Major Depressive Disorder

SAN DIEGO – While an “exciting” ketamine-based product is finally available and approved to treat treatment-resistant depression (TRD), there are still plenty of questions about the use of intranasal esketamine, a psychiatrist told colleagues.

“We have a lot of unmet needs in terms of research,” said Sanjay J. Mathew, MD, of Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, both in Houston, at the annual Psych Congress. “What do we do in the long term? What are the dosing strategies and response predictors? What about elderly patients?”

The Food and Drug Administration approved esketamine nasal spray (Spravato) for TRD in March 2019. Patients with TRD are defined as those with major depressive disorder who have failed at least two different antidepressants.

Dr. Mathew highlighted a 2019 randomized, double-blind, controlled study of patients who reached stable remission after 16 weeks on esketamine. It revealed there’s “a significant enhancement of the time to relapse for patients who remained on ketamine [compared with placebo] – a 51% risk reduction in the median number of days to relapse” (JAMA Psychiatry. 2019;76[9]:893-903).

However, about a quarter of patients still relapsed over the time of the study, Dr. Mathew said. “While this is certainly exciting, we need to talk to our patients about this and set expectations. And we need to emphasize close vigilance, follow-up, and psychotherapy.”

Patients should understand that, if patients are doing remarkably well at 16 weeks, “you’re not out of the woods. You really need to take it long term,” he said.

Dr. Mathew emphasized that patients must take the drug under supervision in a certified facility. “It’s a quick and simple process to do it [get certified] and get registered,” he said. Patients must be monitored over 2 hours and not drive for the rest of the day.

“You need space for some privacy, so a busy [postanesthesia care unit] or ER setting may not be optimal,” he said, adding that, “if you only have one office, it’s hard to pull this off for a number of logistical reasons.”

Dr. Mathew recommended lowering the level of stimulation in the room where the drug is administered. “We have a VA setting that can be loud with code greens blasting over the speaker,” he said. “That is not optimal, but at least we have a private room for our IV infusions. Keep the lights muted, let the patient listen to peaceful music that they enjoy. Having a family member close by can be helpful and comforting to them.”

He added that “you do need a way to recline the head. Having a barber-type chair would be necessary.”

Side effects are common, he said. Sedation is a major risk (49%-61%), as is dissociation (61%-75%). “It’s primarily a sense of alteration – perceptual alterations, altered sense of time, unreality, being disconnected from body, feeling unusually big in fingers or hands, or feeling like you’re unusually tall or skinny.”

Moving forward, more data about long-term effects and ideal doses are needed. “There are many clinics that go above 0.5 milligrams per kg, and some even go to 2. We have no good data,” he said.

People aged over 65 years have lower response rates, and men seem to respond less than women. Dr. Mathew also noted that the studies into the drug generally limited the number of antidepressant failures in patients: “Are there patients too refractory to be considered for this? How refractory is too refractory?”

Dr. Mathew reported various disclosures including a relationship with Janssen, manufacturer of intranasal esketamine.

SAN DIEGO – While an “exciting” ketamine-based product is finally available and approved to treat treatment-resistant depression (TRD), there are still plenty of questions about the use of intranasal esketamine, a psychiatrist told colleagues.

“We have a lot of unmet needs in terms of research,” said Sanjay J. Mathew, MD, of Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, both in Houston, at the annual Psych Congress. “What do we do in the long term? What are the dosing strategies and response predictors? What about elderly patients?”

The Food and Drug Administration approved esketamine nasal spray (Spravato) for TRD in March 2019. Patients with TRD are defined as those with major depressive disorder who have failed at least two different antidepressants.

Dr. Mathew highlighted a 2019 randomized, double-blind, controlled study of patients who reached stable remission after 16 weeks on esketamine. It revealed there’s “a significant enhancement of the time to relapse for patients who remained on ketamine [compared with placebo] – a 51% risk reduction in the median number of days to relapse” (JAMA Psychiatry. 2019;76[9]:893-903).

However, about a quarter of patients still relapsed over the time of the study, Dr. Mathew said. “While this is certainly exciting, we need to talk to our patients about this and set expectations. And we need to emphasize close vigilance, follow-up, and psychotherapy.”

Patients should understand that, if patients are doing remarkably well at 16 weeks, “you’re not out of the woods. You really need to take it long term,” he said.

Dr. Mathew emphasized that patients must take the drug under supervision in a certified facility. “It’s a quick and simple process to do it [get certified] and get registered,” he said. Patients must be monitored over 2 hours and not drive for the rest of the day.

“You need space for some privacy, so a busy [postanesthesia care unit] or ER setting may not be optimal,” he said, adding that, “if you only have one office, it’s hard to pull this off for a number of logistical reasons.”

Dr. Mathew recommended lowering the level of stimulation in the room where the drug is administered. “We have a VA setting that can be loud with code greens blasting over the speaker,” he said. “That is not optimal, but at least we have a private room for our IV infusions. Keep the lights muted, let the patient listen to peaceful music that they enjoy. Having a family member close by can be helpful and comforting to them.”

He added that “you do need a way to recline the head. Having a barber-type chair would be necessary.”

Side effects are common, he said. Sedation is a major risk (49%-61%), as is dissociation (61%-75%). “It’s primarily a sense of alteration – perceptual alterations, altered sense of time, unreality, being disconnected from body, feeling unusually big in fingers or hands, or feeling like you’re unusually tall or skinny.”

Moving forward, more data about long-term effects and ideal doses are needed. “There are many clinics that go above 0.5 milligrams per kg, and some even go to 2. We have no good data,” he said.

