Mental Health

The American Psychiatric Association has released an online screening and assessment tool for eating disorders.

“People with eating disorders have a high rate of mortality and [the disorder is] growing in prevalence among young adults and adolescents,” APA CEO and medical director Saul Levin, MD, MPA, said in a news release.

“It is vital that we equip our clinicians, especially primary care clinicians, with the latest evidence from the APA to empower their decision-making and improve care for their patients,” Dr. Levin added.

The clinical decision support tool was developed by the APA’s guideline writing group in collaboration with AvoMD, a software company that translates clinical evidence into the workflow.

The tool guides clinicians through the screening, assessing, diagnosing, and treatment planning of patients with anorexia nervosa, bulimia nervosa, binge-eating disorder, and other eating disorders.

It’s available free in the electronic health record, on the APA website, and on the AvoMD mobile app.

The tool is based on the APA’s updated practice guidelines for the management of eating disorders, which were released in March.

The tool incorporates guidance on screening tools, levels of care, nutrition, exercise, psychotherapy, and more. Additionally, the tool provides a summary of responses that can be leveraged for easy documentation.

It is intended for use by pediatricians, family physicians, and other primary care and mental health clinicians, including psychiatrists and therapists.

Data published earlier this year show that more than 1 in 5 children worldwide are at risk of developing an eating disorder. Girls are significantly more likely than boys to have disordered eating.

Early diagnosis and treatment are associated with a higher rate of recovery, and extended illness is associated with potentially devastating consequences, the APA notes.

“As an internal medicine physician myself, I see a wide variety of patients and clinical issues,” Joongheum Park, MD, head of product and engineering at AvoMD, said in the release.

“Easy access to the expertise in me and my peers’ workflow is essential to ensuring high-quality care, and partnering with the leading authority on eating disorders to provide this tool will improve clinician efficiency and most importantly, patient outcomes,” Dr. Park added.

A version of this article first appeared on Medscape.com.

The American Psychiatric Association has released an online screening and assessment tool for eating disorders.

“People with eating disorders have a high rate of mortality and [the disorder is] growing in prevalence among young adults and adolescents,” APA CEO and medical director Saul Levin, MD, MPA, said in a news release.

“It is vital that we equip our clinicians, especially primary care clinicians, with the latest evidence from the APA to empower their decision-making and improve care for their patients,” Dr. Levin added.

The clinical decision support tool was developed by the APA’s guideline writing group in collaboration with AvoMD, a software company that translates clinical evidence into the workflow.

The tool guides clinicians through the screening, assessing, diagnosing, and treatment planning of patients with anorexia nervosa, bulimia nervosa, binge-eating disorder, and other eating disorders.

It’s available free in the electronic health record, on the APA website, and on the AvoMD mobile app.

The tool is based on the APA’s updated practice guidelines for the management of eating disorders, which were released in March.

The tool incorporates guidance on screening tools, levels of care, nutrition, exercise, psychotherapy, and more. Additionally, the tool provides a summary of responses that can be leveraged for easy documentation.

It is intended for use by pediatricians, family physicians, and other primary care and mental health clinicians, including psychiatrists and therapists.

Data published earlier this year show that more than 1 in 5 children worldwide are at risk of developing an eating disorder. Girls are significantly more likely than boys to have disordered eating.

Early diagnosis and treatment are associated with a higher rate of recovery, and extended illness is associated with potentially devastating consequences, the APA notes.

“As an internal medicine physician myself, I see a wide variety of patients and clinical issues,” Joongheum Park, MD, head of product and engineering at AvoMD, said in the release.

“Easy access to the expertise in me and my peers’ workflow is essential to ensuring high-quality care, and partnering with the leading authority on eating disorders to provide this tool will improve clinician efficiency and most importantly, patient outcomes,” Dr. Park added.

A version of this article first appeared on Medscape.com.

The American Psychiatric Association has released an online screening and assessment tool for eating disorders.

“People with eating disorders have a high rate of mortality and [the disorder is] growing in prevalence among young adults and adolescents,” APA CEO and medical director Saul Levin, MD, MPA, said in a news release.

“It is vital that we equip our clinicians, especially primary care clinicians, with the latest evidence from the APA to empower their decision-making and improve care for their patients,” Dr. Levin added.

The clinical decision support tool was developed by the APA’s guideline writing group in collaboration with AvoMD, a software company that translates clinical evidence into the workflow.

The tool guides clinicians through the screening, assessing, diagnosing, and treatment planning of patients with anorexia nervosa, bulimia nervosa, binge-eating disorder, and other eating disorders.

It’s available free in the electronic health record, on the APA website, and on the AvoMD mobile app.

The tool is based on the APA’s updated practice guidelines for the management of eating disorders, which were released in March.

The tool incorporates guidance on screening tools, levels of care, nutrition, exercise, psychotherapy, and more. Additionally, the tool provides a summary of responses that can be leveraged for easy documentation.

It is intended for use by pediatricians, family physicians, and other primary care and mental health clinicians, including psychiatrists and therapists.

Data published earlier this year show that more than 1 in 5 children worldwide are at risk of developing an eating disorder. Girls are significantly more likely than boys to have disordered eating.

Early diagnosis and treatment are associated with a higher rate of recovery, and extended illness is associated with potentially devastating consequences, the APA notes.

“As an internal medicine physician myself, I see a wide variety of patients and clinical issues,” Joongheum Park, MD, head of product and engineering at AvoMD, said in the release.

“Easy access to the expertise in me and my peers’ workflow is essential to ensuring high-quality care, and partnering with the leading authority on eating disorders to provide this tool will improve clinician efficiency and most importantly, patient outcomes,” Dr. Park added.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – As the opioid epidemic continues to grow and evolve, the federal government is trying to make it easier for clinicians to treat abusers with the drug buprenorphine, psychiatrists told colleagues at the annual meeting of the American Psychiatric Association. And an injectable version of the drug is making a big difference.

While overall overdose numbers are grim, “the work we’re doing to get people on buprenorphine is working, and our efforts to get people in treatment are paying off,” John A. Renner Jr., MD, of Boston University, said in a presentation at the APA meeting.

As Dr. Renner explained, the United States is now in the fourth wave of nearly a quarter-century of opioid overdose-related deaths. The outbreak began in 1999 as prescription opioids spurred deaths, and heroin overdoses began to rise in 2010. The third wave brought rises in deaths from synthetic opioids such as fentanyl in 2013. In 2015, the fourth wave – driven by deaths from combinations of synthetic opioids and psychostimulants like methamphetamines – started in 2015.

COVID-19 seems to have played a role too: In 2020, opioid overdose deaths spiked during the early months of the pandemic. In 2021, drug-related overdose deaths overall hit a high of 106,889, including 80,411 linked to opioids. In contrast, fewer than 20,000 drug-related overdose deaths were reported in 1999.

On the other hand, deaths from prescription drug overdoses are falling, Dr. Renner said, suggesting “improvement in terms of how clinicians are handling medications and our prescribing practices. But that’s being masked by what’s happened with fentanyl and methamphetamine.”

Buprenorphine (Subutex), used to treat opioid use withdrawal, is itself an opioid and can cause addiction and death in some cases. However, Dr. Renner highlighted a 2023 study that determined that efforts to increase its use from 2019 to 2021 didn’t appear to boost buprenorphine-related overdose deaths in the United States.

New federal regulations aim to make it easier to prescribe buprenorphine. Thanks to Congressional legislation, the Drug Enforcement Administration in January 2023 eliminated regulations requiring clinicians to undergo special training to get an “X-waiver” to be able to prescribe buprenorphine. But they’re not off the hook entirely: As of June 27, 2023, providers must have undergone training in order to apply for – or renew – a DEA license to prescribe certain controlled substances like buprenorphine.

“I’m afraid that people will be able to meet that requirement easily, and they’re not going to get good coordinated teaching,” Dr. Renner said. “I’m not sure that’s really going to improve the quality of care that we’re delivering.”

In regard to treatment, psychiatrist Dong Chan Park, MD, of Boston University, touted a long-acting injectable form of buprenorphine known by the brand name Sublocade. The FDA approved Sublocade in 2017 for patients who’ve been taking sublingual buprenorphine for at least 7 days, although Dr. Park said research suggests the 7-day period may not be necessary.

“We’ve utilized this about 2.5-plus years in my hospital, and it’s really been a game changer for some of our sickest, most challenging patients,” he said at the APA presentation. As he explained, one benefit is that patients can’t repeatedly avoid doses depending on how they feel, as they may do with the sublingual version. “On the first day of injection, you can actually stop the sublingual buprenorphine.”

Dr. Renner emphasized the importance of getting users on buprenorphine as fast as possible. If the treatment begins in the ED, he said, “they need to have a system that is going to be able to pick them up and continue the care.”

Otherwise, the risk is high. “We’re in a very dangerous era,” he said, “where the patient walks out the door, and then they die.”

Dr. Park had no disclosures, and Dr. Renner disclosed royalties from the APA.

SAN FRANCISCO – As the opioid epidemic continues to grow and evolve, the federal government is trying to make it easier for clinicians to treat abusers with the drug buprenorphine, psychiatrists told colleagues at the annual meeting of the American Psychiatric Association. And an injectable version of the drug is making a big difference.

While overall overdose numbers are grim, “the work we’re doing to get people on buprenorphine is working, and our efforts to get people in treatment are paying off,” John A. Renner Jr., MD, of Boston University, said in a presentation at the APA meeting.

As Dr. Renner explained, the United States is now in the fourth wave of nearly a quarter-century of opioid overdose-related deaths. The outbreak began in 1999 as prescription opioids spurred deaths, and heroin overdoses began to rise in 2010. The third wave brought rises in deaths from synthetic opioids such as fentanyl in 2013. In 2015, the fourth wave – driven by deaths from combinations of synthetic opioids and psychostimulants like methamphetamines – started in 2015.

COVID-19 seems to have played a role too: In 2020, opioid overdose deaths spiked during the early months of the pandemic. In 2021, drug-related overdose deaths overall hit a high of 106,889, including 80,411 linked to opioids. In contrast, fewer than 20,000 drug-related overdose deaths were reported in 1999.

On the other hand, deaths from prescription drug overdoses are falling, Dr. Renner said, suggesting “improvement in terms of how clinicians are handling medications and our prescribing practices. But that’s being masked by what’s happened with fentanyl and methamphetamine.”

Buprenorphine (Subutex), used to treat opioid use withdrawal, is itself an opioid and can cause addiction and death in some cases. However, Dr. Renner highlighted a 2023 study that determined that efforts to increase its use from 2019 to 2021 didn’t appear to boost buprenorphine-related overdose deaths in the United States.

New federal regulations aim to make it easier to prescribe buprenorphine. Thanks to Congressional legislation, the Drug Enforcement Administration in January 2023 eliminated regulations requiring clinicians to undergo special training to get an “X-waiver” to be able to prescribe buprenorphine. But they’re not off the hook entirely: As of June 27, 2023, providers must have undergone training in order to apply for – or renew – a DEA license to prescribe certain controlled substances like buprenorphine.

“I’m afraid that people will be able to meet that requirement easily, and they’re not going to get good coordinated teaching,” Dr. Renner said. “I’m not sure that’s really going to improve the quality of care that we’re delivering.”

In regard to treatment, psychiatrist Dong Chan Park, MD, of Boston University, touted a long-acting injectable form of buprenorphine known by the brand name Sublocade. The FDA approved Sublocade in 2017 for patients who’ve been taking sublingual buprenorphine for at least 7 days, although Dr. Park said research suggests the 7-day period may not be necessary.

“We’ve utilized this about 2.5-plus years in my hospital, and it’s really been a game changer for some of our sickest, most challenging patients,” he said at the APA presentation. As he explained, one benefit is that patients can’t repeatedly avoid doses depending on how they feel, as they may do with the sublingual version. “On the first day of injection, you can actually stop the sublingual buprenorphine.”

Dr. Renner emphasized the importance of getting users on buprenorphine as fast as possible. If the treatment begins in the ED, he said, “they need to have a system that is going to be able to pick them up and continue the care.”

Otherwise, the risk is high. “We’re in a very dangerous era,” he said, “where the patient walks out the door, and then they die.”

Dr. Park had no disclosures, and Dr. Renner disclosed royalties from the APA.

SAN FRANCISCO – As the opioid epidemic continues to grow and evolve, the federal government is trying to make it easier for clinicians to treat abusers with the drug buprenorphine, psychiatrists told colleagues at the annual meeting of the American Psychiatric Association. And an injectable version of the drug is making a big difference.

While overall overdose numbers are grim, “the work we’re doing to get people on buprenorphine is working, and our efforts to get people in treatment are paying off,” John A. Renner Jr., MD, of Boston University, said in a presentation at the APA meeting.

As Dr. Renner explained, the United States is now in the fourth wave of nearly a quarter-century of opioid overdose-related deaths. The outbreak began in 1999 as prescription opioids spurred deaths, and heroin overdoses began to rise in 2010. The third wave brought rises in deaths from synthetic opioids such as fentanyl in 2013. In 2015, the fourth wave – driven by deaths from combinations of synthetic opioids and psychostimulants like methamphetamines – started in 2015.

COVID-19 seems to have played a role too: In 2020, opioid overdose deaths spiked during the early months of the pandemic. In 2021, drug-related overdose deaths overall hit a high of 106,889, including 80,411 linked to opioids. In contrast, fewer than 20,000 drug-related overdose deaths were reported in 1999.

On the other hand, deaths from prescription drug overdoses are falling, Dr. Renner said, suggesting “improvement in terms of how clinicians are handling medications and our prescribing practices. But that’s being masked by what’s happened with fentanyl and methamphetamine.”

Buprenorphine (Subutex), used to treat opioid use withdrawal, is itself an opioid and can cause addiction and death in some cases. However, Dr. Renner highlighted a 2023 study that determined that efforts to increase its use from 2019 to 2021 didn’t appear to boost buprenorphine-related overdose deaths in the United States.

New federal regulations aim to make it easier to prescribe buprenorphine. Thanks to Congressional legislation, the Drug Enforcement Administration in January 2023 eliminated regulations requiring clinicians to undergo special training to get an “X-waiver” to be able to prescribe buprenorphine. But they’re not off the hook entirely: As of June 27, 2023, providers must have undergone training in order to apply for – or renew – a DEA license to prescribe certain controlled substances like buprenorphine.

“I’m afraid that people will be able to meet that requirement easily, and they’re not going to get good coordinated teaching,” Dr. Renner said. “I’m not sure that’s really going to improve the quality of care that we’re delivering.”

In regard to treatment, psychiatrist Dong Chan Park, MD, of Boston University, touted a long-acting injectable form of buprenorphine known by the brand name Sublocade. The FDA approved Sublocade in 2017 for patients who’ve been taking sublingual buprenorphine for at least 7 days, although Dr. Park said research suggests the 7-day period may not be necessary.

