Search Results

Keypoint: All-cause mortality risk was lower with stimulant – but not nonstimulant – ADHD medication use. Among individuals with attention-deficit/hyperactivity disorder (ADHD), ADHD medication use is associated with a reduced risk for all-cause mortality and unintentional injuries leading to emergency department (ED) visits, according to study results published in Translational Psychiatry. Previous research has established that ADHD is associated with adverse health outcomes and comorbidities. Although ADHD medications are efficacious in treating ADHD symptoms, relatively little is known about how these medications – both stimulants and nonstimulants – affect mortality and unintentional injuries. To address this knowledge gap, researchers conducted a population-based cohort study using health administrative data in Quebec, Canada. The study evaluated mortality and injury outcomes among individuals with ADHD who were aged 24 years and younger between April 1, 2000, and March 31, 2021. Eligible participants had a physician claim or hospital diagnosis of ADHD. Additionally, the researchers used prescription data to verify ADHD medication use for amphetamine or methylphenidate-based stimulants and nonstimulants. Participants were followed until emigration, death, 25 years of age, or the conclusion of the study. The researchers identified 217,192 participants with ADHD. At study start, 64.2% of the participants were 11 years of age and younger when first diagnosed with ADHD, 64.1% were boys, and 78.5% had a comorbid mental or substance use disorder. The researchers found that the average all-cause mortality rates per 1000 person-years for individuals with ADHD were notably lower during episodes of ADHD medication use (0.26; 95% CI, 0.21-0.32) relative to periods without ADHD medication (0.48; 95% CI, 0.44-0.53). The average rate of injuries leading to ED visits per 1000 person-years was also reduced when individuals were using ADHD medications (91.0; 95% CI, 90.1-91.9) compared with episodes of nonuse (98.3; 95% CI, 97.7-99.0). Hospitalizations due to unintentional injuries showed similar patterns, as the average rates per 1000 person-years were 8.7 (95% CI, 8.5-8.8) without ADHD medication and 7.4 (95% CI, 7.2-7.7) with ADHD medication. These findings were confirmed in hazard ratio models, as the researchers found a reduced risk for all-cause mortality (adjusted hazard ratio [aHR], 0.61; 95% CI, 0.48-0.76) during episodes of ADHD medication use relative to nonuse. This risk reduction was observed during periods of stimulant use alone (aHR, 0.61; 95% CI, 0.48–0.77), but the risk was not reduced with the use of nonstimulants or a combination of stimulants and nonstimulants. The researchers also found that ADHD medication use decreased the risk for unintentional injuries leading to ED admissions (aHR, 0.75; 95% CI, 0.74-0.77) and hospitalizations (aHR, 0.71; 95% CI, 0.68-0.75). This risk reduction was robust across both stimulant and nonstimulant use across both outcomes. Regarding, ADHD medication use also showed a decreased risk with an) compared with no medication use under the public drug plan. This protective effect was similarly observed with stimulant use (aHR 0.76; 95% CI, 0.75–0.77), nonstimulant use (aHR, 0.77; 95% CI, 0.73–0.81), and combined use of stimulants and nonstimulants (aHR, 0.66; 95% CI, 0.62–0.70). The researchers concluded, “The findings of the current study should inform clinical decision making on the choice of starting a pharmacological treatment for ADHD, when a balance needs to be struck between expected benefits and possible risks.” Study limitations include the reliance on prescription claims for ADHD medication use (without verifying medication adherence), potential residual confounding, and a lack of generalizability to other populations or healthcare systems. Note: This article originally appeared on Psychiatry Advisor

Keypoint: A digital media campaign was able to target individuals experiencing early psychosis, but did not improve treatment outcomes. A digital media campaign in New York State showed promise in identifying and engaging young individuals experiencing early psychosis online. However, the campaign did not result in significant improvements in the prompt initiation of treatment and duration of untreated psychosis (DUP), according to study results published in Schizophrenia Bulletin. Although many young people in the United States experience a first episode of psychosis (FEP), there is often a significant amount of time before individuals begin treatment. Because of the adverse health outcomes associated with prolonged DUP, researchers and health officials have increasingly explored methods to increase treatment engagement and shorten DUP. To this aim, investigators conducted a stepped-wedge randomized controlled trial (ClinicalTrials.gov Identifier: NCT03975400) to evaluate the efficacy of a digital marketing campaign aimed at reducing DUP and increasing referrals to FEP services in New York State. The campaign began in October 2020 and expanded in October 2021, targeting 6 clusters of FEP programs across New York. Each cluster underwent the intervention at varying intervals over 18 months, enabling a comparison between the intervention and control conditions before granting all sites access to the campaign. The digital campaign was advertised to target audiences who searched for relevant key terms. Once on the website, individuals were invited to take a quiz and interact with the website. The website also provided peer/clinician support and could refer individuals to mental health/social services. Participants received remote clinical assessments via text or video, identifying psychiatric symptoms and treatment history. Referral options were determined weekly based on clinical information, with suspected FEP referred to programs. The campaign also engaged individuals with suspected clinical high risk (CHR), schizophrenia spectrum disorder, or other psychotic disorders, offering referrals based on their needs. A total of 41,372 visitors accessed the website, of whom 371 proceeded to remote clinical assessment. Out of the 371 individuals assessed, 14.3% (n=53) reported symptoms aligned with psychotic spectrum disorders and these individuals were primarily girls/women (62.2%). Within the cohort of individuals with psychosis symptoms, 10.5% (n=39) showed symptoms consistent with either CHR or FEP, of which 51.3% (n=20) successfully accessed care. Most individuals suspected of CHR (n=26) or FEP (n=13) had no prior treatment (62%). Median durations of psychotic experiences were 1 to 2 years for suspected FEP and 6 months or less for suspected CHR. Among individuals who declined care (n=19), common barriers included lack of familial support, feeling unprepared for psychiatric treatment, and geographical obstacles. The campaign had no significant