People aged over 65 years have lower response rates, and men seem to respond less than women. Dr. Mathew also noted that the studies into the drug generally limited the number of antidepressant failures in patients: “Are there patients too refractory to be considered for this? How refractory is too refractory?”

Dr. Mathew reported various disclosures including a relationship with Janssen, manufacturer of intranasal esketamine.

SAN DIEGO – While an “exciting” ketamine-based product is finally available and approved to treat treatment-resistant depression (TRD), there are still plenty of questions about the use of intranasal esketamine, a psychiatrist told colleagues.

“We have a lot of unmet needs in terms of research,” said Sanjay J. Mathew, MD, of Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, both in Houston, at the annual Psych Congress. “What do we do in the long term? What are the dosing strategies and response predictors? What about elderly patients?”

The Food and Drug Administration approved esketamine nasal spray (Spravato) for TRD in March 2019. Patients with TRD are defined as those with major depressive disorder who have failed at least two different antidepressants.

Dr. Mathew highlighted a 2019 randomized, double-blind, controlled study of patients who reached stable remission after 16 weeks on esketamine. It revealed there’s “a significant enhancement of the time to relapse for patients who remained on ketamine [compared with placebo] – a 51% risk reduction in the median number of days to relapse” (JAMA Psychiatry. 2019;76[9]:893-903).

However, about a quarter of patients still relapsed over the time of the study, Dr. Mathew said. “While this is certainly exciting, we need to talk to our patients about this and set expectations. And we need to emphasize close vigilance, follow-up, and psychotherapy.”

Patients should understand that, if patients are doing remarkably well at 16 weeks, “you’re not out of the woods. You really need to take it long term,” he said.

Dr. Mathew emphasized that patients must take the drug under supervision in a certified facility. “It’s a quick and simple process to do it [get certified] and get registered,” he said. Patients must be monitored over 2 hours and not drive for the rest of the day.

“You need space for some privacy, so a busy [postanesthesia care unit] or ER setting may not be optimal,” he said, adding that, “if you only have one office, it’s hard to pull this off for a number of logistical reasons.”

Dr. Mathew recommended lowering the level of stimulation in the room where the drug is administered. “We have a VA setting that can be loud with code greens blasting over the speaker,” he said. “That is not optimal, but at least we have a private room for our IV infusions. Keep the lights muted, let the patient listen to peaceful music that they enjoy. Having a family member close by can be helpful and comforting to them.”

He added that “you do need a way to recline the head. Having a barber-type chair would be necessary.”

Side effects are common, he said. Sedation is a major risk (49%-61%), as is dissociation (61%-75%). “It’s primarily a sense of alteration – perceptual alterations, altered sense of time, unreality, being disconnected from body, feeling unusually big in fingers or hands, or feeling like you’re unusually tall or skinny.”

Moving forward, more data about long-term effects and ideal doses are needed. “There are many clinics that go above 0.5 milligrams per kg, and some even go to 2. We have no good data,” he said.

People aged over 65 years have lower response rates, and men seem to respond less than women. Dr. Mathew also noted that the studies into the drug generally limited the number of antidepressant failures in patients: “Are there patients too refractory to be considered for this? How refractory is too refractory?”

Dr. Mathew reported various disclosures including a relationship with Janssen, manufacturer of intranasal esketamine.

Four genetic variations appear to link psychotic experiences with other psychiatric disorders, including schizophrenia, major depressive disorder, bipolar disorder, and neurodevelopmental disorders, a large genetic study has concluded.

The findings suggest that psychotic experiences might not be specifically driven by schizophrenia but instead are associated with a generally increased risk for a mental health disorder, reported Sophie E. Legge, PhD, and colleagues. Their study was published in JAMA Psychiatry.

Although it is informative, the study is unlikely to expand the knowledge of schizophrenia-specific genetics.

“Consistent with other studies, the heritability estimate (1.71%) was low, and given that the variance explained in our polygenic risk analysis was also low, the finding suggests that understanding the genetics of psychotic experiences is unlikely to have an important effect on understanding the genetics of schizophrenia specifically,” wrote Dr. Legge, of the MRC Center for Neuropsychiatric Genetics and Genomics in the division of psychological medicine and clinical neurosciences at Cardiff (Wales) University, and colleagues.

The team conducted a genomewide association study (GWAS) using data from 127,966 individuals in the U.K. Biobank. Of these, 6,123 reported any psychotic experience, 2,143 reported distressing psychotic experiences, and 3,337 reported multiple experiences. The remainder served as controls. At the time of the biobank data collection, the subjects were a mean of 64 years of age; 56% were women.

First psychotic experience occurred at a mean of almost 32 years of age, but about a third reported that the first episode occurred before age 20, or that psychotic experiences had been happening ever since they could remember. Another third reported their first experience between ages 40 and 76 years.

The investigators conducted three GWAS studies: one for any psychotic experience, one for distressing experiences, and one for multiple experiences.

No significant genetic associations were found among those with multiple psychotic experiences, the authors said.

But they did find four variants significantly associated with the other experience categories.

Two variants were associated with any psychotic experience. Those with rs10994278, an intronic variant within Ankyrin-3 (ANK3), were 16% more likely to have a psychotic experience (odds ratio, 1.16). Those with intergenic variant rs549656827 were 39% less likely (OR, 0.61). “The ANK3 gene encodes ankyrin-G, a protein that has been shown to regulate the assembly of voltage-gated sodium channels and is essential for normal synaptic function,” the authors said. “ANK3 is one of strongest and most replicated genes for bipolar disorder, and variants within ANK3 have also been associated in the Psychiatric Genomics Consortium cross-disorder GWAS, and in a rare variant analysis of autism spectrum disorder.”