“We’ve utilized this about 2.5-plus years in my hospital, and it’s really been a game changer for some of our sickest, most challenging patients,” he said at the APA presentation. As he explained, one benefit is that patients can’t repeatedly avoid doses depending on how they feel, as they may do with the sublingual version. “On the first day of injection, you can actually stop the sublingual buprenorphine.”

Dr. Renner emphasized the importance of getting users on buprenorphine as fast as possible. If the treatment begins in the ED, he said, “they need to have a system that is going to be able to pick them up and continue the care.”

Otherwise, the risk is high. “We’re in a very dangerous era,” he said, “where the patient walks out the door, and then they die.”

Dr. Park had no disclosures, and Dr. Renner disclosed royalties from the APA.

SAN FRANCISCO – Children randomly assigned to foster care after being institutionalized in infancy have significantly better cognitive and physical outcomes and less severe symptoms of psychopathology than their peers who remain in institutional care, results of a new study suggest.

The study shows that sustained recovery is possible after severe, early-life adversity, study author Kathryn L. Humphreys, PhD, assistant professor, department of psychology and human development, Vanderbilt University, Nashville, Tenn., said in an interview.

Vanderbilt University

“Given the strong evidence from the present study, I hope physicians will play a role in promoting family placements as an alternative to institutional care for children who have been orphaned,” she said.

The findings were presented at the annual meeting of the American Psychiatric Association and were published online in the American Journal of Psychiatry.

Millions of children around the world experience psychosocial deprivation while living in institutions, and many more are neglected in their families of origin. In addition, about 6.7 million children lost a parent or caregiver during the COVID-19 pandemic.

In particular, Romania has a history of institutionalizing children. Through decades of repressive policies from the Romanian dictator Nicolae Ceausescu, child abandonment became a national disaster. Families couldn’t afford to keep their children and were encouraged to turn them over to the state.

The current study was part of the Bucharest Early Intervention Project, initiated in 2001 to examine the impact of high-quality, family-based care on development. It included 136 Romanian children (mean age, about 22 months) who were abandoned at or shortly after birth and were placed in an institution.

Researchers randomly assigned each toddler to 1 of 56 foster families or to continue living in an institution (care as usual). The researchers had to create a foster care network, because such care was extremely limited at the start of the study.
 

Providing stimulating care

Foster parents in the study received regular support from social workers and U.S.-based psychologists. They were encouraged to “make a commitment to treat the child as if it was their own, providing sensitive, stimulating, and nurturing care, not just in the short term but for their whole life,” said Dr. Humphreys.

Foster care programs in the United States have been criticized for focusing on short-term care, she said. “It’s really just a bed to sleep on, clothes to wear, and food to eat rather than the psychological component we think is really important for child development.”

For the study, the researchers assessed the children across multiple developmental domains at baseline and at ages 30, 42, and 54 months. They conducted additional assessments when the kids were aged 8, 12, and 16-18 years.

The primary outcomes were cognitive functioning (IQ), physical growth (height, weight, head circumference), brain electrical activity (relative electroencephalography power in the alpha frequency band), and symptoms of five types of psychopathology (disinhibited social engagement disorder, reactive attachment disorder, ADHD symptoms, externalizing symptoms, and internalizing symptoms).

From over 7,000 observations analyzed across follow-ups, the investigators found that the intervention had an overall significant effect on cognitive, physical, and neural outcomes when considered collectively across waves (beta, 0.26; 95% confidence interval, 0.07-0.46; P = .012). Compared to children who received care as usual, those in foster homes had significantly higher average IQ scores (P < .001) and physical size (P = .008).

The intervention had an overall beneficial effect in regard to psychopathology. The greatest impact involved a reduction in symptoms of reactive attachment disorder (P < .001).

“There are a few forms of psychopathology that seem to almost entirely occur after severe neglect, including reactive attachment disorder; we think of these as disorders of social relatedness that derive from aberrant or insufficient early caregiving experiences,” said Dr. Humphreys. “Being placed in a family reduced the symptoms of reactive attachment disorder to pretty much nonexistent.”

To a lesser extent, the intervention reduced symptoms of disinhibited social engagement disorder. The foster care group also had significantly fewer internalizing symptoms than did children in the care-as-usual group.

But there was no significant overall effect of the intervention on symptoms of ADHD or externalizing problems.
 

Positive effects persisted

For the most part, the positive effects of the intervention on children’s functioning persisted during nearly 2 decades of follow-up. The impact of the intervention “can be described as rapidly apparent by age 30 months and sustained through late adolescence,” wrote the authors.

Regarding the impact of age at the time of placement, the study found that, compared with children placed into foster care later, those who entered foster care earlier (younger than 33 months) had significantly higher IQ scores and relative alpha power, but there was no difference in physical growth.

For some outcomes, the benefits of earlier placement were apparent in early childhood but faded by adolescence. But Dr. Humphreys noted all placements were early by most definitions.

The researchers also assessed stability of foster care placements. Children were considered “stable” if they remained with their original foster family; they were considered “disrupted” if they no longer resided with the family.

Here, the study found some “striking results,” said Dr. Humphreys. The effect of placement stability was largest in adolescence, when, overall, those who had remained with their original foster family had better cognitive and physical outcomes and less severe symptoms of psychopathology compared to those who experienced placement disruptions.

As for sex differences, “it’s a mixed bag,” said Dr. Humphreys, although overall, “we didn’t see strong evidence of sex differences” in terms of outcomes.

The investigators were unable to examine trajectories of children’s functioning, which would have provided important information on aspects such as rate of growth and the shape of growth curves. Specific features of the institutional or foster care environment in Bucharest during the study may limit the generalizability of the findings to other settings.
 

Absolutely unique project

The study examined an “absolutely unique project” and had “very exciting” results that should have “important clinical implications,” commented the American Journal of Psychiatry editor-in-chief Ned Kalin, MD, Hedberg Professor and chair, department of psychiatry, University of Wisconsin–Madison.

The findings are “pretty dramatic,” added Dr. Kalin. “This is probably the study to be thinking about when considering the future of treatment and interventions in children who have suffered from this type of neglect, which is unfortunately extremely common worldwide, including in the U.S.”

In particular, the findings regarding improved psychopathology “bode well for the future,” said Dr. Kalin. “We know these types of problems are risk factors for the later development of depression and anxiety disorders. It will be really interesting to find out, but my guess is these kids will be protected as they mature further.”

The study was supported by the NIH, the John D. and Catherine T. MacArthur Foundation, the Palix Foundation, and the Jacobs Foundation. Dr. Humphreys has received research funding from the Brain and Behavior Research Foundation, the Caplan Foundation, the Jacobs Foundation, the National Science Foundation, the NIH, the Vanderbilt Institute for Clinical and Translational Research, the Vanderbilt Kennedy Center, and Vanderbilt University; she has received honoraria from the Journal of Clinical Child and Adolescent Psychology Future Directions Forum, Learning Grove, the University of Iowa, the University of Texas at Austin, and ZERO TO THREE.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Children randomly assigned to foster care after being institutionalized in infancy have significantly better cognitive and physical outcomes and less severe symptoms of psychopathology than their peers who remain in institutional care, results of a new study suggest.

The study shows that sustained recovery is possible after severe, early-life adversity, study author Kathryn L. Humphreys, PhD, assistant professor, department of psychology and human development, Vanderbilt University, Nashville, Tenn., said in an interview.

Vanderbilt University

“Given the strong evidence from the present study, I hope physicians will play a role in promoting family placements as an alternative to institutional care for children who have been orphaned,” she said.

The findings were presented at the annual meeting of the American Psychiatric Association and were published online in the American Journal of Psychiatry.

Millions of children around the world experience psychosocial deprivation while living in institutions, and many more are neglected in their families of origin. In addition, about 6.7 million children lost a parent or caregiver during the COVID-19 pandemic.

In particular, Romania has a history of institutionalizing children. Through decades of repressive policies from the Romanian dictator Nicolae Ceausescu, child abandonment became a national disaster. Families couldn’t afford to keep their children and were encouraged to turn them over to the state.

The current study was part of the Bucharest Early Intervention Project, initiated in 2001 to examine the impact of high-quality, family-based care on development. It included 136 Romanian children (mean age, about 22 months) who were abandoned at or shortly after birth and were placed in an institution.

Researchers randomly assigned each toddler to 1 of 56 foster families or to continue living in an institution (care as usual). The researchers had to create a foster care network, because such care was extremely limited at the start of the study.
 

Providing stimulating care

Foster parents in the study received regular support from social workers and U.S.-based psychologists. They were encouraged to “make a commitment to treat the child as if it was their own, providing sensitive, stimulating, and nurturing care, not just in the short term but for their whole life,” said Dr. Humphreys.

Foster care programs in the United States have been criticized for focusing on short-term care, she said. “It’s really just a bed to sleep on, clothes to wear, and food to eat rather than the psychological component we think is really important for child development.”

For the study, the researchers assessed the children across multiple developmental domains at baseline and at ages 30, 42, and 54 months. They conducted additional assessments when the kids were aged 8, 12, and 16-18 years.

The primary outcomes were cognitive functioning (IQ), physical growth (height, weight, head circumference), brain electrical activity (relative electroencephalography power in the alpha frequency band), and symptoms of five types of psychopathology (disinhibited social engagement disorder, reactive attachment disorder, ADHD symptoms, externalizing symptoms, and internalizing symptoms).

From over 7,000 observations analyzed across follow-ups, the investigators found that the intervention had an overall significant effect on cognitive, physical, and neural outcomes when considered collectively across waves (beta, 0.26; 95% confidence interval, 0.07-0.46; P = .012). Compared to children who received care as usual, those in foster homes had significantly higher average IQ scores (P < .001) and physical size (P = .008).

The intervention had an overall beneficial effect in regard to psychopathology. The greatest impact involved a reduction in symptoms of reactive attachment disorder (P < .001).

“There are a few forms of psychopathology that seem to almost entirely occur after severe neglect, including reactive attachment disorder; we think of these as disorders of social relatedness that derive from aberrant or insufficient early caregiving experiences,” said Dr. Humphreys. “Being placed in a family reduced the symptoms of reactive attachment disorder to pretty much nonexistent.”

To a lesser extent, the intervention reduced symptoms of disinhibited social engagement disorder. The foster care group also had significantly fewer internalizing symptoms than did children in the care-as-usual group.

But there was no significant overall effect of the intervention on symptoms of ADHD or externalizing problems.
 

Positive effects persisted

For the most part, the positive effects of the intervention on children’s functioning persisted during nearly 2 decades of follow-up. The impact of the intervention “can be described as rapidly apparent by age 30 months and sustained through late adolescence,” wrote the authors.

Regarding the impact of age at the time of placement, the study found that, compared with children placed into foster care later, those who entered foster care earlier (younger than 33 months) had significantly higher IQ scores and relative alpha power, but there was no difference in physical growth.

For some outcomes, the benefits of earlier placement were apparent in early childhood but faded by adolescence. But Dr. Humphreys noted all placements were early by most definitions.

The researchers also assessed stability of foster care placements. Children were considered “stable” if they remained with their original foster family; they were considered “disrupted” if they no longer resided with the family.

Here, the study found some “striking results,” said Dr. Humphreys. The effect of placement stability was largest in adolescence, when, overall, those who had remained with their original foster family had better cognitive and physical outcomes and less severe symptoms of psychopathology compared to those who experienced placement disruptions.

As for sex differences, “it’s a mixed bag,” said Dr. Humphreys, although overall, “we didn’t see strong evidence of sex differences” in terms of outcomes.

The investigators were unable to examine trajectories of children’s functioning, which would have provided important information on aspects such as rate of growth and the shape of growth curves. Specific features of the institutional or foster care environment in Bucharest during the study may limit the generalizability of the findings to other settings.
 

Absolutely unique project

The study examined an “absolutely unique project” and had “very exciting” results that should have “important clinical implications,” commented the American Journal of Psychiatry editor-in-chief Ned Kalin, MD, Hedberg Professor and chair, department of psychiatry, University of Wisconsin–Madison.

The findings are “pretty dramatic,” added Dr. Kalin. “This is probably the study to be thinking about when considering the future of treatment and interventions in children who have suffered from this type of neglect, which is unfortunately extremely common worldwide, including in the U.S.”

In particular, the findings regarding improved psychopathology “bode well for the future,” said Dr. Kalin. “We know these types of problems are risk factors for the later development of depression and anxiety disorders. It will be really interesting to find out, but my guess is these kids will be protected as they mature further.”

The study was supported by the NIH, the John D. and Catherine T. MacArthur Foundation, the Palix Foundation, and the Jacobs Foundation. Dr. Humphreys has received research funding from the Brain and Behavior Research Foundation, the Caplan Foundation, the Jacobs Foundation, the National Science Foundation, the NIH, the Vanderbilt Institute for Clinical and Translational Research, the Vanderbilt Kennedy Center, and Vanderbilt University; she has received honoraria from the Journal of Clinical Child and Adolescent Psychology Future Directions Forum, Learning Grove, the University of Iowa, the University of Texas at Austin, and ZERO TO THREE.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Children randomly assigned to foster care after being institutionalized in infancy have significantly better cognitive and physical outcomes and less severe symptoms of psychopathology than their peers who remain in institutional care, results of a new study suggest.

The study shows that sustained recovery is possible after severe, early-life adversity, study author Kathryn L. Humphreys, PhD, assistant professor, department of psychology and human development, Vanderbilt University, Nashville, Tenn., said in an interview.

Vanderbilt University

“Given the strong evidence from the present study, I hope physicians will play a role in promoting family placements as an alternative to institutional care for children who have been orphaned,” she said.

The findings were presented at the annual meeting of the American Psychiatric Association and were published online in the American Journal of Psychiatry.

Millions of children around the world experience psychosocial deprivation while living in institutions, and many more are neglected in their families of origin. In addition, about 6.7 million children lost a parent or caregiver during the COVID-19 pandemic.

In particular, Romania has a history of institutionalizing children. Through decades of repressive policies from the Romanian dictator Nicolae Ceausescu, child abandonment became a national disaster. Families couldn’t afford to keep their children and were encouraged to turn them over to the state.

The current study was part of the Bucharest Early Intervention Project, initiated in 2001 to examine the impact of high-quality, family-based care on development. It included 136 Romanian children (mean age, about 22 months) who were abandoned at or shortly after birth and were placed in an institution.

Researchers randomly assigned each toddler to 1 of 56 foster families or to continue living in an institution (care as usual). The researchers had to create a foster care network, because such care was extremely limited at the start of the study.
 

Providing stimulating care

Foster parents in the study received regular support from social workers and U.S.-based psychologists. They were encouraged to “make a commitment to treat the child as if it was their own, providing sensitive, stimulating, and nurturing care, not just in the short term but for their whole life,” said Dr. Humphreys.

Foster care programs in the United States have been criticized for focusing on short-term care, she said. “It’s really just a bed to sleep on, clothes to wear, and food to eat rather than the psychological component we think is really important for child development.”