impact on the DUP or the number of referrals to programs for FEP participants. The DUP was similar between the control period (204.2 days) and the campaign period (196.3 days; P =.70), with no notable difference observed). Similarly, the number of program referrals and new admissions showed minimal change between the 2 periods. “This study highlights that online education and professional support alone are not sufficient to overcome help-seeking barriers and that new approaches must be developed to effectively advance the work,” the investigators concluded. Study limitations include the difficulty in assessing the COVID-19 pandemic’s influence on campaign effectiveness, the absence of comprehensive diagnostic assessments, and the potential lack of generalizability to locations outside of New York. Disclosures: Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Among US adolescents surveyed, the prevalence of self-reported delta 8-THC use was 11.4% and the prevalence of self-reported marijuana use was 30.4% Marijuana and delta 8-tetrahydrocannabinol (THC) use is significant among adolescents in the United States, with higher THC usage in states without delta 8-THC regulations or current marijuana legalization, according to study findings published in the Journal of the American Medical Association. Investigators sought to estimate self-reported prevalence of marijuana and delta 8-THC use among adolescents in the US in the past year along with associated sociodemographic and policy factors. The investigators conducted a nationally representative cross-sectional analysis from February to June 2023, using a Monitoring the Future Study (MTF) in-school survey in which a third of the 12th grade respondents were randomly asked about delta 8-THC use. Study respondents included 2186 randomly selected 12th grade students in 27 US states. Self-reported marijuana or delta 8-THC use in the past year (any vs no use, plus the number of occasions substances were used) was the primary endpoint. In the overall analytic sample, respondents had a mean age of 17.7 years; 48.9% were women, 45.8% men, and 5.3% reported other sex or preference or declined to report; and 46.1% were White, 11.1% Black, 23.5% Hispanic, 14.2% multiracial, and 4.0% Asian. Geographically, 16.9% lived in the Northeast US census regions, 22.0% in the Midwest, 24.5% in the West, and 36.7% in the South US census regions. Overall, 34.8% lived in states with delta 8-THC regulations and 44.2% lived in states with adult-use marijuana legalization. More than half (51.7%) of respondents had a parent with a college degree. The investigators found prevalence of self-reported delta 8-THC use in the past year was 11.4% (95% CI, 8.6%-14.2%) and prevalence of self-reported marijuana use was 30.4% (95% CI, 26.5%-34.4%). Among those participants reporting delta 8-THC use (n=295), more than one-third (35.4%) used it 10 or more times in the past year. Western vs Southern census regions showed a lower prevalence of delta 8-THC use (5.0% vs 14.3%; risk difference [RD], -9.4 percentage points; 95% CI, -15.2 to -3.5 percentage points; adjusted risk ratio [aRR], 0.35; 95% CI, 0.16-0.77). Notably, these regions showed a lower prevalence of delta 8-THC use in states where delta 8-THC is regulated vs not regulated (5.7% vs 14.4%; RD, -8.6 percentage points; 95% CI, -12.9 to -4.4 percentage points; aRR, 0.42; 95% CI, 0.23-0.74) and in states with vs without legal adult-use marijuana (8.0% vs 14.0%; RD, -6.0 percentage points; 95% CI, -10.8 to -1.2 percentage points; aRR, 0.56; 95% CI, 0.35-0.91). The investigators found use in the past year for delta 8-THC was lower among Hispanic vs White youth (7.3% vs 14.4%; RD, -7.2 percentage points; 95% CI, -12.2 to -2.1 percentage points; aRR, 0.54; 95% CI, 0.34-0.87) and use in the past year for marijuana was lower among Hispanic vs White youth (24.5% vs 33.0%; RD, -8.5 percentage points; 95% CI, -14.9 to -2.1 percentage points; aRR, 0.74; 95% CI, 0.59-0.94). No difference by sex or parental education was found for delta 8-THC or marijuana use prevalence. Study limitations include the exclusion of 23 states from the survey sample as well as the exclusion of students who were absent or not enrolled in school. Also, the use of hemp-derived products was not measured. The study authors concluded, “In this nationally representative 2023 survey, 11.4% of 2186 US 12th-grade students self-reported delta 8-THC use and 30.4% self-reported marijuana use in the past year. Delta 8-THC use prevalence was higher in the South and Midwest US and in states without legal adult-use marijuana or delta 8-THC regulations.” The investigators added, “Marijuana use prevalence did not differ by cannabis policies.” This article originally appeared on Pulmonology Advisor

Keypoint: Patients treated with iloperidone had significantly larger improvements vs placebo based on the change from baseline in the Young Mania Rating Scale total score. The Food and Drug Administration (FDA) has expanded the approval of Fanapt® (iloperidone) to include the acute treatment of manic or mixed episodes associated with bipolar I disorder in adults. Fanapt is also indicated for the treatment of schizophrenia in adults. The expanded approval was based on data from a phase 3 study (ClinicalTrials.gov Identifier: NCT04819776) that evaluated the efficacy and safety of iloperidone, an atypical antipsychotic, in 414 adults with a history of bipolar I disorder who had a current episode of mania. Patients were randomly assigned 1:1 to receive either oral iloperidone (n=206) or placebo (n=208). Findings showed patients treated with iloperidone had significantly larger improvements vs placebo based on the change from baseline in the Young Mania Rating Scale (YMRS) total score at week 4 (primary endpoint; treatment difference: -4.0 [95% CI, -5.7, -2.25]; P =.000008). Significant improvements were observed as early as week 2. Secondary endpoints, including change from baseline in the Clinician Global Impression of Severity (P =.0005) and Clinician Global Impression of Change (P =.0002) scores, were also statistically significant. The safety profile of iloperidone was found to be consistent with previous trials in patients with schizophrenia. The most common adverse reactions reported were tachycardia, dizziness, dry mouth, increased alanine aminotransferase, nasal congestion, weight gain, and somnolence. “With over 100,000 patient years of experience, Fanapt is a familiar therapeutic agent that offers flexible dosing with a well-known safety profile,” said Mihael H. Polymeropoulos MD, Vanda’s President, CEO and Chairman of the Board. “This FDA approval gives patients and service providers a new treatment option for managing bipolar I disorder.” Note: This article originally appeared on MPR