Two variants were linked to distressing psychotic experiences: rs75459873, intronic to cannabinoid receptor 2 (CNR2), decreased the risk by 34% (OR, 0.66). Intergenic variant rs3849810 increased the risk by 12% (OR, 1.12).

“CNR2 encodes for CB2, one of two well-characterized cannabinoid receptors. Several lines of evidence have implicated the endocannabinoid system in psychiatric disorders, including schizophrenia and depression. The main psychoactive agent of cannabis, tetrahydrocannabinol, can cause acute psychotic symptoms and cognitive impairment. Given that cannabis use is strongly associated with psychotic experiences, we tested, but found no evidence for, a mediating or moderating effect of cannabis use on the association of rs75459873 and distressing psychotic experiences. However, while no evidence was found in this study, a mediating effect of cannabis use cannot be ruled out given the relatively low power of such analyses and the potential measurement error.”

Also, significant genetic correlations were found between any psychotic experiences and major depressive disorder, autism spectrum disorder, ADHD, and schizophrenia. However, the polygenic risk scores for schizophrenia, major depressive disorder, bipolar disorder, ADHD, and autism spectrum disorder, were low.

“We also considered individual psychotic symptoms and found that polygenic risk scores for schizophrenia, bipolar disorder, depression, and ADHD were more strongly associated with delusions of persecution than with the other psychotic symptoms.”

Those with distressing psychotic experiences tended to have more copy number variations (CNVs) associated with schizophrenia (OR, 2.04) and neurodevelopmental disorders (OR, 1.75). The team also found significant associations between distressing experiences and major depressive disorder, ADHD, autism spectrum disorder, and schizophrenia.

“We found particular enrichment of these [polygenic risk scores] in distressing psychotic experiences and for delusions of persecution,” they noted. “ ... All schizophrenia-associated [copy number variations] are also associated with neurodevelopmental disorders such as intellectual disability and autism.”

The study’s strengths include its large sample size. Among its limitations, the researchers said, are the study’s retrospective measurement of psychotic experiences based on self-report from a questionnaire that was online. Gathering the data in that way raised the likelihood of possible error, they said.

Dr. Legge reported having no disclosures.

[email protected]

SOURCE: Legge SE et al. JAMA Psychiatry. 2019 Sep 25. doi: 10.1001/jamapsychiatry.2019.2508.

Four genetic variations appear to link psychotic experiences with other psychiatric disorders, including schizophrenia, major depressive disorder, bipolar disorder, and neurodevelopmental disorders, a large genetic study has concluded.

The findings suggest that psychotic experiences might not be specifically driven by schizophrenia but instead are associated with a generally increased risk for a mental health disorder, reported Sophie E. Legge, PhD, and colleagues. Their study was published in JAMA Psychiatry.

Although it is informative, the study is unlikely to expand the knowledge of schizophrenia-specific genetics.

“Consistent with other studies, the heritability estimate (1.71%) was low, and given that the variance explained in our polygenic risk analysis was also low, the finding suggests that understanding the genetics of psychotic experiences is unlikely to have an important effect on understanding the genetics of schizophrenia specifically,” wrote Dr. Legge, of the MRC Center for Neuropsychiatric Genetics and Genomics in the division of psychological medicine and clinical neurosciences at Cardiff (Wales) University, and colleagues.

The team conducted a genomewide association study (GWAS) using data from 127,966 individuals in the U.K. Biobank. Of these, 6,123 reported any psychotic experience, 2,143 reported distressing psychotic experiences, and 3,337 reported multiple experiences. The remainder served as controls. At the time of the biobank data collection, the subjects were a mean of 64 years of age; 56% were women.

First psychotic experience occurred at a mean of almost 32 years of age, but about a third reported that the first episode occurred before age 20, or that psychotic experiences had been happening ever since they could remember. Another third reported their first experience between ages 40 and 76 years.

The investigators conducted three GWAS studies: one for any psychotic experience, one for distressing experiences, and one for multiple experiences.

No significant genetic associations were found among those with multiple psychotic experiences, the authors said.

But they did find four variants significantly associated with the other experience categories.

Two variants were associated with any psychotic experience. Those with rs10994278, an intronic variant within Ankyrin-3 (ANK3), were 16% more likely to have a psychotic experience (odds ratio, 1.16). Those with intergenic variant rs549656827 were 39% less likely (OR, 0.61). “The ANK3 gene encodes ankyrin-G, a protein that has been shown to regulate the assembly of voltage-gated sodium channels and is essential for normal synaptic function,” the authors said. “ANK3 is one of strongest and most replicated genes for bipolar disorder, and variants within ANK3 have also been associated in the Psychiatric Genomics Consortium cross-disorder GWAS, and in a rare variant analysis of autism spectrum disorder.”

Two variants were linked to distressing psychotic experiences: rs75459873, intronic to cannabinoid receptor 2 (CNR2), decreased the risk by 34% (OR, 0.66). Intergenic variant rs3849810 increased the risk by 12% (OR, 1.12).

“CNR2 encodes for CB2, one of two well-characterized cannabinoid receptors. Several lines of evidence have implicated the endocannabinoid system in psychiatric disorders, including schizophrenia and depression. The main psychoactive agent of cannabis, tetrahydrocannabinol, can cause acute psychotic symptoms and cognitive impairment. Given that cannabis use is strongly associated with psychotic experiences, we tested, but found no evidence for, a mediating or moderating effect of cannabis use on the association of rs75459873 and distressing psychotic experiences. However, while no evidence was found in this study, a mediating effect of cannabis use cannot be ruled out given the relatively low power of such analyses and the potential measurement error.”