For the study, the researchers assessed the children across multiple developmental domains at baseline and at ages 30, 42, and 54 months. They conducted additional assessments when the kids were aged 8, 12, and 16-18 years.

The primary outcomes were cognitive functioning (IQ), physical growth (height, weight, head circumference), brain electrical activity (relative electroencephalography power in the alpha frequency band), and symptoms of five types of psychopathology (disinhibited social engagement disorder, reactive attachment disorder, ADHD symptoms, externalizing symptoms, and internalizing symptoms).

From over 7,000 observations analyzed across follow-ups, the investigators found that the intervention had an overall significant effect on cognitive, physical, and neural outcomes when considered collectively across waves (beta, 0.26; 95% confidence interval, 0.07-0.46; P = .012). Compared to children who received care as usual, those in foster homes had significantly higher average IQ scores (P < .001) and physical size (P = .008).

The intervention had an overall beneficial effect in regard to psychopathology. The greatest impact involved a reduction in symptoms of reactive attachment disorder (P < .001).

“There are a few forms of psychopathology that seem to almost entirely occur after severe neglect, including reactive attachment disorder; we think of these as disorders of social relatedness that derive from aberrant or insufficient early caregiving experiences,” said Dr. Humphreys. “Being placed in a family reduced the symptoms of reactive attachment disorder to pretty much nonexistent.”

To a lesser extent, the intervention reduced symptoms of disinhibited social engagement disorder. The foster care group also had significantly fewer internalizing symptoms than did children in the care-as-usual group.

But there was no significant overall effect of the intervention on symptoms of ADHD or externalizing problems.
 

Positive effects persisted

For the most part, the positive effects of the intervention on children’s functioning persisted during nearly 2 decades of follow-up. The impact of the intervention “can be described as rapidly apparent by age 30 months and sustained through late adolescence,” wrote the authors.

Regarding the impact of age at the time of placement, the study found that, compared with children placed into foster care later, those who entered foster care earlier (younger than 33 months) had significantly higher IQ scores and relative alpha power, but there was no difference in physical growth.

For some outcomes, the benefits of earlier placement were apparent in early childhood but faded by adolescence. But Dr. Humphreys noted all placements were early by most definitions.

The researchers also assessed stability of foster care placements. Children were considered “stable” if they remained with their original foster family; they were considered “disrupted” if they no longer resided with the family.

Here, the study found some “striking results,” said Dr. Humphreys. The effect of placement stability was largest in adolescence, when, overall, those who had remained with their original foster family had better cognitive and physical outcomes and less severe symptoms of psychopathology compared to those who experienced placement disruptions.

As for sex differences, “it’s a mixed bag,” said Dr. Humphreys, although overall, “we didn’t see strong evidence of sex differences” in terms of outcomes.

The investigators were unable to examine trajectories of children’s functioning, which would have provided important information on aspects such as rate of growth and the shape of growth curves. Specific features of the institutional or foster care environment in Bucharest during the study may limit the generalizability of the findings to other settings.
 

Absolutely unique project

The study examined an “absolutely unique project” and had “very exciting” results that should have “important clinical implications,” commented the American Journal of Psychiatry editor-in-chief Ned Kalin, MD, Hedberg Professor and chair, department of psychiatry, University of Wisconsin–Madison.

The findings are “pretty dramatic,” added Dr. Kalin. “This is probably the study to be thinking about when considering the future of treatment and interventions in children who have suffered from this type of neglect, which is unfortunately extremely common worldwide, including in the U.S.”

In particular, the findings regarding improved psychopathology “bode well for the future,” said Dr. Kalin. “We know these types of problems are risk factors for the later development of depression and anxiety disorders. It will be really interesting to find out, but my guess is these kids will be protected as they mature further.”

The study was supported by the NIH, the John D. and Catherine T. MacArthur Foundation, the Palix Foundation, and the Jacobs Foundation. Dr. Humphreys has received research funding from the Brain and Behavior Research Foundation, the Caplan Foundation, the Jacobs Foundation, the National Science Foundation, the NIH, the Vanderbilt Institute for Clinical and Translational Research, the Vanderbilt Kennedy Center, and Vanderbilt University; she has received honoraria from the Journal of Clinical Child and Adolescent Psychology Future Directions Forum, Learning Grove, the University of Iowa, the University of Texas at Austin, and ZERO TO THREE.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – During the pandemic, there was a significant increase in vitamin D deficiency in pediatric patients with major depressive disorder, according to new findings that suggest spending more time indoors may have fueled this uptick.

“We suspect that this may be due to the COVID lockdowns and kids schooling from home and having less time outside,” study investigator Oluwatomiwa Babade, MD, MPH, with Virginia Tech Carilion School of Medicine, Roanoke, Va., said in an interview.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Anecdotal observation confirmed

During the pandemic, investigators noticed an uptick in the number of children and adolescents attending their clinic for psychiatric hospitalization who had low vitamin D levels.

To investigate, they analyzed the records of all patients aged 6-17 years with psychiatric diagnoses and vitamin D level assessment who were admitted into the inpatient psychiatry unit from March 18, 2020, to June 30, 2021.

Among 599 unique patients, 275 (83% female) had a diagnosis of MDD and 226 of these patients were vitamin D deficient (< 30 ng/mL) – a prevalence rate of roughly 82%. Among 246 patients with psychiatric disorders other than MDD, the prevalence of vitamin D deficiency was 76%.

“This was very surprising and much higher than prior to the pandemic. Prior to COVID, the prevalence of vitamin D deficiency was around 14% in similar patients,” Dr. Babade said.

“Now that we are post-lockdown, it would be good to repeat the study. I think the prevalence should drop. That’s my guess,” he added.
 

Important research, no surprises

In a comment, Cemre Robinson, MD, director of the Mount Sinai Pediatric Bone Health and Calcium Metabolism Clinic, New York, said that although the study’s findings aren’t surprising, “it’s important to present such data in adolescents with major depression.”

“These findings reiterate the importance of screening for vitamin D deficiency in children and adolescents, with or without depression, particularly during winter, which is associated with less sun exposure,” Dr. Robinson, assistant professor of pediatrics, endocrinology, and diabetes at Icahn School of Medicine at Mount Sinai, said.

She noted that vitamin D deficiency is prevalent in the general population, and it can be easily corrected with supplementation.

“Vitamin D is important for bone growth, mineralization, and accretion as well as calcium absorption. Adolescence, in particular, is a period of rapid physical, cognitive, and psychosocial growth,” Dr. Robinson said.

“The requirement of all minerals and vitamins changes in this phase of life. Therefore, it is important to have sufficient vitamin D levels during adolescence for several health benefits,” she noted.

Dr. Robinson said that “more research is needed to validate the present findings in adolescents with major depression, and larger studies, including randomized control trials, are required to establish a causal association between MDD and vitamin D deficiency.”

The study had no specific funding. Dr. Babade and Dr. Robinson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – During the pandemic, there was a significant increase in vitamin D deficiency in pediatric patients with major depressive disorder, according to new findings that suggest spending more time indoors may have fueled this uptick.

“We suspect that this may be due to the COVID lockdowns and kids schooling from home and having less time outside,” study investigator Oluwatomiwa Babade, MD, MPH, with Virginia Tech Carilion School of Medicine, Roanoke, Va., said in an interview.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Anecdotal observation confirmed

During the pandemic, investigators noticed an uptick in the number of children and adolescents attending their clinic for psychiatric hospitalization who had low vitamin D levels.

To investigate, they analyzed the records of all patients aged 6-17 years with psychiatric diagnoses and vitamin D level assessment who were admitted into the inpatient psychiatry unit from March 18, 2020, to June 30, 2021.

Among 599 unique patients, 275 (83% female) had a diagnosis of MDD and 226 of these patients were vitamin D deficient (< 30 ng/mL) – a prevalence rate of roughly 82%. Among 246 patients with psychiatric disorders other than MDD, the prevalence of vitamin D deficiency was 76%.

“This was very surprising and much higher than prior to the pandemic. Prior to COVID, the prevalence of vitamin D deficiency was around 14% in similar patients,” Dr. Babade said.

“Now that we are post-lockdown, it would be good to repeat the study. I think the prevalence should drop. That’s my guess,” he added.
 

Important research, no surprises

In a comment, Cemre Robinson, MD, director of the Mount Sinai Pediatric Bone Health and Calcium Metabolism Clinic, New York, said that although the study’s findings aren’t surprising, “it’s important to present such data in adolescents with major depression.”

“These findings reiterate the importance of screening for vitamin D deficiency in children and adolescents, with or without depression, particularly during winter, which is associated with less sun exposure,” Dr. Robinson, assistant professor of pediatrics, endocrinology, and diabetes at Icahn School of Medicine at Mount Sinai, said.

She noted that vitamin D deficiency is prevalent in the general population, and it can be easily corrected with supplementation.

“Vitamin D is important for bone growth, mineralization, and accretion as well as calcium absorption. Adolescence, in particular, is a period of rapid physical, cognitive, and psychosocial growth,” Dr. Robinson said.

“The requirement of all minerals and vitamins changes in this phase of life. Therefore, it is important to have sufficient vitamin D levels during adolescence for several health benefits,” she noted.

Dr. Robinson said that “more research is needed to validate the present findings in adolescents with major depression, and larger studies, including randomized control trials, are required to establish a causal association between MDD and vitamin D deficiency.”

The study had no specific funding. Dr. Babade and Dr. Robinson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – During the pandemic, there was a significant increase in vitamin D deficiency in pediatric patients with major depressive disorder, according to new findings that suggest spending more time indoors may have fueled this uptick.

“We suspect that this may be due to the COVID lockdowns and kids schooling from home and having less time outside,” study investigator Oluwatomiwa Babade, MD, MPH, with Virginia Tech Carilion School of Medicine, Roanoke, Va., said in an interview.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Anecdotal observation confirmed

During the pandemic, investigators noticed an uptick in the number of children and adolescents attending their clinic for psychiatric hospitalization who had low vitamin D levels.

To investigate, they analyzed the records of all patients aged 6-17 years with psychiatric diagnoses and vitamin D level assessment who were admitted into the inpatient psychiatry unit from March 18, 2020, to June 30, 2021.

Among 599 unique patients, 275 (83% female) had a diagnosis of MDD and 226 of these patients were vitamin D deficient (< 30 ng/mL) – a prevalence rate of roughly 82%. Among 246 patients with psychiatric disorders other than MDD, the prevalence of vitamin D deficiency was 76%.

“This was very surprising and much higher than prior to the pandemic. Prior to COVID, the prevalence of vitamin D deficiency was around 14% in similar patients,” Dr. Babade said.

“Now that we are post-lockdown, it would be good to repeat the study. I think the prevalence should drop. That’s my guess,” he added.
 

Important research, no surprises

In a comment, Cemre Robinson, MD, director of the Mount Sinai Pediatric Bone Health and Calcium Metabolism Clinic, New York, said that although the study’s findings aren’t surprising, “it’s important to present such data in adolescents with major depression.”

“These findings reiterate the importance of screening for vitamin D deficiency in children and adolescents, with or without depression, particularly during winter, which is associated with less sun exposure,” Dr. Robinson, assistant professor of pediatrics, endocrinology, and diabetes at Icahn School of Medicine at Mount Sinai, said.

She noted that vitamin D deficiency is prevalent in the general population, and it can be easily corrected with supplementation.

“Vitamin D is important for bone growth, mineralization, and accretion as well as calcium absorption. Adolescence, in particular, is a period of rapid physical, cognitive, and psychosocial growth,” Dr. Robinson said.

“The requirement of all minerals and vitamins changes in this phase of life. Therefore, it is important to have sufficient vitamin D levels during adolescence for several health benefits,” she noted.

Dr. Robinson said that “more research is needed to validate the present findings in adolescents with major depression, and larger studies, including randomized control trials, are required to establish a causal association between MDD and vitamin D deficiency.”

The study had no specific funding. Dr. Babade and Dr. Robinson report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Physically violent events at an inpatient psychiatric unit in Pennsylvania dropped by 59.8% in the months after it implemented a plan to administer antipsychotic medications to patients more quickly – both in the emergency department and in the unit – and improve handoffs between providers and nurses, researchers reported.

“We were able to significantly reduce violence,” said Michael Chen, MD, Lehigh Valley Health Network psychiatry resident and lead author of an abstract presented at the annual meeting of the American Psychiatric Association. “Furthermore, the interventions were effective in reducing episodes of violence rather than redirecting it. And the overall feeling of safety on the inpatient psychiatric unit improved.”

Violence is common in psychiatric units, although it’s not clear how often it occurs. “The data has shown that patients with a psychotic disorder such as schizophrenia or a mood disorder with psychotic features such as bipolar disorder tend to account for most of the episodes of violence on the unit,” Dr. Chen said in an interview. “This inevitably results in a higher risk for violence on inpatient psychiatric units as a large portion of patients admitted to inpatient psychiatric units have these diagnoses.”
 

Enlisting the pharmacy department

For the new study, investigators tracked episodes of violence – including verbal attacks – at an Allentown, Penn.–area inpatient psychiatric unit from December 2021 to September 2022. According to Dr. Chen, unit leaders implemented the new plan in May 2022 in the wake of higher levels of violence during the COVID-19 pandemic and the concurrent staff shortages.

Clinic leaders sought to identify potentially aggressive patients in the emergency department and treat them with antipsychotics prior to admission to the psychiatric unit, ensure that the pharmacy provides access to as-needed or standing medications, and develop “standardized huddles to ensure proper handoffs between providers and nurses.”

Medical staff relied on the Dynamic Appraisal of Situational Aggression scale, risk factors, and clinical judgment to determine which patients had the potential to be violent, Dr. Chen said.

As for treatment, first-line antipsychotics are typically given orally, but they can be injected if patients must be treated over their objections, he said. “We would only consider starting standing medications against objections in patients who are involuntarily committed.”

During the 5 months before the intervention was implemented versus the following 5 months, the average monthly number of physically violent events in the psychiatric unit fell from 12.4 to 4.8 (–61.1%, P = .04), and verbal threats dipped from 7.2 to 4 (–44.4%, P = .15). The total average number of violent events per month, including violence against property, fell from an average of 25.4 to 10.2 (–59.8%, P = .03).

The total patient population didn’t vary significantly over time, Dr. Chen said. “Thus, the decrease in violence was not correlated with a decrease in patient load.”

While “there were concerns that there would just be higher episodes of violence in the ED while psychiatry patients awaited placement,” Dr. Chen said, the numbers actually showed reductions in violence in that setting. The average number of physically violent events per month in the ED fell from 49.6 to 39.4 (–20.6%, P = .03). Verbal threats dropped from 38 to 34.6 (–8.9%, P = .5) and overall violent events dipped from 87.6 to 74 (–15.6%, P = .08).