Suicidal thoughts and behaviors (STBs) are among the most dreaded complications of treatment-resistant depression (TRD), which is associated with elevated risk of death from suicide as well as from other conditions, even when compared with nonresistant depression. According to 1 meta-analysis, the overall incidence of suicide and suicide attempts among adults with TRD is between 2 and 10 times that of individuals with nonresistant depression. Approximately 30% of individuals with TRD attempt suicide at least once in their lifetime, compared with about 15% of those with nonresistant depression. Even when compared with individuals with unipolar depression, patients with a history of TRD should be considered at high risk for STBs. Risk Factors Although many years of suicide research has generated a large body of knowledge about risk factors, we still know relatively little about the causal associations among risk factors and STBs, and the mechanisms through which risk factors translate into thoughts, behaviors, and fatal outcomes. As in other areas of clinical medicine, prediction models of suicide that work reasonably well in the general population may not generalize to diverse subpopulations, creating a risk of exacerbating rather than addressing health disparities. While we know a lot about suicide risk factors, we know far less about how to predict imminent risk of suicide, which—given the tragic intractability of suicide death across the past century5—remains the holy grail of suicide research. It remains unclear whether TRD is associated with any unique suicide risk profiles; still-growing knowledge indicates that risk factors for STBs among individuals with TRD closely resemble those for other individuals. For example, prior suicide attempts are the strongest risk factor for suicide death in TRD and in the general population. Moreover, factors often associated with TRD are also independent risk factors for STBs. These factors include early life adversity, personality disorders, anxiety, insomnia, chronic pain, substance use disorders, other co-occurring medical conditions, hopelessness, diminished problem-solving ability, low socioeconomic status, a paucity of social supports, and recent psychiatric hospitalization. While depression is associated with the presence of suicidal thoughts, other factors such as psychiatric comorbidity and impulsivity may be better predictors of STBs and suicide. In terms of psychological components of suicide risk, the influential Interpersonal Theory of Suicide proposed by Joiner et al focuses on 3 interconnected risk factors for suicidal thoughts: “thwarted belongingness,” “perceived burdensomeness,” and “hopelessness.”9 Although this theory is transdiagnostic, its relevance to the experience of many patients with TRD is clinically compelling. The growing literature on suicide risk factors suggests that TRD may be associated with increased risk of STBs largely because of its close association with other risk factors for STBs; these factors are often connected with TRD as contributing factors to treatment resistance or as consequences. The bad news is that managing depression itself may influence only part of the complex risk equation, potentially affecting suicidal thoughts more than acts. The good news is that there may be multiple levers that influence the transition from ideas to behavior. Many of these levers are directly relevant to the comprehensive, multimodal evaluation and care of patients with TRD. Treatments A range of pharmacological, psychological, and neurostimulation therapies have shown promise for reducing STBs including among individuals with TRD. In some studies, the antisuicide effects of treatment have appeared to be somewhat dissociable from the antidepressant effects, though this remains an area of continued inquiry. In addition, the impacts of treatments on suicidal ideation and attempts have been better studied than their impact on suicide deaths. Finally, in many treatment studies relevant to TRD and STBs, STBs have been assessed primarily as secondary outcome measures in studies not adequately powered to test these outcomes; there remains much need for well-designed studies in TRD cohorts in which STBs are the primary outcomes of interest. Clozapine: Based largely on the International Suicide Prevention Trial, clozapine was the first medication approved by the US Food and Drug Administration (FDA) to prevent suicidal behavior, specifically in individuals with schizophrenia or schizoaffective disorder. Because of its substantial adverse effect burden and monitoring requirements, clozapine has not been widely used or studied as an antidepressant adjunct among TRD cohorts. Its superiority in reducing suicide risk compared with newer second-generation antipsychotics approved for antidepressant augmentation in TRD has not been established. Ketamine and esketamine: Esketamine also carries a specific FDA indication for suicidality (since August 2020), particularly in the context of MDD, following its initial approval for TRD. Although data on the efficacy of intranasal esketamine or intravenous racemic ketamine for suicidality in TRD have been mixed, some studies have shown rapid reduction in suicidal ideation after single or repeated doses, sometimes independent of reduction in other core depressive symptoms. A topic of further research is whether effects on ideation persist beyond the period of active treatment and whether they translate into fewer suicide attempts and deaths. Lithium: The potential antisuicide effects of lithium have been reported for several decades. These effects have had some support from large pharmaco-epidemiological studies, particularly among individuals with bipolar disorder. A meta-analysis by Cipriani and colleagues demonstrated reduction in STBs among individuals with unipolar as well as bipolar illness; the authors hypothesized that lithium’s apparent antisuicide benefits may be related to prevention of relapse and/or reduced aggression and impulsivity. No adequate studies to date have compared lithium against other combinations or adjunctive antidepressant strategies in TRD with suicide as a primary outcome. Buprenorphine: Recent years have seen a resurgence of interest in opioid mechanisms in depression treatment, particularly κ receptor antagonists, which appear to be associated with little or no abuse liability compared with mu agonists. Although no opioid agents have been approved for major depressive disorder (MDD) or TRD, a small proof-of-concept, placebo-controlled trial of ultralow-dose buprenorphine (mean dose 0.44 mg), a partial μ agonist and κ antagonist, showed rapid onset reduction of suicidal ideation among individuals with depression when added to ongoing pharmacotherapy.14 This benefit persisted for the 4-week trial, suggesting potential promise in opioid mechanisms to reduce STBs in TRD. Neurostimulation: Studies on most forms of neurostimulation treatments used in TRD have shown reductions