Also, significant genetic correlations were found between any psychotic experiences and major depressive disorder, autism spectrum disorder, ADHD, and schizophrenia. However, the polygenic risk scores for schizophrenia, major depressive disorder, bipolar disorder, ADHD, and autism spectrum disorder, were low.

“We also considered individual psychotic symptoms and found that polygenic risk scores for schizophrenia, bipolar disorder, depression, and ADHD were more strongly associated with delusions of persecution than with the other psychotic symptoms.”

Those with distressing psychotic experiences tended to have more copy number variations (CNVs) associated with schizophrenia (OR, 2.04) and neurodevelopmental disorders (OR, 1.75). The team also found significant associations between distressing experiences and major depressive disorder, ADHD, autism spectrum disorder, and schizophrenia.

“We found particular enrichment of these [polygenic risk scores] in distressing psychotic experiences and for delusions of persecution,” they noted. “ ... All schizophrenia-associated [copy number variations] are also associated with neurodevelopmental disorders such as intellectual disability and autism.”

The study’s strengths include its large sample size. Among its limitations, the researchers said, are the study’s retrospective measurement of psychotic experiences based on self-report from a questionnaire that was online. Gathering the data in that way raised the likelihood of possible error, they said.

Dr. Legge reported having no disclosures.

[email protected]

SOURCE: Legge SE et al. JAMA Psychiatry. 2019 Sep 25. doi: 10.1001/jamapsychiatry.2019.2508.

Four genetic variations appear to link psychotic experiences with other psychiatric disorders, including schizophrenia, major depressive disorder, bipolar disorder, and neurodevelopmental disorders, a large genetic study has concluded.

The findings suggest that psychotic experiences might not be specifically driven by schizophrenia but instead are associated with a generally increased risk for a mental health disorder, reported Sophie E. Legge, PhD, and colleagues. Their study was published in JAMA Psychiatry.

Although it is informative, the study is unlikely to expand the knowledge of schizophrenia-specific genetics.

“Consistent with other studies, the heritability estimate (1.71%) was low, and given that the variance explained in our polygenic risk analysis was also low, the finding suggests that understanding the genetics of psychotic experiences is unlikely to have an important effect on understanding the genetics of schizophrenia specifically,” wrote Dr. Legge, of the MRC Center for Neuropsychiatric Genetics and Genomics in the division of psychological medicine and clinical neurosciences at Cardiff (Wales) University, and colleagues.

The team conducted a genomewide association study (GWAS) using data from 127,966 individuals in the U.K. Biobank. Of these, 6,123 reported any psychotic experience, 2,143 reported distressing psychotic experiences, and 3,337 reported multiple experiences. The remainder served as controls. At the time of the biobank data collection, the subjects were a mean of 64 years of age; 56% were women.

First psychotic experience occurred at a mean of almost 32 years of age, but about a third reported that the first episode occurred before age 20, or that psychotic experiences had been happening ever since they could remember. Another third reported their first experience between ages 40 and 76 years.

The investigators conducted three GWAS studies: one for any psychotic experience, one for distressing experiences, and one for multiple experiences.

No significant genetic associations were found among those with multiple psychotic experiences, the authors said.

But they did find four variants significantly associated with the other experience categories.

Two variants were associated with any psychotic experience. Those with rs10994278, an intronic variant within Ankyrin-3 (ANK3), were 16% more likely to have a psychotic experience (odds ratio, 1.16). Those with intergenic variant rs549656827 were 39% less likely (OR, 0.61). “The ANK3 gene encodes ankyrin-G, a protein that has been shown to regulate the assembly of voltage-gated sodium channels and is essential for normal synaptic function,” the authors said. “ANK3 is one of strongest and most replicated genes for bipolar disorder, and variants within ANK3 have also been associated in the Psychiatric Genomics Consortium cross-disorder GWAS, and in a rare variant analysis of autism spectrum disorder.”

Two variants were linked to distressing psychotic experiences: rs75459873, intronic to cannabinoid receptor 2 (CNR2), decreased the risk by 34% (OR, 0.66). Intergenic variant rs3849810 increased the risk by 12% (OR, 1.12).

“CNR2 encodes for CB2, one of two well-characterized cannabinoid receptors. Several lines of evidence have implicated the endocannabinoid system in psychiatric disorders, including schizophrenia and depression. The main psychoactive agent of cannabis, tetrahydrocannabinol, can cause acute psychotic symptoms and cognitive impairment. Given that cannabis use is strongly associated with psychotic experiences, we tested, but found no evidence for, a mediating or moderating effect of cannabis use on the association of rs75459873 and distressing psychotic experiences. However, while no evidence was found in this study, a mediating effect of cannabis use cannot be ruled out given the relatively low power of such analyses and the potential measurement error.”

Also, significant genetic correlations were found between any psychotic experiences and major depressive disorder, autism spectrum disorder, ADHD, and schizophrenia. However, the polygenic risk scores for schizophrenia, major depressive disorder, bipolar disorder, ADHD, and autism spectrum disorder, were low.

“We also considered individual psychotic symptoms and found that polygenic risk scores for schizophrenia, bipolar disorder, depression, and ADHD were more strongly associated with delusions of persecution than with the other psychotic symptoms.”