Why did the interventions seem to work? “Standing doses as well as as-needed medications started for psychiatric patients in the emergency department have been crucial to prevent delay of care,” Dr. Chen said. Enlisting the pharmacy department “helped ensure all patients had appropriate as-needed medications to prevent them from decompensating on the units,” he added, and “involvement of nursing and ancillary staff in high-risk rounds allowed the treatment team to rapidly anticipate and address concerns.”

The study authors also reported that nursing staff felt safer. Scores on a perception-of-safety scale – with 1 most unsafe and 7 most safe – improved from 3.3 to 4.2 (+27%, P < .01).

Dr. Chen said there was a “minimal” increase in cost to implement the intervention, although coordination is necessary. “The emergency department and psychiatry department have to work together to initiate treatment in the ED while awaiting beds,” he said. “The treatment team needs to communicate concerns during rounds. The pharmacist and psychiatrist need to work together to ensure that proper as-needed medications are available.”
 

‘Good clinical practice’

In an interview, psychiatrist Mark J. Russ, MD, of NewYork-Presbyterian/Westchester Behavioral Health and Weill Cornell Medical College, said violent incidents in inpatient psychiatric units are influenced by many factors, such as history of violence, substance use, history of trauma, psychosis/paranoia, and medical problems.

The units themselves can contribute to the risk of violence through power struggles and lack of attention paid to respect and dignity, he said. “Attention to these issues is important in reducing violence,” he noted. “Generalized training for staff in de-escalation techniques and trauma-informed care is imperative. There may be value in developing specialized psychiatric ICUs where staff are meticulously trained in these and other approaches.”

The new study, Dr. Russ said, suggests that “early identification of patients at risk of engaging in violent behavior on the inpatient unit, pharmacologic treatment, and good communication helps reduce violence.” The findings, he added, suggest that “interventions known to constitute good clinical practice are indeed helpful.”

However, he cautioned that “treating all at-risk patients with antipsychotics, regardless of their psychiatric diagnosis, might well be considered chemical restraint, depending on [the] circumstances.”

There was no study funding. The study authors and Dr. Russ have no disclosures.

SAN FRANCISCO – Physically violent events at an inpatient psychiatric unit in Pennsylvania dropped by 59.8% in the months after it implemented a plan to administer antipsychotic medications to patients more quickly – both in the emergency department and in the unit – and improve handoffs between providers and nurses, researchers reported.

“We were able to significantly reduce violence,” said Michael Chen, MD, Lehigh Valley Health Network psychiatry resident and lead author of an abstract presented at the annual meeting of the American Psychiatric Association. “Furthermore, the interventions were effective in reducing episodes of violence rather than redirecting it. And the overall feeling of safety on the inpatient psychiatric unit improved.”

Violence is common in psychiatric units, although it’s not clear how often it occurs. “The data has shown that patients with a psychotic disorder such as schizophrenia or a mood disorder with psychotic features such as bipolar disorder tend to account for most of the episodes of violence on the unit,” Dr. Chen said in an interview. “This inevitably results in a higher risk for violence on inpatient psychiatric units as a large portion of patients admitted to inpatient psychiatric units have these diagnoses.”
 

Enlisting the pharmacy department

For the new study, investigators tracked episodes of violence – including verbal attacks – at an Allentown, Penn.–area inpatient psychiatric unit from December 2021 to September 2022. According to Dr. Chen, unit leaders implemented the new plan in May 2022 in the wake of higher levels of violence during the COVID-19 pandemic and the concurrent staff shortages.

Clinic leaders sought to identify potentially aggressive patients in the emergency department and treat them with antipsychotics prior to admission to the psychiatric unit, ensure that the pharmacy provides access to as-needed or standing medications, and develop “standardized huddles to ensure proper handoffs between providers and nurses.”

Medical staff relied on the Dynamic Appraisal of Situational Aggression scale, risk factors, and clinical judgment to determine which patients had the potential to be violent, Dr. Chen said.

As for treatment, first-line antipsychotics are typically given orally, but they can be injected if patients must be treated over their objections, he said. “We would only consider starting standing medications against objections in patients who are involuntarily committed.”

During the 5 months before the intervention was implemented versus the following 5 months, the average monthly number of physically violent events in the psychiatric unit fell from 12.4 to 4.8 (–61.1%, P = .04), and verbal threats dipped from 7.2 to 4 (–44.4%, P = .15). The total average number of violent events per month, including violence against property, fell from an average of 25.4 to 10.2 (–59.8%, P = .03).

The total patient population didn’t vary significantly over time, Dr. Chen said. “Thus, the decrease in violence was not correlated with a decrease in patient load.”

While “there were concerns that there would just be higher episodes of violence in the ED while psychiatry patients awaited placement,” Dr. Chen said, the numbers actually showed reductions in violence in that setting. The average number of physically violent events per month in the ED fell from 49.6 to 39.4 (–20.6%, P = .03). Verbal threats dropped from 38 to 34.6 (–8.9%, P = .5) and overall violent events dipped from 87.6 to 74 (–15.6%, P = .08).

Why did the interventions seem to work? “Standing doses as well as as-needed medications started for psychiatric patients in the emergency department have been crucial to prevent delay of care,” Dr. Chen said. Enlisting the pharmacy department “helped ensure all patients had appropriate as-needed medications to prevent them from decompensating on the units,” he added, and “involvement of nursing and ancillary staff in high-risk rounds allowed the treatment team to rapidly anticipate and address concerns.”

The study authors also reported that nursing staff felt safer. Scores on a perception-of-safety scale – with 1 most unsafe and 7 most safe – improved from 3.3 to 4.2 (+27%, P < .01).

Dr. Chen said there was a “minimal” increase in cost to implement the intervention, although coordination is necessary. “The emergency department and psychiatry department have to work together to initiate treatment in the ED while awaiting beds,” he said. “The treatment team needs to communicate concerns during rounds. The pharmacist and psychiatrist need to work together to ensure that proper as-needed medications are available.”
 

‘Good clinical practice’

In an interview, psychiatrist Mark J. Russ, MD, of NewYork-Presbyterian/Westchester Behavioral Health and Weill Cornell Medical College, said violent incidents in inpatient psychiatric units are influenced by many factors, such as history of violence, substance use, history of trauma, psychosis/paranoia, and medical problems.

The units themselves can contribute to the risk of violence through power struggles and lack of attention paid to respect and dignity, he said. “Attention to these issues is important in reducing violence,” he noted. “Generalized training for staff in de-escalation techniques and trauma-informed care is imperative. There may be value in developing specialized psychiatric ICUs where staff are meticulously trained in these and other approaches.”

The new study, Dr. Russ said, suggests that “early identification of patients at risk of engaging in violent behavior on the inpatient unit, pharmacologic treatment, and good communication helps reduce violence.” The findings, he added, suggest that “interventions known to constitute good clinical practice are indeed helpful.”

However, he cautioned that “treating all at-risk patients with antipsychotics, regardless of their psychiatric diagnosis, might well be considered chemical restraint, depending on [the] circumstances.”

There was no study funding. The study authors and Dr. Russ have no disclosures.

SAN FRANCISCO – Physically violent events at an inpatient psychiatric unit in Pennsylvania dropped by 59.8% in the months after it implemented a plan to administer antipsychotic medications to patients more quickly – both in the emergency department and in the unit – and improve handoffs between providers and nurses, researchers reported.

“We were able to significantly reduce violence,” said Michael Chen, MD, Lehigh Valley Health Network psychiatry resident and lead author of an abstract presented at the annual meeting of the American Psychiatric Association. “Furthermore, the interventions were effective in reducing episodes of violence rather than redirecting it. And the overall feeling of safety on the inpatient psychiatric unit improved.”

Violence is common in psychiatric units, although it’s not clear how often it occurs. “The data has shown that patients with a psychotic disorder such as schizophrenia or a mood disorder with psychotic features such as bipolar disorder tend to account for most of the episodes of violence on the unit,” Dr. Chen said in an interview. “This inevitably results in a higher risk for violence on inpatient psychiatric units as a large portion of patients admitted to inpatient psychiatric units have these diagnoses.”
 

Enlisting the pharmacy department

For the new study, investigators tracked episodes of violence – including verbal attacks – at an Allentown, Penn.–area inpatient psychiatric unit from December 2021 to September 2022. According to Dr. Chen, unit leaders implemented the new plan in May 2022 in the wake of higher levels of violence during the COVID-19 pandemic and the concurrent staff shortages.

Clinic leaders sought to identify potentially aggressive patients in the emergency department and treat them with antipsychotics prior to admission to the psychiatric unit, ensure that the pharmacy provides access to as-needed or standing medications, and develop “standardized huddles to ensure proper handoffs between providers and nurses.”

Medical staff relied on the Dynamic Appraisal of Situational Aggression scale, risk factors, and clinical judgment to determine which patients had the potential to be violent, Dr. Chen said.

As for treatment, first-line antipsychotics are typically given orally, but they can be injected if patients must be treated over their objections, he said. “We would only consider starting standing medications against objections in patients who are involuntarily committed.”

During the 5 months before the intervention was implemented versus the following 5 months, the average monthly number of physically violent events in the psychiatric unit fell from 12.4 to 4.8 (–61.1%, P = .04), and verbal threats dipped from 7.2 to 4 (–44.4%, P = .15). The total average number of violent events per month, including violence against property, fell from an average of 25.4 to 10.2 (–59.8%, P = .03).

The total patient population didn’t vary significantly over time, Dr. Chen said. “Thus, the decrease in violence was not correlated with a decrease in patient load.”

While “there were concerns that there would just be higher episodes of violence in the ED while psychiatry patients awaited placement,” Dr. Chen said, the numbers actually showed reductions in violence in that setting. The average number of physically violent events per month in the ED fell from 49.6 to 39.4 (–20.6%, P = .03). Verbal threats dropped from 38 to 34.6 (–8.9%, P = .5) and overall violent events dipped from 87.6 to 74 (–15.6%, P = .08).

Why did the interventions seem to work? “Standing doses as well as as-needed medications started for psychiatric patients in the emergency department have been crucial to prevent delay of care,” Dr. Chen said. Enlisting the pharmacy department “helped ensure all patients had appropriate as-needed medications to prevent them from decompensating on the units,” he added, and “involvement of nursing and ancillary staff in high-risk rounds allowed the treatment team to rapidly anticipate and address concerns.”

The study authors also reported that nursing staff felt safer. Scores on a perception-of-safety scale – with 1 most unsafe and 7 most safe – improved from 3.3 to 4.2 (+27%, P < .01).

Dr. Chen said there was a “minimal” increase in cost to implement the intervention, although coordination is necessary. “The emergency department and psychiatry department have to work together to initiate treatment in the ED while awaiting beds,” he said. “The treatment team needs to communicate concerns during rounds. The pharmacist and psychiatrist need to work together to ensure that proper as-needed medications are available.”
 

‘Good clinical practice’

In an interview, psychiatrist Mark J. Russ, MD, of NewYork-Presbyterian/Westchester Behavioral Health and Weill Cornell Medical College, said violent incidents in inpatient psychiatric units are influenced by many factors, such as history of violence, substance use, history of trauma, psychosis/paranoia, and medical problems.

The units themselves can contribute to the risk of violence through power struggles and lack of attention paid to respect and dignity, he said. “Attention to these issues is important in reducing violence,” he noted. “Generalized training for staff in de-escalation techniques and trauma-informed care is imperative. There may be value in developing specialized psychiatric ICUs where staff are meticulously trained in these and other approaches.”

The new study, Dr. Russ said, suggests that “early identification of patients at risk of engaging in violent behavior on the inpatient unit, pharmacologic treatment, and good communication helps reduce violence.” The findings, he added, suggest that “interventions known to constitute good clinical practice are indeed helpful.”

However, he cautioned that “treating all at-risk patients with antipsychotics, regardless of their psychiatric diagnosis, might well be considered chemical restraint, depending on [the] circumstances.”

There was no study funding. The study authors and Dr. Russ have no disclosures.

Stress-related disorders and anxiety are associated with a higher risk of out-of-hospital cardiac arrest (OHCA), a new case-control study suggests.

Investigators compared more than 35,000 OHCA case patients with a similar number of matched control persons and found an almost 1.5 times higher hazard of long-term stress conditions among OHCA case patients, compared with control persons, with a similar hazard for anxiety. Posttraumatic stress disorder was associated with an almost twofold higher risk of OHCA.

The findings applied equally to men and women and were independent of the presence of cardiovascular disease (CVD).

“This study raises awareness of the higher risks of OHCA and early risk monitoring to prevent OHCA in patients with stress-related disorders and anxiety,” write Talip Eroglu, of the department of cardiology, Copenhagen University Hospital, and colleagues.

The study was published online  in BMJ Open Heart.
 

Stress disorders and anxiety overrepresented

OHCA “predominantly arises from lethal cardiac arrhythmias ... that occur most frequently in the setting of coronary heart disease,” the authors write. However, increasing evidence suggests that rates of OHCA may also be increased in association with noncardiac diseases.

Individuals with stress-related disorders and anxiety are “overrepresented” among victims of cardiac arrest as well as those with multiple CVDs. But previous studies of OHCA have been limited by small numbers of cardiac arrests. In addition, those studies involved only data from selected populations or used in-hospital diagnosis to identify cardiac arrest, thereby potentially omitting OHCA patients who died prior to hospital admission.

The researchers therefore turned to data from Danish health registries that include a large, unselected cohort of patients with OHCA to investigate whether long-term stress conditions (that is, PTSD and adjustment disorder) or anxiety disorder were associated with OHCA.

They stratified the cohort according to sex, age, and CVD to identify which risk factor confers the highest risk of OHCA in patients with long-term stress conditions or anxiety, and they conducted sensitivity analyses of potential confounders, such as depression.

The design was a nested-case control model in which records at an individual patient level across registries were cross-linked to data from other national registries and were compared to matched control persons from the general population (35,195 OHCAs and 351,950 matched control persons; median IQR age, 72 [62-81] years; 66.82% men).

The prevalence of comorbidities and use of cardiovascular drugs were higher among OHCA case patients than among non-OHCA control persons.
 

Keep aware of stress and anxiety as risk factors

Among OHCA and non-OHCA participants, long-term stress conditions were diagnosed in 0.92% and 0.45%, respectively. Anxiety was diagnosed in 0.85% of OHCA case patients and in 0.37% of non-OHCA control persons.

These conditions were associated with a higher rate of OHCA after adjustment for common OHCA risk factors.

Detrimental to the heart, not just the psyche

Glenn Levine, MD, master clinician and professor of medicine, Baylor College of Medicine, Houston, called it an “important study in that it is a large, nationwide cohort study and thus provides important information to complement much smaller, focused studies.”

Like those other studies, “it finds that negative psychological health, specifically, long-term stress (as well as anxiety), is associated with a significantly increased risk of out-of-hospital cardiac arrest,” continued Dr. Levine, who is the chief of the cardiology section at Michael E. DeBakey VA Medical Center, Houston, and was not involved with the study.

Dr. Levine thinks the study “does a good job, as best one can for such a study, in trying to control for other factors, and zeroing in specifically on stress (and anxiety), trying to assess their independent contributions to the risk of developing cardiac arrest.”