in STBs. These include studies on electroconvulsive therapy,15-17 repetitive transcranial magnetic stimulation,18-20 and vagus nerve stimulation. Among investigational neurostimulation treatments, similar preliminary promising results for STBs have been reported with magnetic seizure therapy and transcranial direct current stimulation. Anecdotal reports suggested increased suicide risk among depressed individuals receiving deep brain stimulation though this has not been observed in other studies. Psychotherapies: A large body of data suggests that psychological therapies have a role in treating TRD and are often critical in the approach to TRD. Similarly, numerous studies suggest that first-line, evidence-based psychotherapies have a role in reducing risk of STBs. These include cognitive behavior therapy; dialectical behavior therapy; interpersonal psychotherapy; acceptance and commitment therapy; and collaborative assessment and management of suicidality,32 a therapeutic framework specifically designed for patients with suicidality. Brief and ultrabrief therapy interventions have also been found to be effective.33 Though promising, most studies have focused on suicidal ideation rather than suicide attempts or deaths, and no controlled trials to our knowledge have focused on STBs specifically in TRD populations. Managing Risk Core components in the management of suicide risk among patients with TRD include regular assessment, safety planning, and supporting a hopeful and realistic therapeutic stance. Assessment of suicide risk: Comprehensive assessment of suicide risk includes appreciation of longer-term demographic and clinical risk factors, identification of current and past suicidal thoughts, and evaluation of potentially impulsive emotional and behavioral responses to stressful circumstances. Psychiatric practice over the next decade will likely increasingly integrate a range of novel risk assessment and mitigation approaches, including machine learning techniques that scour electronic health records, behavioral tasks to evaluate implicit cognitions, and the use of ecological momentary assessment from digital devices coupled with patient prompts to support coping and help-seeking behaviors and messaging to clinical teams in the context of imminent risk. Many health systems have adopted standardized suicide risk screens, such as the Columbia-Suicide Severity Rating Scale (Figure 1), which includes questions clinicians use in routine assessments for patients with TRD. Using a standardized scale, routine assessment, and documentation of suicide risk among patients at elevated risk is integral to good clinical practice. Safety planning: For the many patients with TRD who are at high risk for suicide, clinicians and patients should collaboratively agree upon a safety plan34 that typically includes (1) identifying warning signs for suicidal behavior; (2) using coping activities, including relaxation and distraction; (3) reminding of individuals and social situations that can provide distraction; (4) listing contact information for personal supports in a crisis; (5) recording phone numbers for professional and emergency resources and the 988 suicide prevention lifelines; and (6) describing steps to make the environment safer (eg, reducing access to firearms or stockpiled medications). The safety plan should be maintained by the patient and clinician and updated regularly, particularly at key transitions such as hospital discharge. Therapeutic stance: Recurrently dashed hopes, growing pessimism, self-blame, persistent suffering, and social isolation are often core experiences of individuals with TRD. Joiner’s triad of thwarted belongingness, perceived burdensomeness, and hopelessness are evocative of this experience and the enhanced risk of suicide they entail. Clinicians working with patients with TRD and suicidality are not immune to absorbing the nihilism of the individuals they work with. Aspects of a positive therapeutic approach can be found in the Table. Concluding Thoughts TRD is associated with elevated risk for STBs and suicide death even when compared with depression without documented resistance. Risk factors for suicide in TRD appear to be largely similar to those in the general population and are often themselves risk factors for and/or consequences of TRD. A range of therapeutic targets are likely to be relevant for reducing risk of suicide in TRD. Several pharmacotherapies have shown potential antisuicide benefits, including clozapine, ketamine/esketamine, lithium, and buprenorphine. However, research in this area is still evolving with few studies involving active comparators or long-term follow-up and not all focused on TRD. Most forms of neurostimulation have been associated with reduction in suicidal ideation though this remains a nascent area of research. Several psychotherapies show substantial promise for reducing STBs, though most have focused on suicidal thoughts rather than suicide and none have been adequately studied in TRD. An optimal therapeutic approach to suicide in TRD involves screening and ongoing assessment, suicide planning, a hopeful but realistic therapeutic stance that emphasizes attainable goals and consistency in the treatment relationship, and recruitment of consultation and peer supports to address therapeutic blind spots and burnout. While TRD is associated with elevated risk of suicide, most individuals with TRD do not attempt suicide and many achieve reduction in suffering and a meaningful quality of life. Note: This article originally appeared on Psychiatric Times

SAN DIEGO — In the clinical opinion of Jenny E. Murase, MD, caring for patients with delusional infestation — the conviction that one is infested by animate or inanimate pathogens without medical or microbiological evidence of a true infestation — puts a dermatologist's communication skills to the ultimate test. "The fact that delusional infestation is a fixed, false belief [means] we will never agree with patients on the etiology by definition," Dr Murase, a dermatologist with the Palo Alto Foundation Medical Group, Mountain View, California, said at the annual meeting of the American Academy of Dermatology. "But somehow, we must come to some kind of an agreement on how to approach this therapeutically." Patients with delusional infestation (DI) often describe a cutaneous sensation of itching or crawling, biting, stinging — a pins and needles sensation. "Formication is when there's a crawling sensation on the surface of the skin," she said. "That's something we can agree on — the fact that there is a shared understanding that they're experiencing some kind of sensation in their skin." First described in 1894, several different terms have been used to describe DI in the past, including acarophobia, delusions of parasitosis, Ekbom syndrome, and Morgellons disease. The current term used for DI