Those with distressing psychotic experiences tended to have more copy number variations (CNVs) associated with schizophrenia (OR, 2.04) and neurodevelopmental disorders (OR, 1.75). The team also found significant associations between distressing experiences and major depressive disorder, ADHD, autism spectrum disorder, and schizophrenia.

“We found particular enrichment of these [polygenic risk scores] in distressing psychotic experiences and for delusions of persecution,” they noted. “ ... All schizophrenia-associated [copy number variations] are also associated with neurodevelopmental disorders such as intellectual disability and autism.”

The study’s strengths include its large sample size. Among its limitations, the researchers said, are the study’s retrospective measurement of psychotic experiences based on self-report from a questionnaire that was online. Gathering the data in that way raised the likelihood of possible error, they said.

Dr. Legge reported having no disclosures.

[email protected]

SOURCE: Legge SE et al. JAMA Psychiatry. 2019 Sep 25. doi: 10.1001/jamapsychiatry.2019.2508.

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

[email protected]

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

[email protected]

As youth suicides continue to climb nationwide, a growing body of research shows that the deaths are happening at higher rates in rural communities.

Courtesy Dr. Kriechman

In 2017, suicides reached their highest point since 2000, a trend driven by a sharp rise in male suicides and in youth aged 15-19 years, according to an analysis published recently in JAMA (2019 Jun 18. doi: 10.1001/jama.2019.5054). Among youth aged 15-19 years, the suicide rate was 12 per 100,000 in 2017 (18 per 100,000 in males and 5 per 100,000 in females), compared with 8 per 100,000 in 2000, the study found. Across all age groups, the highest suicide rates and greatest rate increases are in rural counties, according to data from the Centers for Disease Control and Prevention (CDC).

Now, a unique initiative in New Mexico is working to combat those alarming trends through an alliance of community leaders that strives to strengthen resilience and build peer support for at-risk youth.

The Alliance-Building for Suicide Prevention & Youth Resilience (ASPYR) program, created by the University of New Mexico (UNM), Albuquerque, focuses on training professionals and advocates within New Mexico communities in a strength-based, youth-directed, collaborative approach for the assessment and treatment of suicidality. A diversity of community members undergo the training, including health and behavioral health care providers, peer support and community support workers, youth and community advocates, educators, and first responders. The initiative also supports and facilitates the development of a communitywide crisis intervention plan that promotes youth safety and resilience.

“ASPYR is unique, in that we actively involve youth to guide our program, versus an adult-only led program,” says Laura Rombach, program manager for ASPYR and a senior program therapist in the department of psychiatry and behavioral sciences at UNM. “Youth offer feedback about our training and ideas about how to best prevent suicide in their schools and communities. New Mexico is underresourced, and individuals living in rural/frontier areas do not always have access to licensed behavioral health providers, so our training is developed for licensed providers as well as peers and paraprofessionals to increase the knowledge of care for individuals experiencing a suicidal crisis.”
 

Rural populations present challenges

The many rural pockets of New Mexico pose numerous obstacles for antisuicide advocates.

Of the 33 counties in New Mexico, six are identified by the Census Bureau as completely “rural,” and an additional six are defined as mostly rural, according to the University of New Mexico Bureau of Business & Economic Research. Even among counties considered “urban” however, a considerable amount of the population lives in rural areas, according to the bureau. San Juan County, for example, which is considered urban by the Census Bureau, had an estimated 34% of residents living in rural areas in 2010.

Poverty adds to the difficulty. In 2017, nearly one in five New Mexicans (20%) lived below the poverty line, and the state had the second-highest rate of children under 18 years living in poverty in the country, according to a report by the New Mexico Department of Workforce Solutions.

“New Mexico is an impoverished state with limited capacity, especially in regards to behavioral health services,” said Avi Kriechman, MD, principal investigator for ASPYR at UNM and a child, adolescent, and family psychiatrist at the university. “It is also challenging to create a truly statewide effort where there is limited public transportation, problematic Internet connection, and other barriers to involving those who live and work in rural and frontier New Mexico.”

Addressing suicide among the many native and Indigenous people in rural New Mexico presents another unique set of challenges, said Mary Roessel, MD, a Santa Fe, N.M.–based psychiatrist who specializes in cultural psychiatry. Native and Indigenous residents often have a general mistrust of outsiders and a stigma against mental illnesses, Dr. Roessel said in an interview.

“One of the problems is being able to identify when a person has attempted suicide in some of these small, private, Pueblo communities because they are very closed,” she said. “At times, we don’t get the information to go in and help them. They’re trying to address or deal with the problem themselves.”

To address the many barriers of rural New Mexico, ASPYR works hard to recognize, identify, and support preexisting community resources that are often neglected in needs assessment and stakeholder identification, Dr. Kriechman said. This can include food banks, church care committees, youth advocacy groups, local caregiving, and spiritual traditions, among others. Frequently, many community caregivers and agencies have not connected or communicated with one another and often are unaware of all they have to offer, he said.

“We try to build capacity through community trainings, which include a widely diverse group of providers, advocates, and supports,” he continued. “Our trainings involve highlighting and building upon local and cultural practices and traditions of healing, caregiving, and support. A significant part of our onsite training involves assembling a representative group of local providers in health care, behavioral health care, peer & community support and advocacy, education, first responders to community crises, and government and nonprofit agencies, then facilitating a community conversation between the panel and training attendees about how best to move forward in a synergistic and systemic manner to support youth safety and resilience.”
 