The take-home message for clinicians and patients “is that negative psychological stress factors, such as stress and anxiety, are not only detrimental to one’s psychological health but likely increase one’s risk for adverse cardiac events, such as cardiac arrest,” he stated.

No specific funding for the study was disclosed. Mr. Eroglu has disclosed no relevant financial relationships. The other authors’ disclosures are listed in the original article. Dr. Levine reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Stress-related disorders and anxiety are associated with a higher risk of out-of-hospital cardiac arrest (OHCA), a new case-control study suggests.

Investigators compared more than 35,000 OHCA case patients with a similar number of matched control persons and found an almost 1.5 times higher hazard of long-term stress conditions among OHCA case patients, compared with control persons, with a similar hazard for anxiety. Posttraumatic stress disorder was associated with an almost twofold higher risk of OHCA.

The findings applied equally to men and women and were independent of the presence of cardiovascular disease (CVD).

“This study raises awareness of the higher risks of OHCA and early risk monitoring to prevent OHCA in patients with stress-related disorders and anxiety,” write Talip Eroglu, of the department of cardiology, Copenhagen University Hospital, and colleagues.

The study was published online  in BMJ Open Heart.
 

Stress disorders and anxiety overrepresented

OHCA “predominantly arises from lethal cardiac arrhythmias ... that occur most frequently in the setting of coronary heart disease,” the authors write. However, increasing evidence suggests that rates of OHCA may also be increased in association with noncardiac diseases.

Individuals with stress-related disorders and anxiety are “overrepresented” among victims of cardiac arrest as well as those with multiple CVDs. But previous studies of OHCA have been limited by small numbers of cardiac arrests. In addition, those studies involved only data from selected populations or used in-hospital diagnosis to identify cardiac arrest, thereby potentially omitting OHCA patients who died prior to hospital admission.

The researchers therefore turned to data from Danish health registries that include a large, unselected cohort of patients with OHCA to investigate whether long-term stress conditions (that is, PTSD and adjustment disorder) or anxiety disorder were associated with OHCA.

They stratified the cohort according to sex, age, and CVD to identify which risk factor confers the highest risk of OHCA in patients with long-term stress conditions or anxiety, and they conducted sensitivity analyses of potential confounders, such as depression.

The design was a nested-case control model in which records at an individual patient level across registries were cross-linked to data from other national registries and were compared to matched control persons from the general population (35,195 OHCAs and 351,950 matched control persons; median IQR age, 72 [62-81] years; 66.82% men).

The prevalence of comorbidities and use of cardiovascular drugs were higher among OHCA case patients than among non-OHCA control persons.
 

Keep aware of stress and anxiety as risk factors

Among OHCA and non-OHCA participants, long-term stress conditions were diagnosed in 0.92% and 0.45%, respectively. Anxiety was diagnosed in 0.85% of OHCA case patients and in 0.37% of non-OHCA control persons.

These conditions were associated with a higher rate of OHCA after adjustment for common OHCA risk factors.

Detrimental to the heart, not just the psyche

Glenn Levine, MD, master clinician and professor of medicine, Baylor College of Medicine, Houston, called it an “important study in that it is a large, nationwide cohort study and thus provides important information to complement much smaller, focused studies.”

Like those other studies, “it finds that negative psychological health, specifically, long-term stress (as well as anxiety), is associated with a significantly increased risk of out-of-hospital cardiac arrest,” continued Dr. Levine, who is the chief of the cardiology section at Michael E. DeBakey VA Medical Center, Houston, and was not involved with the study.

Dr. Levine thinks the study “does a good job, as best one can for such a study, in trying to control for other factors, and zeroing in specifically on stress (and anxiety), trying to assess their independent contributions to the risk of developing cardiac arrest.”

The take-home message for clinicians and patients “is that negative psychological stress factors, such as stress and anxiety, are not only detrimental to one’s psychological health but likely increase one’s risk for adverse cardiac events, such as cardiac arrest,” he stated.

No specific funding for the study was disclosed. Mr. Eroglu has disclosed no relevant financial relationships. The other authors’ disclosures are listed in the original article. Dr. Levine reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Stress-related disorders and anxiety are associated with a higher risk of out-of-hospital cardiac arrest (OHCA), a new case-control study suggests.

Investigators compared more than 35,000 OHCA case patients with a similar number of matched control persons and found an almost 1.5 times higher hazard of long-term stress conditions among OHCA case patients, compared with control persons, with a similar hazard for anxiety. Posttraumatic stress disorder was associated with an almost twofold higher risk of OHCA.

The findings applied equally to men and women and were independent of the presence of cardiovascular disease (CVD).

“This study raises awareness of the higher risks of OHCA and early risk monitoring to prevent OHCA in patients with stress-related disorders and anxiety,” write Talip Eroglu, of the department of cardiology, Copenhagen University Hospital, and colleagues.

The study was published online  in BMJ Open Heart.
 

Stress disorders and anxiety overrepresented

OHCA “predominantly arises from lethal cardiac arrhythmias ... that occur most frequently in the setting of coronary heart disease,” the authors write. However, increasing evidence suggests that rates of OHCA may also be increased in association with noncardiac diseases.

Individuals with stress-related disorders and anxiety are “overrepresented” among victims of cardiac arrest as well as those with multiple CVDs. But previous studies of OHCA have been limited by small numbers of cardiac arrests. In addition, those studies involved only data from selected populations or used in-hospital diagnosis to identify cardiac arrest, thereby potentially omitting OHCA patients who died prior to hospital admission.

The researchers therefore turned to data from Danish health registries that include a large, unselected cohort of patients with OHCA to investigate whether long-term stress conditions (that is, PTSD and adjustment disorder) or anxiety disorder were associated with OHCA.

They stratified the cohort according to sex, age, and CVD to identify which risk factor confers the highest risk of OHCA in patients with long-term stress conditions or anxiety, and they conducted sensitivity analyses of potential confounders, such as depression.

The design was a nested-case control model in which records at an individual patient level across registries were cross-linked to data from other national registries and were compared to matched control persons from the general population (35,195 OHCAs and 351,950 matched control persons; median IQR age, 72 [62-81] years; 66.82% men).

The prevalence of comorbidities and use of cardiovascular drugs were higher among OHCA case patients than among non-OHCA control persons.
 

Keep aware of stress and anxiety as risk factors

Among OHCA and non-OHCA participants, long-term stress conditions were diagnosed in 0.92% and 0.45%, respectively. Anxiety was diagnosed in 0.85% of OHCA case patients and in 0.37% of non-OHCA control persons.

These conditions were associated with a higher rate of OHCA after adjustment for common OHCA risk factors.

Detrimental to the heart, not just the psyche

Glenn Levine, MD, master clinician and professor of medicine, Baylor College of Medicine, Houston, called it an “important study in that it is a large, nationwide cohort study and thus provides important information to complement much smaller, focused studies.”

Like those other studies, “it finds that negative psychological health, specifically, long-term stress (as well as anxiety), is associated with a significantly increased risk of out-of-hospital cardiac arrest,” continued Dr. Levine, who is the chief of the cardiology section at Michael E. DeBakey VA Medical Center, Houston, and was not involved with the study.

Dr. Levine thinks the study “does a good job, as best one can for such a study, in trying to control for other factors, and zeroing in specifically on stress (and anxiety), trying to assess their independent contributions to the risk of developing cardiac arrest.”

The take-home message for clinicians and patients “is that negative psychological stress factors, such as stress and anxiety, are not only detrimental to one’s psychological health but likely increase one’s risk for adverse cardiac events, such as cardiac arrest,” he stated.

No specific funding for the study was disclosed. Mr. Eroglu has disclosed no relevant financial relationships. The other authors’ disclosures are listed in the original article. Dr. Levine reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mass shootings, often on school campuses, have become a regular and sad reality in the United States.
 

The statistics are grim. Every day 12 children die from gun violence in America and another 32 are shot and injured. Since the Columbine High School shooting in 1999, more than 338,000 students in the United States have experienced school gun violence, according to the nonprofit organization Sandy Hook Promise.

A new analysis from the Columbia Mass Murder Database (CMMD) sheds fresh light on the debate over whether mental illness or easy access to guns is the key driver of mass shootings.

The findings, which are published in the Journal of Forensic Sciences, show that most perpetrators of mass school shootings are young, White men without serious mental illness.
 

A ‘straw man’

Mental health is often used as a “straw man” in debates about mass shootings, lead investigator Ragy Girgis, MD, told this news organization.

“There are many factors that contribute to the mass shooting epidemic, including gun access, criminality, substance use and misuse, and many others. Mental illness is incidental in the vast majority of cases,” said Dr. Girgis, with Columbia University Irving Medical Center, New York, and the New York State Psychiatric Institute.

“People with serious mental illness constitute only a small portion of the perpetrators of gun violence in this country,” coinvestigator Paul Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University, New York, told this news organization.

Using the CMMD, the researchers examined 82 incidents of mass murder perpetrated in academic settings including schools, colleges, and universities. The average number of victims of these incidents was eight. More than half (60%) of mass school shootings involved at least one semi- or fully automatic firearm.

All 82 incidents were initiated by men (mean age, 28), and 67% were White. About two-thirds (63%) involved guns.

More than three-quarters (77%) of all perpetrators of mass murders in academic settings had no recorded history of psychotic symptoms.

Despite the absence of serious mental illness, almost half (46%) of the mass school shooters took their own lives at the scene, suggesting that they viewed themselves as engaging in some form of “final act,” the researchers note.

“The major difference between mass shooters in school settings and elsewhere is the higher rate of suicide by the perpetrators in school settings. That suggests that the shootings are often part of a preexisting intent to die on the part of the shooter,” said Dr. Appelbaum.
 

Epidemic of emptiness

He noted that the typical profile of a mass school shooter is that of “a young male with anger problems, often as a result of bullying or abuse, frequently described as a loner, who has signaled a desire to kill other people.”

“If we only focus on mental illness, we will miss the warning signs in the majority of cases associated with victimization (such as bullying) and consequent anger,” Dr. Appelbaum said.

Dr. Girgis said there is a need to deal with the “epidemic of emptiness, narcissism, anger, and societal rejection felt by many young men/boys who, when combined with a desire to take their own lives and a great need for notoriety, feel that perpetrating a mass school shooting is their only option.”

“We also need to understand why it is so easy for so many mass school shooters to obtain firearms that are not theirs – either illegally or from someone else who themselves may have obtained the firearm legally,” Dr. Girgis said.

“All countries have people with mental illness,” Dr. Appelbaum said, “but among developed countries the U.S. is unique in the easy availability of weapons and in our disproportionate rate of murders.”

He also noted that school shootings are not a problem that clinicians are going to solve.

“Although they can be alert to signals from their patients of an intent to harm people in a school (or other) setting, the vast majority of shooters are not receiving treatment for a mental disorder,” Dr. Appelbaum said.

“This is a problem that can only be substantially diminished by reducing access to firearms, which includes requirements for safe storage, universal background checks, waiting periods to purchase firearms, and similar means-oriented interventions,” he added.
 

Need for regular mental health checks

Thea Gallagher, PsyD, who was not involved in the study, noted that mass school shooters may not have a psychotic illness, but with mental health there is a “spectrum, and obviously, that individual is struggling to some extent, most likely, mentally, if they are at a place where they are willing to take the lives of others and themselves.”

“We need to understand more about how people get to this place and the issues people are struggling with. We need to push for yearly mental health checks just like the yearly physical,” Dr. Gallagher, with the department of psychiatry at NYU Langone Health, New York, told this news organization.

“The more that we create conversation and moments to talk about how people are feeling internally, the better chance we have to give people who are struggling healthy coping strategies and the opportunity to process their emotions and not bury them,” Dr. Gallagher said.

Support for the study was provided in part by the New York State Office of Mental Hygiene, and the Elizabeth K. Dollard Charitable Trust. Dr. Girgis has received royalties and/or advances from books on mental health published by Wipf and Stock, and Routledge/Taylor and Francis. He has consulted for Noble Insights, IMS Expert Services, and Fowler White Burnett. Dr. Appelbaum and Dr. Gallagher report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mass shootings, often on school campuses, have become a regular and sad reality in the United States.
 

The statistics are grim. Every day 12 children die from gun violence in America and another 32 are shot and injured. Since the Columbine High School shooting in 1999, more than 338,000 students in the United States have experienced school gun violence, according to the nonprofit organization Sandy Hook Promise.

A new analysis from the Columbia Mass Murder Database (CMMD) sheds fresh light on the debate over whether mental illness or easy access to guns is the key driver of mass shootings.

The findings, which are published in the Journal of Forensic Sciences, show that most perpetrators of mass school shootings are young, White men without serious mental illness.
 

A ‘straw man’

Mental health is often used as a “straw man” in debates about mass shootings, lead investigator Ragy Girgis, MD, told this news organization.

“There are many factors that contribute to the mass shooting epidemic, including gun access, criminality, substance use and misuse, and many others. Mental illness is incidental in the vast majority of cases,” said Dr. Girgis, with Columbia University Irving Medical Center, New York, and the New York State Psychiatric Institute.

“People with serious mental illness constitute only a small portion of the perpetrators of gun violence in this country,” coinvestigator Paul Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University, New York, told this news organization.

Using the CMMD, the researchers examined 82 incidents of mass murder perpetrated in academic settings including schools, colleges, and universities. The average number of victims of these incidents was eight. More than half (60%) of mass school shootings involved at least one semi- or fully automatic firearm.

All 82 incidents were initiated by men (mean age, 28), and 67% were White. About two-thirds (63%) involved guns.

More than three-quarters (77%) of all perpetrators of mass murders in academic settings had no recorded history of psychotic symptoms.

Despite the absence of serious mental illness, almost half (46%) of the mass school shooters took their own lives at the scene, suggesting that they viewed themselves as engaging in some form of “final act,” the researchers note.

“The major difference between mass shooters in school settings and elsewhere is the higher rate of suicide by the perpetrators in school settings. That suggests that the shootings are often part of a preexisting intent to die on the part of the shooter,” said Dr. Appelbaum.
 

Epidemic of emptiness

He noted that the typical profile of a mass school shooter is that of “a young male with anger problems, often as a result of bullying or abuse, frequently described as a loner, who has signaled a desire to kill other people.”

“If we only focus on mental illness, we will miss the warning signs in the majority of cases associated with victimization (such as bullying) and consequent anger,” Dr. Appelbaum said.

Dr. Girgis said there is a need to deal with the “epidemic of emptiness, narcissism, anger, and societal rejection felt by many young men/boys who, when combined with a desire to take their own lives and a great need for notoriety, feel that perpetrating a mass school shooting is their only option.”

“We also need to understand why it is so easy for so many mass school shooters to obtain firearms that are not theirs – either illegally or from someone else who themselves may have obtained the firearm legally,” Dr. Girgis said.

