symptoms and improved functioning. Increased activation seen before treatment in many frontal and parietal brain regions also improved after CBT, declining to levels equal to or lower than those of non-anxious children. According to the researchers, the reduced activation in these brain areas may reflect more efficient engagement of cognitive control networks following CBT. However, eight brain regions, including the right amygdala, continued to show higher activity in anxious compared to non-anxious children after treatment. This persistent pattern of enhanced activation suggests some brain regions, particularly limbic areas that modulate responses to anxiety-provoking stimuli, may be less responsive to the acute effects of CBT. Changing activity in these regions may require a longer duration of CBT, additional forms of treatment, or directly targeting subcortical brain areas. “Understanding the brain circuitry underpinning feelings of severe anxiety and determining which circuits normalize and which do not as anxiety symptoms improve with CBT is critical for advancing treatment and making it more effective for all children,” said first author Simone Haller, Ph.D., Director of Research and Analytics in the NIMH Neuroscience and Novel Therapeutics Unit. In this study, all children with anxiety received CBT. For comparison purposes, the researchers also measured brain activity in a separate sample of 87 youth who were at high risk for anxiety based on their infant temperament (for example, showing a high sensitivity to new situations). Because these children were not diagnosed with an anxiety disorder, they had not received CBT treatment. Their brain scans were taken at 10 and 13 years. In adolescents at temperamental risk for anxiety, higher brain activity was related to increased anxiety symptoms over time and matched the brain activity seen in children diagnosed with an anxiety disorder before treatment. This provides preliminary evidence that the brain changes in children with anxiety were driven by CBT and that they may offer a reliable neural marker of anxiety treatment. Anxiety disorders are common in children and can cause them significant distress in social and academic situations. They are also chronic, with a strong link into adulthood when they become harder to treat. Despite the effectiveness of CBT, many children continue to show anxiety symptoms after treatment. Enhancing the therapy to treat anxiety more effectively during childhood can have short- and long-term benefits and prevent more serious problems later in life. This study provides evidence—in a large group of unmedicated youth with anxiety disorders—of altered brain circuitry underlying treatment effects of CBT. The findings could, in time, be used to enhance treatment outcomes by targeting brain circuits linked to clinical improvement. This is particularly important for the subset of children who did not significantly improve after short-term CBT. “The next step for this research is to understand which children are most likely to respond. Are there factors we can assess before treatment begins to make the most informed decisions about who should get which treatment and when? Answering these questions would further translate our research findings into clinical practice,” said Brotman. This article originally appeared on www.nimh.nih.gov