Peers support peers

While ASPYR encompasses elements of other suicide prevention models, two unique cornerstones of the program are its emphasis on resilience and promotion of peer support. The strength-based, youth-directed approach includes creating a youth-directed safety plan, enlisting peers as support and reducing access to lethal means.

Regarding the youth safety plan, Dr. Kriechman explained that, rather than being prescribed and instructed in expert-selected and expert-driven coping skills, youth are offered a menu of options that most speak to their strengths, values, experience, and preferences. Young people also select a peer who, if they wish, accompanies them to sessions, and supports and coaches them at home.

“Peers are often more influential than parents, siblings, family members, and adults regarding youth behavior,” Dr. Kriechman said. “Most often, it is a peer that a youth-at-risk turns to for support, counsel, role models, and understanding. Youth who wish to offer their peers support can quickly be trained to provide early identification of youth at risk, motivational support to seek help, and a ‘warm hand-off’ to community resources.”

In addition, a Youth Advisory Council established as part of the program draws from young people across New Mexico to participate in state and national conferences, and conduct outreach efforts to peers.

ASPYR Youth council member Serenity Gomez, a senior at the Public Academy for Performing Arts in Albuquerque, became interested in ASPYR after volunteering for the American Foundation for Suicide Prevention in 2016. As a youth council member, Ms. Gomez said she helps create projects to raise suicide awareness, whether through posters, stickers, social media, poetry, or songs.

“My experience as a youth council member has really opened my eyes and has made me more motivated to help others,” she said in an interview. “It has also showed me that talking about suicide doesn’t always have to be a slideshow of facts. You can reach people through music, poetry, storytelling, and so much more. Many people are afraid to talk about suicide because it’s such a scary idea, but if we all talk about it and bring more awareness, then we can find the support everyone needs. In ASPYR, specifically, I hope to reach youth and help all youth learn to support each other.”

Since ASPYR launched in 2017, the program has provided both onsite and online trainings to hundreds of New Mexicans, and has helped rural and frontier communities start working on collaborative approaches to promoting youth safety and resilience, Dr. Kriechman said. Following community consultations, numerous rural communities have since formed systems of care to identify, support, and treat youth at risk. In addition to the youth council, an Advisory Community Council has also been established that welcomes any New Mexico resident interested in working on the mission of preventing youth suicide.

The program’s approach of focusing on strengths, rather than deficits, has resonated strongly with community providers with whom the program partners, Dr. Kriechman added. For example, the program shifts from “no-suicide contracts” to safety planning, focusing on reasons for living rather than reasons for dying, and shifting from prescribing coping skills to strengthening preexisting coping skills in young people.

“An ultimate hope for ASPYR is emphasizing that recovery from any of life’s challenges is far more than symptom reduction or agency collaboration,” Dr. Kriechman said. “It is the understanding that a life of value and meaning, the instillation of hope and support for the unique strengths, competencies, skills, and understandings of each individual, is honored, respected, and supported.”

[email protected]

SAN FRANCISCO – In a proof-of-concept study, music provided an alternative to oral psychotropic medication in calming agitated patients at an inpatient psychiatric facility. Music has been studied as a treatment for agitation in dementia patients but not so much in psychiatric patients, according to Trevor Scudamore, MD, who is a resident fellow at State University of New York, Syracuse.

Jim Kling/MDedge News

“The other thing is that music has been more looked at in group therapy settings than as adjunct therapy, or as an option as an as-needed medication for agitation,” Dr. Scudamore said in an interview. He presented the study at a poster session at the annual meeting of the American Psychiatric Association.

When agitation arose, the program allowed patients to choose between an oral medication or music, which entailed a 30-minute session listening to a preset playlist using a wireless headphone. Playlist options included a variety of musical genres, and participants could sit in one place or roam around while listening.

Traditionally, agitated patients had the choice of an oral medication. If the patient refused and then escalated, they had to accept an intravenous medication. “Now there’s a choice between an oral medication and music, almost like a third layer in defusing agitation in the patient. If they refuse music, then they could go for oral medication, and then [IV medication]. They’re given a little bit more options. Maybe they don’t feel so confined, which is an interesting way of helping possibly defuse anxiety from a situation. That needs to be explored further,” Dr. Scudamore said.

The study had a two-phase, cross-sectional design. The first 3 months, the study included 71 patients, who were used to establish a baseline of agitation and psychotropic medication use. They introduced the music intervention during the second 3-month period, with 101 participants. After they listened to music, the patients completed a self-report form using the Likert scale, and nursing staff observed the patients status during the initial anxiety/agitation, while they listened to music, and 15 minutes after the listening session.

That need for commitment from nurses presented a challenge to implementation. They had to hand out headphones, keep track of them, and make sure they got the headphones back. “It is a lot more work than just giving 50 mg of hydroxyzine,” said coauthor Christopher Botash, MD, who also is a resident at the university.

Study participants had a range of psychiatric ills, including substance abuse (61%), depression (51%), psychosis (28%), trauma (26%), personality disorder (20%), and anxiety (17%).

As part of a preliminary report, the researchers presented data from surveys completed by nine nurses and 31 patients. After the music implementation, the average length of stay declined (10.49 to 8.20 days; difference, 2.29 days), as did the median length of stay (6.5 to 5.0 days). The two most commonly prescribed antipsychotics saw a decrease in administrations, from 3.37 to 2.93/month for haloperidol, and from 3.83 to 2.73 administrations/month for olanzapine.

A total of 56% of the nursing staff stated that the music therapy program helped calm down the patients. Nurses who disagreed cited the tendency for patients to intrude at the nursing station asking for the music, though this improved as patients learned the routine. Ninety-six percent of the patients reported satisfaction with the experience.