“All countries have people with mental illness,” Dr. Appelbaum said, “but among developed countries the U.S. is unique in the easy availability of weapons and in our disproportionate rate of murders.”

He also noted that school shootings are not a problem that clinicians are going to solve.

“Although they can be alert to signals from their patients of an intent to harm people in a school (or other) setting, the vast majority of shooters are not receiving treatment for a mental disorder,” Dr. Appelbaum said.

“This is a problem that can only be substantially diminished by reducing access to firearms, which includes requirements for safe storage, universal background checks, waiting periods to purchase firearms, and similar means-oriented interventions,” he added.
 

Need for regular mental health checks

Thea Gallagher, PsyD, who was not involved in the study, noted that mass school shooters may not have a psychotic illness, but with mental health there is a “spectrum, and obviously, that individual is struggling to some extent, most likely, mentally, if they are at a place where they are willing to take the lives of others and themselves.”

“We need to understand more about how people get to this place and the issues people are struggling with. We need to push for yearly mental health checks just like the yearly physical,” Dr. Gallagher, with the department of psychiatry at NYU Langone Health, New York, told this news organization.

“The more that we create conversation and moments to talk about how people are feeling internally, the better chance we have to give people who are struggling healthy coping strategies and the opportunity to process their emotions and not bury them,” Dr. Gallagher said.

Support for the study was provided in part by the New York State Office of Mental Hygiene, and the Elizabeth K. Dollard Charitable Trust. Dr. Girgis has received royalties and/or advances from books on mental health published by Wipf and Stock, and Routledge/Taylor and Francis. He has consulted for Noble Insights, IMS Expert Services, and Fowler White Burnett. Dr. Appelbaum and Dr. Gallagher report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mass shootings, often on school campuses, have become a regular and sad reality in the United States.
 

The statistics are grim. Every day 12 children die from gun violence in America and another 32 are shot and injured. Since the Columbine High School shooting in 1999, more than 338,000 students in the United States have experienced school gun violence, according to the nonprofit organization Sandy Hook Promise.

A new analysis from the Columbia Mass Murder Database (CMMD) sheds fresh light on the debate over whether mental illness or easy access to guns is the key driver of mass shootings.

The findings, which are published in the Journal of Forensic Sciences, show that most perpetrators of mass school shootings are young, White men without serious mental illness.
 

A ‘straw man’

Mental health is often used as a “straw man” in debates about mass shootings, lead investigator Ragy Girgis, MD, told this news organization.

“There are many factors that contribute to the mass shooting epidemic, including gun access, criminality, substance use and misuse, and many others. Mental illness is incidental in the vast majority of cases,” said Dr. Girgis, with Columbia University Irving Medical Center, New York, and the New York State Psychiatric Institute.

“People with serious mental illness constitute only a small portion of the perpetrators of gun violence in this country,” coinvestigator Paul Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University, New York, told this news organization.

Using the CMMD, the researchers examined 82 incidents of mass murder perpetrated in academic settings including schools, colleges, and universities. The average number of victims of these incidents was eight. More than half (60%) of mass school shootings involved at least one semi- or fully automatic firearm.

All 82 incidents were initiated by men (mean age, 28), and 67% were White. About two-thirds (63%) involved guns.

More than three-quarters (77%) of all perpetrators of mass murders in academic settings had no recorded history of psychotic symptoms.

Despite the absence of serious mental illness, almost half (46%) of the mass school shooters took their own lives at the scene, suggesting that they viewed themselves as engaging in some form of “final act,” the researchers note.

“The major difference between mass shooters in school settings and elsewhere is the higher rate of suicide by the perpetrators in school settings. That suggests that the shootings are often part of a preexisting intent to die on the part of the shooter,” said Dr. Appelbaum.
 

Epidemic of emptiness

He noted that the typical profile of a mass school shooter is that of “a young male with anger problems, often as a result of bullying or abuse, frequently described as a loner, who has signaled a desire to kill other people.”

“If we only focus on mental illness, we will miss the warning signs in the majority of cases associated with victimization (such as bullying) and consequent anger,” Dr. Appelbaum said.

Dr. Girgis said there is a need to deal with the “epidemic of emptiness, narcissism, anger, and societal rejection felt by many young men/boys who, when combined with a desire to take their own lives and a great need for notoriety, feel that perpetrating a mass school shooting is their only option.”

“We also need to understand why it is so easy for so many mass school shooters to obtain firearms that are not theirs – either illegally or from someone else who themselves may have obtained the firearm legally,” Dr. Girgis said.

“All countries have people with mental illness,” Dr. Appelbaum said, “but among developed countries the U.S. is unique in the easy availability of weapons and in our disproportionate rate of murders.”

He also noted that school shootings are not a problem that clinicians are going to solve.

“Although they can be alert to signals from their patients of an intent to harm people in a school (or other) setting, the vast majority of shooters are not receiving treatment for a mental disorder,” Dr. Appelbaum said.

“This is a problem that can only be substantially diminished by reducing access to firearms, which includes requirements for safe storage, universal background checks, waiting periods to purchase firearms, and similar means-oriented interventions,” he added.
 

Need for regular mental health checks

Thea Gallagher, PsyD, who was not involved in the study, noted that mass school shooters may not have a psychotic illness, but with mental health there is a “spectrum, and obviously, that individual is struggling to some extent, most likely, mentally, if they are at a place where they are willing to take the lives of others and themselves.”

“We need to understand more about how people get to this place and the issues people are struggling with. We need to push for yearly mental health checks just like the yearly physical,” Dr. Gallagher, with the department of psychiatry at NYU Langone Health, New York, told this news organization.

“The more that we create conversation and moments to talk about how people are feeling internally, the better chance we have to give people who are struggling healthy coping strategies and the opportunity to process their emotions and not bury them,” Dr. Gallagher said.

Support for the study was provided in part by the New York State Office of Mental Hygiene, and the Elizabeth K. Dollard Charitable Trust. Dr. Girgis has received royalties and/or advances from books on mental health published by Wipf and Stock, and Routledge/Taylor and Francis. He has consulted for Noble Insights, IMS Expert Services, and Fowler White Burnett. Dr. Appelbaum and Dr. Gallagher report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Adding online mindfulness and self-compassion training to usual care may improve quality of life (QOL) in adults with atopic dermatitis (AD), according to results of a small randomized controlled trial in Japan.

“We found that skin disease–specific QOL improved over time with a large effect size,” lead study author Sanae Kishimoto, MHS, MPH, of the School of Public Health, Graduate School of Medicine at Kyoto University and colleagues write in JAMA Dermatology. “These findings suggest that mindfulness and self-compassion training is an effective treatment option for adults with AD.”
 

A bothersome disease that worsens quality of life

AD, a chronic, relapsing, inflammatory, multifactorial skin disease involving intense itching, affects an estimated 15%-30% of children and 2%-10% of adults, with the incidence increasing in industrialized countries, the authors state. 

d3sign/Getty Images

Measured by disability-adjusted life years, AD has the highest disease burden among skin diseases, and people with AD commonly have anxiety, depression, and sleep problems. Treatments include medications, other skin care, and lifestyle changes. New biologics appear to be effective but are expensive and need to be studied for their long-term safety, the authors add.

“Stress can make the skin worse, but at the same time the skin disease and symptoms cause stress,” Peter A. Lio, MD, who was not involved in the study, told this news organization by email. “This vicious cycle contributes greatly to impairing quality of life.”
 

A program focused on wise, kind self-care

In the SMiLE study, the authors recruited adults with moderate to severe AD and Dermatology Life Quality Index (DLQI) score above 6 from dermatology clinics and through online announcements over 1 year beginning in July 2019.

Participants averaged 36.3 years of age, 80% were women, and their mean AD duration was 26.6 years. Everyone was allowed to receive usual care during the study, except for dupilumab (a newly marketed drug when the study started), psychotherapy, or other mindfulness training.

The researchers randomly assigned 56 adults to receive mindfulness training in addition to their usual care and 51 to the wait list plus usual care. Those in the training group received eight weekly 90-minute online mindfulness and self-compassion sessions. Each group-based session was conducted at the same time and day of the week and included meditation, informal psychoeducation, inquiry, and a short lecture, along with an optional 1-day silent meditation retreat at week 7 and an optional 2-hour videoconferencing booster session at week 13.

The intervention encouraged a nonjudgmental relationship with stress using mindfulness-based stress reduction (MBSR) and emphasized a compassionate relationship with oneself during suffering using mindful self-compassion (MSC). The program was developed and taught by lead author Dr. Kishimoto, a Japanese licensed clinical psychologist who has a history of AD, the paper notes.

At 13 weeks, after completing electronic assessments, patients in the training group showed greater improvement in the DLQI score than those on the wait list (between-group difference estimate, –6.34; 95% confidence interval, –8.27 to –4.41; P < .001). The standardized effect size (Cohen’s d) at 13 weeks was –1.06 (95% CI, –1.39 to –0.74).

Patients in the training group also improved more in all secondary outcomes: severity, itch- and scratch-related visual analog scales, self-compassion, mindfulness, psychological symptoms, and adherence to dermatologist-advised treatments.

They were also more likely to follow their dermatologist’s medical treatment plans, including moisturizer and topical steroid use.

One serious adverse event, endometrial cancer in one patient, was judged to be unrelated to the intervention.
 

Online format may give more patients access to treatment

“With relatively limited data in the literature, this particularly well-done, important study is likely to positively shape thinking around this topic,” said Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago. “This study nicely demonstrates that an online approach can be effective.

“In theory, these methods or techniques could democratize treatments like this, and open them up to many more patients,” he added. He would like to see partially or entirely automated apps (free of cost), similar to meditation “apps,” to treat patients more cost-effectively.

Dr. Lio explained that excluding participants on dupilumab (Dupixent) makes the results slightly less generalizable to patients with moderate to severe AD, who may have the most serious QOL challenges and who are often candidates for dupilumab.

“However, given that we almost never have all the known variables for a study, we are generally comfortable extrapolating that the intervention would likely be helpful for patients taking dupilumab as well, despite it not being specifically evaluated in that group,” he said.

Susan Massick, MD, of the department of dermatology at the Ohio State University Wexner Medical Center in Columbus, advises clinicians to take a multipronged approach to treating the physical and behavioral components of AD and to embrace therapies beyond prescription medications.

“Self-compassion training is another tool in our toolbox toward finding the right fix for our patients,” Dr. Massick said by email. She was not involved with this research.

“I applaud the focus of this study on behavioral health training as a means toward wellness and improved mindfulness,” she added. “I was impressed by the extent to which these simple measures helped improve the quality of life for patients who used the training.”

U.S. patients can benefit from these findings

“My sense is that AD patients the world over have many similar characteristics and concerns, so I would anticipate that the results would be comparable in a U.S. population,” Dr. Lio said. “Other studies performed in the U.S. also support this line of thinking.”

Although the study involved highly motivated patients in Japan, the suffering that patients with AD experience is universal regardless of race or ethnicity, Dr. Massick said. “Americans may be even more willing to embrace mindfulness and self-compassion training as a path toward better health and wellness.”

The study was funded by the Japan Agency for Medical Research and Development and the Mental Health Okamoto Memorial Foundation, the KDDI Foundation, the Pfizer Health Research Foundation, and the Japan Society for the Promotion of Science.

Dr. Kishimoto and several coauthors report relevant financial relationships with pharmaceutical companies. Dr. Lio reports financial relationships with Sanofi and Regeneron, the joint developers of dupilumab. Dr. Massick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Adding online mindfulness and self-compassion training to usual care may improve quality of life (QOL) in adults with atopic dermatitis (AD), according to results of a small randomized controlled trial in Japan.

“We found that skin disease–specific QOL improved over time with a large effect size,” lead study author Sanae Kishimoto, MHS, MPH, of the School of Public Health, Graduate School of Medicine at Kyoto University and colleagues write in JAMA Dermatology. “These findings suggest that mindfulness and self-compassion training is an effective treatment option for adults with AD.”
 

A bothersome disease that worsens quality of life

AD, a chronic, relapsing, inflammatory, multifactorial skin disease involving intense itching, affects an estimated 15%-30% of children and 2%-10% of adults, with the incidence increasing in industrialized countries, the authors state. 

d3sign/Getty Images

Measured by disability-adjusted life years, AD has the highest disease burden among skin diseases, and people with AD commonly have anxiety, depression, and sleep problems. Treatments include medications, other skin care, and lifestyle changes. New biologics appear to be effective but are expensive and need to be studied for their long-term safety, the authors add.

“Stress can make the skin worse, but at the same time the skin disease and symptoms cause stress,” Peter A. Lio, MD, who was not involved in the study, told this news organization by email. “This vicious cycle contributes greatly to impairing quality of life.”
 

A program focused on wise, kind self-care

In the SMiLE study, the authors recruited adults with moderate to severe AD and Dermatology Life Quality Index (DLQI) score above 6 from dermatology clinics and through online announcements over 1 year beginning in July 2019.

Participants averaged 36.3 years of age, 80% were women, and their mean AD duration was 26.6 years. Everyone was allowed to receive usual care during the study, except for dupilumab (a newly marketed drug when the study started), psychotherapy, or other mindfulness training.

The researchers randomly assigned 56 adults to receive mindfulness training in addition to their usual care and 51 to the wait list plus usual care. Those in the training group received eight weekly 90-minute online mindfulness and self-compassion sessions. Each group-based session was conducted at the same time and day of the week and included meditation, informal psychoeducation, inquiry, and a short lecture, along with an optional 1-day silent meditation retreat at week 7 and an optional 2-hour videoconferencing booster session at week 13.

The intervention encouraged a nonjudgmental relationship with stress using mindfulness-based stress reduction (MBSR) and emphasized a compassionate relationship with oneself during suffering using mindful self-compassion (MSC). The program was developed and taught by lead author Dr. Kishimoto, a Japanese licensed clinical psychologist who has a history of AD, the paper notes.

At 13 weeks, after completing electronic assessments, patients in the training group showed greater improvement in the DLQI score than those on the wait list (between-group difference estimate, –6.34; 95% confidence interval, –8.27 to –4.41; P < .001). The standardized effect size (Cohen’s d) at 13 weeks was –1.06 (95% CI, –1.39 to –0.74).

Patients in the training group also improved more in all secondary outcomes: severity, itch- and scratch-related visual analog scales, self-compassion, mindfulness, psychological symptoms, and adherence to dermatologist-advised treatments.

They were also more likely to follow their dermatologist’s medical treatment plans, including moisturizer and topical steroid use.

One serious adverse event, endometrial cancer in one patient, was judged to be unrelated to the intervention.
 

Online format may give more patients access to treatment

“With relatively limited data in the literature, this particularly well-done, important study is likely to positively shape thinking around this topic,” said Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago. “This study nicely demonstrates that an online approach can be effective.

“In theory, these methods or techniques could democratize treatments like this, and open them up to many more patients,” he added. He would like to see partially or entirely automated apps (free of cost), similar to meditation “apps,” to treat patients more cost-effectively.