includes other animate or inanimate pathogens besides parasites. The average dermatologist manages two to three patients with DI every 5 years, "so it's not uncommon," said Dr Murase, who also holds a faculty position in the department of dermatology at the University of California, San Francisco. Females are about 2.5 times more likely to be affected compared with males, she said, and 8%-12% of patients with DI have a friend or relative who shares the symptom, and they often accompany them to the office visit. "Initially, you're trying to determine if this a primary condition where it's only the cutaneous condition the patient is experiencing, or if there is a secondary condition like an underlying psychiatric disorder or medical condition or drug use that contributes to the sensation," she said. According to a descriptive study of 115 patients with DI, 50% had at least one drug detected in hair samples, and nearly 60% had evidence of some cognitive impairment that could not be explained by deficits in IQ. Another study of 147 patients with DI seen at the Mayo Clinic between 2001 and 2007 found that 81% had a prior psychiatric condition and 26% had a shared psychotic disorder. Phased Approach to Treatment Dr Murase discussed her phased approach to caring for patients with DI, based on a review article that she and colleagues published in the International Journal of Dermatology. Phase 1 involves preparing for the visit by asking staff to refer to patients with DI as VIPs and allowing them to talk freely about the sensation they're experiencing. "The goal is to improve the patient's condition, not to convince the patient that he or she is delusional," Dr Murase explained. "Many patients can't distinguish between when they're talking to the doctor and when they're talking to a nurse or a nurse practitioner; they like to feel that they're being heard and listened to." She also recommends scheduling patients with DI for the end of the day and arranging frequent follow-up visits. "Making them feel valued is the bottom line," she emphasized. "Remember: They're less likely to respect socially defined boundaries like time constraints, so you do have to set boundaries, and don't take what they may say to you personally. You're not going to be able to care for that individual unless you do that. They may appear defiant, frustrated, and angry, but the fact that they showed up in your office means that you can help that person." Phase 2 of care for these patients consists of building a therapeutic rapport by greeting them with a smile and positive attitude and using welcoming body language such as sitting side-by-side during the office visit as opposed to face-to-face, "so it's a less aggressive approach," she said. Next, ask about their goal with a question such as, "Is it more important for you to find the bug/virus or to improve your condition?" During the visit, "you're continually shifting from etiology — which they are desperate to understand — to a shared desire for treatment," Dr Murase said. "No one knows what causes DI and remember, in medicine we treat patients when the exact etiology is unknown. So, we're not doing anything that differently. Focus on the effect that the symptoms are having on their life. Say something like, 'it must be so miserable to be living this way. I really want to help you.' " Phase 3 of care for patients with DI involves performing a thorough history and physical exam. The initial office visit should include a full body exam to rule out any underlying dermatologic condition that may be causing the sensation they're complaining about. She cited a retrospective study of 108 patients who presented to the Mayo Clinic with DI as the main reason for their office visit. Of the 80 patients who had a biopsy, 61% had chronic dermatitis; 48% had excoriation, ulceration, or erosion; and 31% had nonspecific dermal inflammation. Whether to perform a biopsy or not is controversial, Dr Murase added, because it's probably not going to change the clinical impression or diagnosis. "If you agree to do the biopsy, get a verbal contract with the patient," she advised. "You might say, 'We're going to do this. You're going to choose the site, we're going to do a biopsy, but we are going to be in agreement here that, if we can't find the etiology, that you will still be open to going on therapy.' This is important because it establishes a therapeutic alliance." Since patients with DI often bring in their own specimens, she also recommends providing them with microscope glass slides without cover slips and asking them to use clear tape, not tape that is opaque or matted, to cover the specimen. To rule out other illnesses and conditions that could be triggering the perceived DI, she said lab tests to consider include a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, calcium, hemoglobin A1c, vitamin B12, urinalysis, toxicology screen, HIV/hepatitis C, and rapid plasma reagin. Starting Treatment Phase 4 of care for patients with DI involves initiating therapy, which includes demonstrating empathy by reflecting on the detrimental effects of the patient's reported sensations on their quality of life. "Emphasize that you are not questioning their experience, and that you don't doubt that they feel things on their skin," Dr Murase said. "Recommend medications on an empirical or 'trial and error' pragmatic basis. I often tell patients, 'I will never give up on you if you will never give up on me.'" For treating patients with DI, her first-generation antipsychotic of choice is pimozide. She starts at a dose of 0.5 mg, building up to 2-3 mg once a day. Haloperidol is another option: 0.5 mg to start, building up to 1-5 mg every night at bedtime. "This requires monitoring for bone suppression via CBC and hypermetabolic complications via fasting lipids and HbA1c," she said. "There is also an increased risk of prolonged QT with pimozide and risk of extrapyramidal symptoms and tardive dyskinesia." Second-generation antipsychotics to consider include risperidone (0.5 mg to start, building up to 102 mg at bedtime); olanzapine (2.5 mg to start, building up to 5-10 mg at bedtime); aripiprazole (2-5 mg to start, build ing up to 10-15 mg a day), and quetiapine (12.5 mg to start, building up to 200 mg at bedtime). For all medical therapy she recommends starting patients with a low dose, increasing by 0.5 mg every 2-3 weeks, and let them be "stable and comfortable" for 3-4 months, and then taper down the dose by 0.5 mg every 2-4 weeks or more slowly. In the medical chart, Dr Murase recommends avoiding use of the terms "psychosis" and "delusions." Instead, "formication" (tactile hallucination of insects crawling on or within the skin) or "cutaneous dysesthesia" are better terms if patients access their records, she said. Note: This article originally appeared on MDedge.com, part of the Medscape Professional Network.