It was challenging for the researchers to implement the study, since offering music was a break in the routine. “The staff really does rely a lot on the meds, so oftentimes we would have to say, ‘Hey, have you offered the music yet?’ It’s a bit of a culture change,” Dr. Botash said.

The study, which Dr. Scudamore and Dr. Botash coauthored with Nekpen S. Ekure, MD, did not receive external funding. Dr. Scudamore and Dr. Botash had no relevant financial disclosures.

SAN FRANCISCO – In a proof-of-concept study, music provided an alternative to oral psychotropic medication in calming agitated patients at an inpatient psychiatric facility. Music has been studied as a treatment for agitation in dementia patients but not so much in psychiatric patients, according to Trevor Scudamore, MD, who is a resident fellow at State University of New York, Syracuse.

Jim Kling/MDedge News

“The other thing is that music has been more looked at in group therapy settings than as adjunct therapy, or as an option as an as-needed medication for agitation,” Dr. Scudamore said in an interview. He presented the study at a poster session at the annual meeting of the American Psychiatric Association.

When agitation arose, the program allowed patients to choose between an oral medication or music, which entailed a 30-minute session listening to a preset playlist using a wireless headphone. Playlist options included a variety of musical genres, and participants could sit in one place or roam around while listening.

Traditionally, agitated patients had the choice of an oral medication. If the patient refused and then escalated, they had to accept an intravenous medication. “Now there’s a choice between an oral medication and music, almost like a third layer in defusing agitation in the patient. If they refuse music, then they could go for oral medication, and then [IV medication]. They’re given a little bit more options. Maybe they don’t feel so confined, which is an interesting way of helping possibly defuse anxiety from a situation. That needs to be explored further,” Dr. Scudamore said.

The study had a two-phase, cross-sectional design. The first 3 months, the study included 71 patients, who were used to establish a baseline of agitation and psychotropic medication use. They introduced the music intervention during the second 3-month period, with 101 participants. After they listened to music, the patients completed a self-report form using the Likert scale, and nursing staff observed the patients status during the initial anxiety/agitation, while they listened to music, and 15 minutes after the listening session.

That need for commitment from nurses presented a challenge to implementation. They had to hand out headphones, keep track of them, and make sure they got the headphones back. “It is a lot more work than just giving 50 mg of hydroxyzine,” said coauthor Christopher Botash, MD, who also is a resident at the university.

Study participants had a range of psychiatric ills, including substance abuse (61%), depression (51%), psychosis (28%), trauma (26%), personality disorder (20%), and anxiety (17%).

As part of a preliminary report, the researchers presented data from surveys completed by nine nurses and 31 patients. After the music implementation, the average length of stay declined (10.49 to 8.20 days; difference, 2.29 days), as did the median length of stay (6.5 to 5.0 days). The two most commonly prescribed antipsychotics saw a decrease in administrations, from 3.37 to 2.93/month for haloperidol, and from 3.83 to 2.73 administrations/month for olanzapine.

A total of 56% of the nursing staff stated that the music therapy program helped calm down the patients. Nurses who disagreed cited the tendency for patients to intrude at the nursing station asking for the music, though this improved as patients learned the routine. Ninety-six percent of the patients reported satisfaction with the experience.

It was challenging for the researchers to implement the study, since offering music was a break in the routine. “The staff really does rely a lot on the meds, so oftentimes we would have to say, ‘Hey, have you offered the music yet?’ It’s a bit of a culture change,” Dr. Botash said.

The study, which Dr. Scudamore and Dr. Botash coauthored with Nekpen S. Ekure, MD, did not receive external funding. Dr. Scudamore and Dr. Botash had no relevant financial disclosures.

SAN FRANCISCO – In a proof-of-concept study, music provided an alternative to oral psychotropic medication in calming agitated patients at an inpatient psychiatric facility. Music has been studied as a treatment for agitation in dementia patients but not so much in psychiatric patients, according to Trevor Scudamore, MD, who is a resident fellow at State University of New York, Syracuse.

Jim Kling/MDedge News

“The other thing is that music has been more looked at in group therapy settings than as adjunct therapy, or as an option as an as-needed medication for agitation,” Dr. Scudamore said in an interview. He presented the study at a poster session at the annual meeting of the American Psychiatric Association.

When agitation arose, the program allowed patients to choose between an oral medication or music, which entailed a 30-minute session listening to a preset playlist using a wireless headphone. Playlist options included a variety of musical genres, and participants could sit in one place or roam around while listening.

Traditionally, agitated patients had the choice of an oral medication. If the patient refused and then escalated, they had to accept an intravenous medication. “Now there’s a choice between an oral medication and music, almost like a third layer in defusing agitation in the patient. If they refuse music, then they could go for oral medication, and then [IV medication]. They’re given a little bit more options. Maybe they don’t feel so confined, which is an interesting way of helping possibly defuse anxiety from a situation. That needs to be explored further,” Dr. Scudamore said.

The study had a two-phase, cross-sectional design. The first 3 months, the study included 71 patients, who were used to establish a baseline of agitation and psychotropic medication use. They introduced the music intervention during the second 3-month period, with 101 participants. After they listened to music, the patients completed a self-report form using the Likert scale, and nursing staff observed the patients status during the initial anxiety/agitation, while they listened to music, and 15 minutes after the listening session.