Dr. Lio explained that excluding participants on dupilumab (Dupixent) makes the results slightly less generalizable to patients with moderate to severe AD, who may have the most serious QOL challenges and who are often candidates for dupilumab.

“However, given that we almost never have all the known variables for a study, we are generally comfortable extrapolating that the intervention would likely be helpful for patients taking dupilumab as well, despite it not being specifically evaluated in that group,” he said.

Susan Massick, MD, of the department of dermatology at the Ohio State University Wexner Medical Center in Columbus, advises clinicians to take a multipronged approach to treating the physical and behavioral components of AD and to embrace therapies beyond prescription medications.

“Self-compassion training is another tool in our toolbox toward finding the right fix for our patients,” Dr. Massick said by email. She was not involved with this research.

“I applaud the focus of this study on behavioral health training as a means toward wellness and improved mindfulness,” she added. “I was impressed by the extent to which these simple measures helped improve the quality of life for patients who used the training.”

U.S. patients can benefit from these findings

“My sense is that AD patients the world over have many similar characteristics and concerns, so I would anticipate that the results would be comparable in a U.S. population,” Dr. Lio said. “Other studies performed in the U.S. also support this line of thinking.”

Although the study involved highly motivated patients in Japan, the suffering that patients with AD experience is universal regardless of race or ethnicity, Dr. Massick said. “Americans may be even more willing to embrace mindfulness and self-compassion training as a path toward better health and wellness.”

The study was funded by the Japan Agency for Medical Research and Development and the Mental Health Okamoto Memorial Foundation, the KDDI Foundation, the Pfizer Health Research Foundation, and the Japan Society for the Promotion of Science.

Dr. Kishimoto and several coauthors report relevant financial relationships with pharmaceutical companies. Dr. Lio reports financial relationships with Sanofi and Regeneron, the joint developers of dupilumab. Dr. Massick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Adding online mindfulness and self-compassion training to usual care may improve quality of life (QOL) in adults with atopic dermatitis (AD), according to results of a small randomized controlled trial in Japan.

“We found that skin disease–specific QOL improved over time with a large effect size,” lead study author Sanae Kishimoto, MHS, MPH, of the School of Public Health, Graduate School of Medicine at Kyoto University and colleagues write in JAMA Dermatology. “These findings suggest that mindfulness and self-compassion training is an effective treatment option for adults with AD.”
 

A bothersome disease that worsens quality of life

AD, a chronic, relapsing, inflammatory, multifactorial skin disease involving intense itching, affects an estimated 15%-30% of children and 2%-10% of adults, with the incidence increasing in industrialized countries, the authors state. 

d3sign/Getty Images

Measured by disability-adjusted life years, AD has the highest disease burden among skin diseases, and people with AD commonly have anxiety, depression, and sleep problems. Treatments include medications, other skin care, and lifestyle changes. New biologics appear to be effective but are expensive and need to be studied for their long-term safety, the authors add.

“Stress can make the skin worse, but at the same time the skin disease and symptoms cause stress,” Peter A. Lio, MD, who was not involved in the study, told this news organization by email. “This vicious cycle contributes greatly to impairing quality of life.”
 

A program focused on wise, kind self-care

In the SMiLE study, the authors recruited adults with moderate to severe AD and Dermatology Life Quality Index (DLQI) score above 6 from dermatology clinics and through online announcements over 1 year beginning in July 2019.

Participants averaged 36.3 years of age, 80% were women, and their mean AD duration was 26.6 years. Everyone was allowed to receive usual care during the study, except for dupilumab (a newly marketed drug when the study started), psychotherapy, or other mindfulness training.

The researchers randomly assigned 56 adults to receive mindfulness training in addition to their usual care and 51 to the wait list plus usual care. Those in the training group received eight weekly 90-minute online mindfulness and self-compassion sessions. Each group-based session was conducted at the same time and day of the week and included meditation, informal psychoeducation, inquiry, and a short lecture, along with an optional 1-day silent meditation retreat at week 7 and an optional 2-hour videoconferencing booster session at week 13.

The intervention encouraged a nonjudgmental relationship with stress using mindfulness-based stress reduction (MBSR) and emphasized a compassionate relationship with oneself during suffering using mindful self-compassion (MSC). The program was developed and taught by lead author Dr. Kishimoto, a Japanese licensed clinical psychologist who has a history of AD, the paper notes.

At 13 weeks, after completing electronic assessments, patients in the training group showed greater improvement in the DLQI score than those on the wait list (between-group difference estimate, –6.34; 95% confidence interval, –8.27 to –4.41; P < .001). The standardized effect size (Cohen’s d) at 13 weeks was –1.06 (95% CI, –1.39 to –0.74).

Patients in the training group also improved more in all secondary outcomes: severity, itch- and scratch-related visual analog scales, self-compassion, mindfulness, psychological symptoms, and adherence to dermatologist-advised treatments.

They were also more likely to follow their dermatologist’s medical treatment plans, including moisturizer and topical steroid use.

One serious adverse event, endometrial cancer in one patient, was judged to be unrelated to the intervention.
 

Online format may give more patients access to treatment

“With relatively limited data in the literature, this particularly well-done, important study is likely to positively shape thinking around this topic,” said Dr. Lio, of the departments of dermatology and pediatrics at Northwestern University, Chicago. “This study nicely demonstrates that an online approach can be effective.

“In theory, these methods or techniques could democratize treatments like this, and open them up to many more patients,” he added. He would like to see partially or entirely automated apps (free of cost), similar to meditation “apps,” to treat patients more cost-effectively.

Dr. Lio explained that excluding participants on dupilumab (Dupixent) makes the results slightly less generalizable to patients with moderate to severe AD, who may have the most serious QOL challenges and who are often candidates for dupilumab.

“However, given that we almost never have all the known variables for a study, we are generally comfortable extrapolating that the intervention would likely be helpful for patients taking dupilumab as well, despite it not being specifically evaluated in that group,” he said.

Susan Massick, MD, of the department of dermatology at the Ohio State University Wexner Medical Center in Columbus, advises clinicians to take a multipronged approach to treating the physical and behavioral components of AD and to embrace therapies beyond prescription medications.

“Self-compassion training is another tool in our toolbox toward finding the right fix for our patients,” Dr. Massick said by email. She was not involved with this research.

“I applaud the focus of this study on behavioral health training as a means toward wellness and improved mindfulness,” she added. “I was impressed by the extent to which these simple measures helped improve the quality of life for patients who used the training.”

U.S. patients can benefit from these findings

“My sense is that AD patients the world over have many similar characteristics and concerns, so I would anticipate that the results would be comparable in a U.S. population,” Dr. Lio said. “Other studies performed in the U.S. also support this line of thinking.”

Although the study involved highly motivated patients in Japan, the suffering that patients with AD experience is universal regardless of race or ethnicity, Dr. Massick said. “Americans may be even more willing to embrace mindfulness and self-compassion training as a path toward better health and wellness.”

The study was funded by the Japan Agency for Medical Research and Development and the Mental Health Okamoto Memorial Foundation, the KDDI Foundation, the Pfizer Health Research Foundation, and the Japan Society for the Promotion of Science.

Dr. Kishimoto and several coauthors report relevant financial relationships with pharmaceutical companies. Dr. Lio reports financial relationships with Sanofi and Regeneron, the joint developers of dupilumab. Dr. Massick reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Patients taking antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs), often report emotional blunting even as their depression eases, new research shows.

Emotional blunting can be described as feeling emotionally flat and incapable of finding pleasure. The patient may feel less sadness, guilt, or hopelessness, but that may come at the cost of feeling less joy, surprise, and happiness. Some people with SSRI-induced blunting even report caring less about important relationships.

Mujeeb U. Shad

It’s an issue that needs greater attention, study investigator Mujeeb U. Shad, MD, with Valley Health Services and University of Nevada, Las Vegas, said in an interview.

“Patients may come to the clinic and report feeling emotionally and cognitively flat and not be taken seriously by their provider, but they are genuinely reporting something that is happening to them and decreasing their quality of life,” Dr. Shad explained.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Something ‘missing’

Dr. Shad said that the genesis for the study came from a resident who noticed that many patients receiving SSRIs reported feeling better and not as bothered by the depression, yet, at the same time, they felt something was “missing. Their families would say, ‘You’re better but you’re not the same person.’ ”

To investigate further, the researchers did a “scoping review” of 25 original studies that assessed antidepressant-related emotional blunting. Until now, there hasn’t been a systematic review of this issue, Dr. Shad said.

Ten of the studies looked at the role of SSRIs in emotional blunting, whereas the other 15 looked at serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and second-generation antipsychotic medications.

The results of the review show that emotional blunting is a significant patient-reported concern. It often presents as a subjective complaint of changed personality, feeling a lesser intensity of overall emotions, and the manifestation of not being oneself often attributed to antidepressant use, the researchers found. Emotional blunting was more commonly associated with SSRIs than with the other medications in the studies.

Common clinical strategies to manage antidepressant-induced emotional blunting reported in the literature include dose reduction or switching to a different antidepressant class; however, the literature did not make the distinction between emotional blunting as a primary symptom of depression or an adverse effect of antidepressants.

Dr. Shad said that there is a need to develop valid and reliable measures to assess emotional blunting related to antidepressants.

He noted that optimal patient care should include pre- and posttreatment assessment of emotional blunting. One useful tool is the Oxford Questionnaire on the Emotional Side-Effects of Antidepressants.
 

Can’t get to the top

Jacob Cross, MD, who wasn’t involved in the study, said that he has seen the impact of antidepressant-related emotional blunting first-hand.

“I’ve had multiple patients report emotional blunting on antidepressant therapy,” Dr. Cross, with the department of psychiatry, Rush Medical College, Chicago, said.

“These patients feel like their emotions are not as high and not as low; so they experience directional improvement, but they’re still not feeling like they can get that top peak emotion. It’s kind of similar to anhedonia. They’re just feeling like a little cut off, like they’re climbing a cliff and just can’t get to that top,” Dr. Cross said.

For a patient with emotional blunting, Dr. Cross said he might “switch to an antidepressant that’s more stimulating like an SNRI from an SSRI. You could also lower the dose and see if that helps, but I usually change the drug class.”

The study had no specific funding. Dr. Shad and Dr. Cross have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Patients taking antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs), often report emotional blunting even as their depression eases, new research shows.

Emotional blunting can be described as feeling emotionally flat and incapable of finding pleasure. The patient may feel less sadness, guilt, or hopelessness, but that may come at the cost of feeling less joy, surprise, and happiness. Some people with SSRI-induced blunting even report caring less about important relationships.

Mujeeb U. Shad

It’s an issue that needs greater attention, study investigator Mujeeb U. Shad, MD, with Valley Health Services and University of Nevada, Las Vegas, said in an interview.

“Patients may come to the clinic and report feeling emotionally and cognitively flat and not be taken seriously by their provider, but they are genuinely reporting something that is happening to them and decreasing their quality of life,” Dr. Shad explained.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Something ‘missing’

Dr. Shad said that the genesis for the study came from a resident who noticed that many patients receiving SSRIs reported feeling better and not as bothered by the depression, yet, at the same time, they felt something was “missing. Their families would say, ‘You’re better but you’re not the same person.’ ”

To investigate further, the researchers did a “scoping review” of 25 original studies that assessed antidepressant-related emotional blunting. Until now, there hasn’t been a systematic review of this issue, Dr. Shad said.

Ten of the studies looked at the role of SSRIs in emotional blunting, whereas the other 15 looked at serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and second-generation antipsychotic medications.

The results of the review show that emotional blunting is a significant patient-reported concern. It often presents as a subjective complaint of changed personality, feeling a lesser intensity of overall emotions, and the manifestation of not being oneself often attributed to antidepressant use, the researchers found. Emotional blunting was more commonly associated with SSRIs than with the other medications in the studies.

Common clinical strategies to manage antidepressant-induced emotional blunting reported in the literature include dose reduction or switching to a different antidepressant class; however, the literature did not make the distinction between emotional blunting as a primary symptom of depression or an adverse effect of antidepressants.

Dr. Shad said that there is a need to develop valid and reliable measures to assess emotional blunting related to antidepressants.

He noted that optimal patient care should include pre- and posttreatment assessment of emotional blunting. One useful tool is the Oxford Questionnaire on the Emotional Side-Effects of Antidepressants.
 

Can’t get to the top

Jacob Cross, MD, who wasn’t involved in the study, said that he has seen the impact of antidepressant-related emotional blunting first-hand.

“I’ve had multiple patients report emotional blunting on antidepressant therapy,” Dr. Cross, with the department of psychiatry, Rush Medical College, Chicago, said.

“These patients feel like their emotions are not as high and not as low; so they experience directional improvement, but they’re still not feeling like they can get that top peak emotion. It’s kind of similar to anhedonia. They’re just feeling like a little cut off, like they’re climbing a cliff and just can’t get to that top,” Dr. Cross said.

For a patient with emotional blunting, Dr. Cross said he might “switch to an antidepressant that’s more stimulating like an SNRI from an SSRI. You could also lower the dose and see if that helps, but I usually change the drug class.”

The study had no specific funding. Dr. Shad and Dr. Cross have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Patients taking antidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs), often report emotional blunting even as their depression eases, new research shows.

Emotional blunting can be described as feeling emotionally flat and incapable of finding pleasure. The patient may feel less sadness, guilt, or hopelessness, but that may come at the cost of feeling less joy, surprise, and happiness. Some people with SSRI-induced blunting even report caring less about important relationships.

Mujeeb U. Shad

It’s an issue that needs greater attention, study investigator Mujeeb U. Shad, MD, with Valley Health Services and University of Nevada, Las Vegas, said in an interview.

“Patients may come to the clinic and report feeling emotionally and cognitively flat and not be taken seriously by their provider, but they are genuinely reporting something that is happening to them and decreasing their quality of life,” Dr. Shad explained.

The study was presented at the annual meeting of the American Psychiatric Association.
 

Something ‘missing’

Dr. Shad said that the genesis for the study came from a resident who noticed that many patients receiving SSRIs reported feeling better and not as bothered by the depression, yet, at the same time, they felt something was “missing. Their families would say, ‘You’re better but you’re not the same person.’ ”

To investigate further, the researchers did a “scoping review” of 25 original studies that assessed antidepressant-related emotional blunting. Until now, there hasn’t been a systematic review of this issue, Dr. Shad said.

Ten of the studies looked at the role of SSRIs in emotional blunting, whereas the other 15 looked at serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and second-generation antipsychotic medications.

The results of the review show that emotional blunting is a significant patient-reported concern. It often presents as a subjective complaint of changed personality, feeling a lesser intensity of overall emotions, and the manifestation of not being oneself often attributed to antidepressant use, the researchers found. Emotional blunting was more commonly associated with SSRIs than with the other medications in the studies.

Common clinical strategies to manage antidepressant-induced emotional blunting reported in the literature include dose reduction or switching to a different antidepressant class; however, the literature did not make the distinction between emotional blunting as a primary symptom of depression or an adverse effect of antidepressants.