A persistent state of anger or annoyance coupled with frequent and intense temper outbursts in children and adolescents often signals clinically impairing irritability. Clinical irritability disrupts a child's daily life and can continue to cause problems into adulthood. Although irritability is one of the leading reasons children are seen for psychiatric care, it is understudied compared to other childhood disorders. Critically, evidence-based treatments for clinical irritability are also lacking. In a new study, researchers at the National Institute of Mental Health (NIMH) successfully used exposure-based cognitive behavioral therapy (CBT) to treat severe irritability in children. This promising breakthrough underscores the importance of tailored interventions in this area of child psychiatry. What is severe irritability in children? This study focused on severe and impairing irritability and temper outbursts in youth. All children feel angry or irritable at times. Severe irritability is more serious and can cause problems at home, during school, and with friends. Irritability and outbursts are part of many mental disorders, but they are core symptoms of disruptive mood dysregulation disorder (DMDD). DMDD is diagnosed in children and adolescents who show ongoing irritability, frequent anger, and intense temper outbursts. Symptoms of DMDD are severe and require treatment. Children with this high level of irritability get angry often and to a degree that is disproportionate to the situation and their age. When angry, they show temper outbursts, usually involving high motor activity and verbal or physical aggression. These children are also persistently irritable or cranky most of the time and across many situations. How did the researchers treat severe irritability in children? Researchers led by Melissa Brotman, Ph.D., in the NIMH Intramural Research Program tested a novel treatment for irritability. Developed in Dr. Brotman’s lab, the exposure-based CBT treatment draws on a highly effective treatment for anxiety—exposure therapy. In this pilot study, the researchers examined the effectiveness, acceptability, and feasibility of exposure therapy for severe irritability. Forty children (8–17 years) participated in the study, which took place at the NIH Clinical Center . Children had to have at least one of two core DMDD symptoms: chronically irritable mood or severe temper outbursts. Some children also had co-occurring anxiety or attention-deficit/hyperactivity disorder (ADHD), but they were not eligible for participation if diagnosed with other disorders, such as bipolar disorder, substance use disorder, schizophrenia, or autism spectrum disorder. All children received 12 sessions of exposure-based CBT following an established manual written by Dr. Brotman. Each treatment session had a child and a parent portion. The child portion focused on increasing tolerance to frustration. Clinicians carefully exposed children to anger-provoking situations, gradually moving up a hierarchy specific to that child. Examples could be taking away a preferred item (for example, stopping a video game or getting off the iPad) or starting a disagreeable activity (for example, brushing teeth or doing homework). Clinicians worked with the child to learn to tolerate and constructively respond to their feelings without a temper outburst. The parent portion focused on parent management skills. Parents were taught to actively ignore their child’s temper outbursts to stop reinforcing those behaviors. Instead, they learned how to focus on and consistently reward positive behaviors. Children were randomly assigned to be observed for either 2, 4, or 6 weeks before starting treatment. Clinical observers were blind to when active treatment began. This observation period allowed the researchers to confirm that symptoms changed only after treatment started and were not accounted for by the clinician’s expectations of the treatment. Clinicians, children, and their parents rated the child’s irritability symptoms and overall functioning during the observation period, during treatment, and 3 and 6 months after treatment. Depression, anxiety, and ADHD symptoms were also assessed for comparison. The acceptability, feasibility, and safety of the therapy were determined by rates of study dropout and adverse events. Did exposure-based CBT treatment help children with severe irritability? Irritability symptoms decreased significantly during treatment based on clinician, child, and parent reports. Overall functioning also improved—by the end of treatment, 65% of children were significantly improved or recovered based on the clinician measure. Symptoms did not return after treatment stopped and, in fact, treatment gains were maintained at the 3- and 6-month follow-ups. When examining the core symptoms of DMDD, 60% of children were considered recovered on the Temper Outburst scale and 25% were recovered on the Irritable Mood scale at the end of treatment. This result suggests a stronger effect of exposure therapy in decreasing temper outbursts compared to improving irritable mood. In contrast, the treatment was not associated with significant changes in anxiety, depression, or ADHD symptoms, suggesting its specificity in targeting irritability. No families dropped out once treatment began, suggesting exposure therapy was acceptable and feasible. Similarly, no adverse events were reported, supporting the safety of using exposure therapy with children. What can researchers do next to further treatment for children with severe irritability? Taken together, these results support the effectiveness, acceptability, and feasibility of exposure therapy for youth with severe irritability. Irritability symptoms and overall functioning improved during treatment per clinician, child, and parent reports and were maintained for several months after treatment stopped. This study has some limitations. First, it had a relatively small sample size with a limited racial, ethnic, and socioeconomic composition, which limits the generalizability of the results. Second, the study did not include a control group of children with irritability who did not receive treatment. Although the researchers addressed this concern by having multiple observation periods, comparing this novel treatment to current clinical care is a critical next step. Third, the study included a wide age range, making it important to test whether there are differences in outcomes based on age. Last, because clinicians delivered the child and parent components at the same time, future studies could examine the individual contribution of child exposure therapy versus parent management skills to determine whether one is driving treatment effects. The positive results from this pilot study set the foundation to further explore CBT treatment for childhood irritability. Although the therapy is not yet ready for clinical practice, it offers one of the few evidence-based treatments for this frequent and impairing childhood disorder. The researchers plan to test and refine the exposure therapy in larger, more controlled clinical trials to advance treatment for children with severe irritability and their families. Note: This article originally appeared on NIMH