That need for commitment from nurses presented a challenge to implementation. They had to hand out headphones, keep track of them, and make sure they got the headphones back. “It is a lot more work than just giving 50 mg of hydroxyzine,” said coauthor Christopher Botash, MD, who also is a resident at the university.

Study participants had a range of psychiatric ills, including substance abuse (61%), depression (51%), psychosis (28%), trauma (26%), personality disorder (20%), and anxiety (17%).

As part of a preliminary report, the researchers presented data from surveys completed by nine nurses and 31 patients. After the music implementation, the average length of stay declined (10.49 to 8.20 days; difference, 2.29 days), as did the median length of stay (6.5 to 5.0 days). The two most commonly prescribed antipsychotics saw a decrease in administrations, from 3.37 to 2.93/month for haloperidol, and from 3.83 to 2.73 administrations/month for olanzapine.

A total of 56% of the nursing staff stated that the music therapy program helped calm down the patients. Nurses who disagreed cited the tendency for patients to intrude at the nursing station asking for the music, though this improved as patients learned the routine. Ninety-six percent of the patients reported satisfaction with the experience.

It was challenging for the researchers to implement the study, since offering music was a break in the routine. “The staff really does rely a lot on the meds, so oftentimes we would have to say, ‘Hey, have you offered the music yet?’ It’s a bit of a culture change,” Dr. Botash said.

The study, which Dr. Scudamore and Dr. Botash coauthored with Nekpen S. Ekure, MD, did not receive external funding. Dr. Scudamore and Dr. Botash had no relevant financial disclosures.

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

SAN FRANCISCO – Psychiatrists see and interact with people who are being sex and labor trafficked “all the time” – and can learn more about how to identify these individuals, Rachel Robitz, MD, said at the annual meeting of the American Psychiatric Association.

In an exclusive video, Mollie Gordon, MD, interviewed Dr. Robitz about the intersection between trafficking and mental health. “What scares me the most is some of the statistics about self-harm,” said Dr. Robitz. “One study of sex-trafficked adults found that about 40% of them had a history of a suicide attempt. A study of sex-trafficked minors found that about 30% of them had a history of moderate to severe self-harm behavior.”

One way to ensure that trafficked individuals are not missed in clinical settings is to develop protocols like those described in the Health, Education, Advocacy, Linkage (HEAL) trafficking toolkit, Dr. Robitz said. Other resources include those provided by the Department of Health & Human Services’s Office on Trafficking in Persons.

Dr. Robitz, who is double boarded in psychiatry and family medicine, is with the University of California, Davis. She previously worked for a program for homeless youth and for many programs aimed at helping adult and youth survivors of human trafficking. Dr. Robitz has no disclosures. Dr. Gordon is associate professor of psychiatry in the Menninger department of behavioral health at Baylor College of Medicine, Houston. She is a founding member of the Houston Area Human Trafficking Health Care Consortium. Dr. Gordon has no disclosures.

[email protected]

SAN FRANCISCO – Psychiatrists see and interact with people who are being sex and labor trafficked “all the time” – and can learn more about how to identify these individuals, Rachel Robitz, MD, said at the annual meeting of the American Psychiatric Association.

In an exclusive video, Mollie Gordon, MD, interviewed Dr. Robitz about the intersection between trafficking and mental health. “What scares me the most is some of the statistics about self-harm,” said Dr. Robitz. “One study of sex-trafficked adults found that about 40% of them had a history of a suicide attempt. A study of sex-trafficked minors found that about 30% of them had a history of moderate to severe self-harm behavior.”

One way to ensure that trafficked individuals are not missed in clinical settings is to develop protocols like those described in the Health, Education, Advocacy, Linkage (HEAL) trafficking toolkit, Dr. Robitz said. Other resources include those provided by the Department of Health & Human Services’s Office on Trafficking in Persons.

Dr. Robitz, who is double boarded in psychiatry and family medicine, is with the University of California, Davis. She previously worked for a program for homeless youth and for many programs aimed at helping adult and youth survivors of human trafficking. Dr. Robitz has no disclosures. Dr. Gordon is associate professor of psychiatry in the Menninger department of behavioral health at Baylor College of Medicine, Houston. She is a founding member of the Houston Area Human Trafficking Health Care Consortium. Dr. Gordon has no disclosures.

[email protected]

SAN FRANCISCO – Psychiatrists see and interact with people who are being sex and labor trafficked “all the time” – and can learn more about how to identify these individuals, Rachel Robitz, MD, said at the annual meeting of the American Psychiatric Association.

In an exclusive video, Mollie Gordon, MD, interviewed Dr. Robitz about the intersection between trafficking and mental health. “What scares me the most is some of the statistics about self-harm,” said Dr. Robitz. “One study of sex-trafficked adults found that about 40% of them had a history of a suicide attempt. A study of sex-trafficked minors found that about 30% of them had a history of moderate to severe self-harm behavior.”

One way to ensure that trafficked individuals are not missed in clinical settings is to develop protocols like those described in the Health, Education, Advocacy, Linkage (HEAL) trafficking toolkit, Dr. Robitz said. Other resources include those provided by the Department of Health & Human Services’s Office on Trafficking in Persons.

Dr. Robitz, who is double boarded in psychiatry and family medicine, is with the University of California, Davis. She previously worked for a program for homeless youth and for many programs aimed at helping adult and youth survivors of human trafficking. Dr. Robitz has no disclosures. Dr. Gordon is associate professor of psychiatry in the Menninger department of behavioral health at Baylor College of Medicine, Houston. She is a founding member of the Houston Area Human Trafficking Health Care Consortium. Dr. Gordon has no disclosures.

[email protected]