Dr. Shad said that there is a need to develop valid and reliable measures to assess emotional blunting related to antidepressants.

He noted that optimal patient care should include pre- and posttreatment assessment of emotional blunting. One useful tool is the Oxford Questionnaire on the Emotional Side-Effects of Antidepressants.
 

Can’t get to the top

Jacob Cross, MD, who wasn’t involved in the study, said that he has seen the impact of antidepressant-related emotional blunting first-hand.

“I’ve had multiple patients report emotional blunting on antidepressant therapy,” Dr. Cross, with the department of psychiatry, Rush Medical College, Chicago, said.

“These patients feel like their emotions are not as high and not as low; so they experience directional improvement, but they’re still not feeling like they can get that top peak emotion. It’s kind of similar to anhedonia. They’re just feeling like a little cut off, like they’re climbing a cliff and just can’t get to that top,” Dr. Cross said.

For a patient with emotional blunting, Dr. Cross said he might “switch to an antidepressant that’s more stimulating like an SNRI from an SSRI. You could also lower the dose and see if that helps, but I usually change the drug class.”

The study had no specific funding. Dr. Shad and Dr. Cross have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Only 11% of eating disorder apps protect the privacy of users as is mandated by the Health Insurance Portability and Accountability Act, according to the results of a new study.

Federal laws require those handling sensitive health information to have policies and security safeguards in place to protect such information, whether it’s stored on paper or electronically.

“As it stands right now, there’s not enough evidence to support using these apps as an adjunct to clinical care,” study author Theodora O’Leary, a 4th-year medical student at Tufts University, Boston, said in an interview. “We need more research on the efficacy of these apps because right now not enough of them meet HIPAA [standards] and don’t have privacy and security measures.”

Pauline Anderson

The findings were presented at the annual meeting of the American Psychiatric Association.

Eating disorders (EDs) are a common mental health condition affecting almost 1 in 10 Americans over their lifetime. Yet only about a third of patients with an eating disorder receive adequate treatment.

The pandemic saw a rise in eating disorders and in the use of mental health apps “to kind of fill the gap because people couldn’t be seen in person,” said Ms. O’Leary.
 

Inexpensive and accessible

Smartphone apps have a lot of advantages for patients with an ED. For one thing, they’re relatively inexpensive and accessible; most Americans already own one or more devices on which these apps can be used.

They’re also a feasible means of delivering psychological interventions, which are often recommended for EDs. Among these interventions, cognitive-behavioral therapy (CBT) has the largest evidence base for this condition.

Also, as many individuals with an ED may be reluctant to seek treatment because of stigma and shame, the anonymity afforded by an app could increase access to the help they seek.

But Ms. O’Leary warned the Food and Drug Administration does not regulate these apps, and people are sharing their personal health information on them.

The researchers conducted a review of commercially available eating disorder apps by searching the Apple and Google play stores using key phrases such as “eating disorder,” “anorexia,” and “binge eating disorder.”

They found 16 relevant apps that they added to the publicly available apps already in a database at Tufts, for a total of about 36 that were evaluated in the study (the number fluctuates as apps are deleted.)

They then reviewed the apps using the 105 questions based on the APA’s app evaluation model, which covers categories such as efficacy, privacy, accessibility, and clinical applicability. And they used filters to group apps by characteristics such as function, cost, and features.

The vast majority were self-help apps, which include things like journaling, meditation, and information on CBT. Others were reference apps that provide related definitions and sometimes include surveys to determine, for example, if the user has an eating disorder.

About 44% of the apps track mood, and 53% track symptoms. Some 56% include journaling, 42% mindfulness, 53% goal setting, and 42% psychoeducation.
 

Hybrid care

Only 5% of apps allow for “hybrid” care. This, explained Ms. O’Leary, is when clinicians use their own app to access patients’ apps, allowing them to track food restrictions and therapies, and make comments.

“The hybrid is viewed as the best form of app”, she said. “It’s almost like an adjunct to clinical care.”

Hybrid apps also tend to have patient safety features, she added. And these apps meet HIPAA standards, which only 11% of the apps in the study did.

Only 15% of apps advised patients to take steps in case of an emergency, and 11% had supporting studies. And where there was supporting research, much of it was funded by the app creators, said Ms. O’Leary.

For example, an app provided by Noom (the weight loss program that promises to help change habits and mindsets around food) “has a bunch of feasibility studies but they’re all funded by Noom”, which can introduce bias, she explained.

None of the apps were created by an accredited health care institution, she noted. “And I think only one app out of all the eating disorder apps we looked at was from a nonprofit.”

About 17% of the apps offer help with a “coach” or “expert”. However, these apps often fail to disclose the definition of a coach or state they’re not a replacement for medical care.
 

Coaching apps more expensive

Additionally, these coaching apps are often some of the most expensive, said Ms. O’Leary.

Daniel E. Gih, MD, associate professor at the University of Nebraska Medical Center, Omaha, helped start an eating disorders program at the University of Michigan and continues to treat patients with eating disorders. He said the increase in the use of eating disorder apps isn’t surprising as the incidence of these disorders increased in the wake of pandemic restrictions, especially among young people.

“Patients are likely doing more research on their medical conditions and trying to crowdsource information or self-treat,” Dr. Gih said.

It’s unclear whether “shame or just the general lack of specialized eating disorder professionals,” including physicians, is driving some of the interest in these apps, he added.

Dr. Gih stressed eating disorder apps should not only include screening for suicidality, but also explicitly tell patients to seek immediate attention if they show certain signs – for example, fainting, chest pain, or blood in emesis.

“The apps may be giving patients false hope or delaying medical care,” he said. “Apps are likely not sufficient enough to replace a multidisciplinary team with experience and expertise in eating disorders.”

Ms. O’Leary and Dr. Gih report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Only 11% of eating disorder apps protect the privacy of users as is mandated by the Health Insurance Portability and Accountability Act, according to the results of a new study.

Federal laws require those handling sensitive health information to have policies and security safeguards in place to protect such information, whether it’s stored on paper or electronically.

“As it stands right now, there’s not enough evidence to support using these apps as an adjunct to clinical care,” study author Theodora O’Leary, a 4th-year medical student at Tufts University, Boston, said in an interview. “We need more research on the efficacy of these apps because right now not enough of them meet HIPAA [standards] and don’t have privacy and security measures.”

Pauline Anderson

The findings were presented at the annual meeting of the American Psychiatric Association.

Eating disorders (EDs) are a common mental health condition affecting almost 1 in 10 Americans over their lifetime. Yet only about a third of patients with an eating disorder receive adequate treatment.

The pandemic saw a rise in eating disorders and in the use of mental health apps “to kind of fill the gap because people couldn’t be seen in person,” said Ms. O’Leary.
 

Inexpensive and accessible

Smartphone apps have a lot of advantages for patients with an ED. For one thing, they’re relatively inexpensive and accessible; most Americans already own one or more devices on which these apps can be used.

They’re also a feasible means of delivering psychological interventions, which are often recommended for EDs. Among these interventions, cognitive-behavioral therapy (CBT) has the largest evidence base for this condition.

Also, as many individuals with an ED may be reluctant to seek treatment because of stigma and shame, the anonymity afforded by an app could increase access to the help they seek.

But Ms. O’Leary warned the Food and Drug Administration does not regulate these apps, and people are sharing their personal health information on them.

The researchers conducted a review of commercially available eating disorder apps by searching the Apple and Google play stores using key phrases such as “eating disorder,” “anorexia,” and “binge eating disorder.”

They found 16 relevant apps that they added to the publicly available apps already in a database at Tufts, for a total of about 36 that were evaluated in the study (the number fluctuates as apps are deleted.)

They then reviewed the apps using the 105 questions based on the APA’s app evaluation model, which covers categories such as efficacy, privacy, accessibility, and clinical applicability. And they used filters to group apps by characteristics such as function, cost, and features.

The vast majority were self-help apps, which include things like journaling, meditation, and information on CBT. Others were reference apps that provide related definitions and sometimes include surveys to determine, for example, if the user has an eating disorder.

About 44% of the apps track mood, and 53% track symptoms. Some 56% include journaling, 42% mindfulness, 53% goal setting, and 42% psychoeducation.
 

Hybrid care

Only 5% of apps allow for “hybrid” care. This, explained Ms. O’Leary, is when clinicians use their own app to access patients’ apps, allowing them to track food restrictions and therapies, and make comments.

“The hybrid is viewed as the best form of app”, she said. “It’s almost like an adjunct to clinical care.”

Hybrid apps also tend to have patient safety features, she added. And these apps meet HIPAA standards, which only 11% of the apps in the study did.

Only 15% of apps advised patients to take steps in case of an emergency, and 11% had supporting studies. And where there was supporting research, much of it was funded by the app creators, said Ms. O’Leary.

For example, an app provided by Noom (the weight loss program that promises to help change habits and mindsets around food) “has a bunch of feasibility studies but they’re all funded by Noom”, which can introduce bias, she explained.

None of the apps were created by an accredited health care institution, she noted. “And I think only one app out of all the eating disorder apps we looked at was from a nonprofit.”

About 17% of the apps offer help with a “coach” or “expert”. However, these apps often fail to disclose the definition of a coach or state they’re not a replacement for medical care.
 

Coaching apps more expensive

Additionally, these coaching apps are often some of the most expensive, said Ms. O’Leary.

Daniel E. Gih, MD, associate professor at the University of Nebraska Medical Center, Omaha, helped start an eating disorders program at the University of Michigan and continues to treat patients with eating disorders. He said the increase in the use of eating disorder apps isn’t surprising as the incidence of these disorders increased in the wake of pandemic restrictions, especially among young people.

“Patients are likely doing more research on their medical conditions and trying to crowdsource information or self-treat,” Dr. Gih said.

It’s unclear whether “shame or just the general lack of specialized eating disorder professionals,” including physicians, is driving some of the interest in these apps, he added.

Dr. Gih stressed eating disorder apps should not only include screening for suicidality, but also explicitly tell patients to seek immediate attention if they show certain signs – for example, fainting, chest pain, or blood in emesis.

“The apps may be giving patients false hope or delaying medical care,” he said. “Apps are likely not sufficient enough to replace a multidisciplinary team with experience and expertise in eating disorders.”

Ms. O’Leary and Dr. Gih report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO – Only 11% of eating disorder apps protect the privacy of users as is mandated by the Health Insurance Portability and Accountability Act, according to the results of a new study.

Federal laws require those handling sensitive health information to have policies and security safeguards in place to protect such information, whether it’s stored on paper or electronically.

“As it stands right now, there’s not enough evidence to support using these apps as an adjunct to clinical care,” study author Theodora O’Leary, a 4th-year medical student at Tufts University, Boston, said in an interview. “We need more research on the efficacy of these apps because right now not enough of them meet HIPAA [standards] and don’t have privacy and security measures.”

Pauline Anderson

The findings were presented at the annual meeting of the American Psychiatric Association.

Eating disorders (EDs) are a common mental health condition affecting almost 1 in 10 Americans over their lifetime. Yet only about a third of patients with an eating disorder receive adequate treatment.

The pandemic saw a rise in eating disorders and in the use of mental health apps “to kind of fill the gap because people couldn’t be seen in person,” said Ms. O’Leary.
 

Inexpensive and accessible

Smartphone apps have a lot of advantages for patients with an ED. For one thing, they’re relatively inexpensive and accessible; most Americans already own one or more devices on which these apps can be used.

They’re also a feasible means of delivering psychological interventions, which are often recommended for EDs. Among these interventions, cognitive-behavioral therapy (CBT) has the largest evidence base for this condition.

Also, as many individuals with an ED may be reluctant to seek treatment because of stigma and shame, the anonymity afforded by an app could increase access to the help they seek.

But Ms. O’Leary warned the Food and Drug Administration does not regulate these apps, and people are sharing their personal health information on them.

The researchers conducted a review of commercially available eating disorder apps by searching the Apple and Google play stores using key phrases such as “eating disorder,” “anorexia,” and “binge eating disorder.”

They found 16 relevant apps that they added to the publicly available apps already in a database at Tufts, for a total of about 36 that were evaluated in the study (the number fluctuates as apps are deleted.)

They then reviewed the apps using the 105 questions based on the APA’s app evaluation model, which covers categories such as efficacy, privacy, accessibility, and clinical applicability. And they used filters to group apps by characteristics such as function, cost, and features.

The vast majority were self-help apps, which include things like journaling, meditation, and information on CBT. Others were reference apps that provide related definitions and sometimes include surveys to determine, for example, if the user has an eating disorder.

About 44% of the apps track mood, and 53% track symptoms. Some 56% include journaling, 42% mindfulness, 53% goal setting, and 42% psychoeducation.
 

Hybrid care

Only 5% of apps allow for “hybrid” care. This, explained Ms. O’Leary, is when clinicians use their own app to access patients’ apps, allowing them to track food restrictions and therapies, and make comments.

“The hybrid is viewed as the best form of app”, she said. “It’s almost like an adjunct to clinical care.”

Hybrid apps also tend to have patient safety features, she added. And these apps meet HIPAA standards, which only 11% of the apps in the study did.

Only 15% of apps advised patients to take steps in case of an emergency, and 11% had supporting studies. And where there was supporting research, much of it was funded by the app creators, said Ms. O’Leary.

For example, an app provided by Noom (the weight loss program that promises to help change habits and mindsets around food) “has a bunch of feasibility studies but they’re all funded by Noom”, which can introduce bias, she explained.

None of the apps were created by an accredited health care institution, she noted. “And I think only one app out of all the eating disorder apps we looked at was from a nonprofit.”

About 17% of the apps offer help with a “coach” or “expert”. However, these apps often fail to disclose the definition of a coach or state they’re not a replacement for medical care.
 

Coaching apps more expensive

Additionally, these coaching apps are often some of the most expensive, said Ms. O’Leary.

Daniel E. Gih, MD, associate professor at the University of Nebraska Medical Center, Omaha, helped start an eating disorders program at the University of Michigan and continues to treat patients with eating disorders. He said the increase in the use of eating disorder apps isn’t surprising as the incidence of these disorders increased in the wake of pandemic restrictions, especially among young people.

“Patients are likely doing more research on their medical conditions and trying to crowdsource information or self-treat,” Dr. Gih said.

It’s unclear whether “shame or just the general lack of specialized eating disorder professionals,” including physicians, is driving some of the interest in these apps, he added.

Dr. Gih stressed eating disorder apps should not only include screening for suicidality, but also explicitly tell patients to seek immediate attention if they show certain signs – for example, fainting, chest pain, or blood in emesis.

“The apps may be giving patients false hope or delaying medical care,” he said. “Apps are likely not sufficient enough to replace a multidisciplinary team with experience and expertise in eating disorders.”

Ms. O’Leary and Dr. Gih report no relevant financial relationships.

A version of this article first appeared on Medscape.com.