Keypoint: People experiencing psychological symptoms of menopause may benefit from CBT or mindfulness. Psychosocial interventions of cognitive behavioral therapy (CBT) and mindfulness-based interventions (MBI) improve depression and anxiety during menopause, according to systematic review and meta-analysis findings published in the Journal of Affective Disorders. These interventions also improved cognition and quality of life for individuals experiencing menopause. Although menopause is commonly associated with physiological symptoms like menstrual cycle changes, hot flashes, and night sweats, people experiencing menopause also frequently experience cognitive impairment, depression, and anxiety. Hormone replacement therapy is typically the first line treatment for physiological symptoms of menopause, but relatively little is known about the efficacy of psychosocial interventions for the improvement of non-physiological symptoms. To this aim, investigators conducted a systematic review and meta-analysis to determine if cognitive behavioral therapy (CBT) and mindfulness-based interventions (MBI) are effective in improving depression and anxiety among people experiencing menopause. The investigators searched publication databases from inception to August 2023 for randomized controlled trials assessing CBT and MBI for menopausal transition and reported at least 1 outcome related to cognition, mood, or quality of life. Overall, 30 studies were included for analysis, with a pooled sample size of 3501 participants. On average, participants were between 47 to 59 years of age, 2686 were undergoing gradual menopause, and 815 had treatment-induced menopause. OF the included studies, 20 reported mood outcomes, 4 assessed cognition, and 24 evaluated quality of life outcomes. Most psychosocial interventions were primarily group-based and conducted in person. For the meta-analysis, a total of 11 studies had available data on anxiety and 12 studies had data for depression outcomes. The investigators found that anxiety significantly improved with both MBI (d, -0.56; 95% CI, -0.74 to -0.39) and CBT (d, -0.22; 95% CI, -0.35 to -0.10). Similarly, depressive symptoms among people experiencing menopause were significantly reduced with MBI (d, -0.27; 95% CI, -0.45 to -0.09) and CBT (d, -0.33; 95% CI, -0.45 to -0.21). However, there was considerable heterogeneity of MBI data for anxiety (I2, 85.48%) and significant heterogeneity of CBT data for depression (I2, 85.48%). The investigators also found that cognition (d, -0.23; 95% CI, -0.40 to -0.06) and quality of life (d, -0.78; 95% CI, -0.93 to -0.63) were significantly improved with psychosocial interventions, though there was considerable heterogeneity of data and smaller sample sizes for these analyses. The overall quality of included studies was moderate, although 66.7% of the studies were judged to have some concerns for risk for bias, 23.3% of the studies had high risk for bias, and 10.0% had low risk for bias. “The findings of this review add to existing menopause literature by supporting the effectiveness of psychosocial interventions on non-physiological symptoms of mood, cognition, and quality of life,” the investigators noted. Study authors concluded, “Our review could inform the development of menopause services, in which enhanced professional training could pave the way for integrating mindfulness and CBT as conventional healthcare service options. At the center of treatment is the understanding of menopausal symptoms and embracing sufficient social support.” These findings may be limited by the failure to collect data regarding menopausal status, a lack of consideration or defining of participants who may identify as non-binary or trans men, and relatively short follow-up times for symptom changes. Note: This article originally appeared on Psychiatry Advisor

Keypoint: Patients with posttraumatic epilepsy vs those without a history of head injury or seizure/epilepsy had an approximately 3-fold increase in dementia risk. Compared with patients without a history of head injury or seizure/epilepsy, patients with posttraumatic epilepsy are at a greater risk of developing dementia, according to study findings published in JAMA Neurology. Posttraumatic epilepsy, accounting for 5%-20% of acquired epilepsies, has previously been linked to worse short-term outcomes. There is, however, a limited understanding of its long-term consequences. These uncertainties presented the need for additional investigation into the cognitive impacts and dementia susceptibility among individuals with posttraumatic epilepsy in contrast to individuals with either head injury or epilepsy alone. Using data through December 2019, with a median follow-up of 25.4 years, researchers conducted a prospective cohort study involving 12,558 older adults (mean age, 54.3; women, 57.7%; Black, 28.2%) already enrolled in the Atherosclerosis Risk in Communities (ARIC) study to determine the association between posttraumatic epilepsy and dementia risk. The primary outcome of interest was dementia, which was defined using cognitive assessments, informant interviews, and International Classification of Diseases (ICD) and death certificate codes. Head injury was defined by self-report and ICD diagnostic codes, seizure/epilepsy was defined using ICD codes, and posttraumatic epilepsy was defined as a diagnosis of seizure/epilepsy occurring more than 7 days after injury. Dementia risk was estimated using adjusted Cox and Fine and Gray proportional hazards models and head injury, seizure/epilepsy, and posttraumatic epilepsy were analyzed as time-varying exposures. At baseline, patients were grouped into 1 of 4 time-varying exposure categories: no head injury and no seizure/epilepsy (n=9962; 79.3%); head injury (n=1811; 14.4%); seizure/epilepsy (n=640; 5.1%); or posttraumatic epilepsy (n=145; 1.2%). Over a period of 250,372 person-years of follow-up, 2498 cases of dementia were observed. Compared with patients in the no head injury or seizure/epilepsy group, patients with posttraumatic epilepsy demonstrated the lowest cumulative dementia-free survival, which was associated with 4.85 (95% CI, 3.72-6.33) times greater risk for dementia. Compared with no head injury or seizure/epilepsy, head injury and seizure/epilepsy were associated with 1.64 (95% CI, 1.48-1.82) and 2.81 (95% CI, 2.39-3.31) times the risk for dementia, respectively. This risk for dementia remained significantly higher in patients with posttraumatic epilepsy than that associated with head injury alone or seizure/epilepsy alone, even after adjusting for vascular and genetic risk factors. Models considering the competing risk for death alone and death and stroke revealed a 3-fold increased risk for dementia with posttraumatic epilepsy. Stronger associations were observed in younger participants, with no evidence for interaction by sex or race. In secondary analyses, associations were similar for posttraumatic epilepsy occurring post-first (hazard ratio [HR], 4.63; 95% CI, 3.46-6.21) or post-second (HR, 4.24; 95% CI, 2.27-7.92) head injury, and with posttraumatic epilepsy occurring after mild (HR, 5.03; 95% CI, 3.57-7.09) or moderate/severe/penetrating (HR, 3.15; 95% CI, 1.82-5.46) head injuries. Compared with individuals in the seizure/epilepsy only group, as well as individuals in the head injury only group, individuals with head injuries following seizures/epilepsy were found to have a higher risk for dementia. However, compared with those in the posttraumatic epilepsy group, patients with head injuries following seizures/epilepsy had a lower risk for dementia. Compared with later onset (more than 3 years after head injury) posttraumatic epilepsy (HR, 3.06; 95% CI, 2.21-4.08), earlier onset (within 3 years of head injury) posttraumatic epilepsy demonstrated a stronger association with dementia (HR, 7.30; 95% CI, 5.14-10.37). This pattern was maintained even when the timing of posttraumatic epilepsy onset after head injury was stratified by injury severity. Study limitations included the limited generalizability of results to individuals who sustained a prior head injury at baseline, potentially confounding factors such as frailty, and reliance on self-reported data and ICD codes with inherent sensitivity and specificity limitations. “These findings provide evidence that PTE [posttraumatic epilepsy] is associated with long-term outcomes and supports both the prevention of head injuries via public health measures and further research into the underlying mechanisms and the risk factors for the development of PTE, so that efforts can also be focused on the prevention of PTE after a head injury,” researchers concluded. Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures. Note: This article originally appeared on Neurology Advisor

Social Media Cause Depression How heavy Instagram and Facebook use may be affecting kids negatively Quick Read Studies show that depression among teenagers and young adults has gotten more common over the past decade. Social media use has also increased during the same time. It’s hard to say for sure that social media causes depression. Still, there are several ways that using social media could harm kids. Some experts think that connecting with peers online is less emotionally fulfilling than connecting in person. Research shows that teenagers who spend more time on social media also feel more isolated. It could be that kids who already feel isolated use social media more. But it could be that using social media actually makes kids feel isolated. Another theory is that social media is bad for teenagers’ self-esteem. Seeing lots of perfect pictures online might make kids (especially girls) view themselves negatively. Feeling bad about themselves can lead to depression. Social media can also cut into the time that kids spend on activities that make them feel good, like exercise and hobbies. Additionally, it can distract from important tasks like homework. Having to juggle those responsibilities can increase kids’ stress. Studies also suggest that using social media at night interferes with restful sleep for many teenagers. It’s important for parents to check in with kids about their social media use and help them develop healthy habits. You can encourage kids to turn off notifications, spend plenty of time on offline activities that make them feel good, and put phones away before bedtime. You can also set a good example by modeling balance in your own use of social media. Finally, be sure to keep an eye out for signs of depression and get professional help if you’re worried. It’s especially important to check on kids who are under a lot of stress. Full Artilce: Is using social media making our kids unhappy? Evidence is mounting that there is a link between social media and depression. In several studies, teenage and young adult users who spend the most time on Instagram, Facebook and other platforms were shown to have a substantially (from 13 to 66 percent) higher rate of reported depression than those who spent the least time. Does that mean that Instagram and TikTok are actually causing depression? These studies show a correlation, not causation. But it’s worth a serious look at how social media could be affecting teenagers and young adults negatively. One reason the correlation seems more than coincidental is that an increase in depression occurred in tandem with the rise in smartphone use. A 2017 study of over half a million eighth through 12th graders found that the number exhibiting high levels of depressive symptoms increased by 33 percent between 2010 and 2015. In the same period, the suicide rate for girls in that age group increased by 65 percent. Smartphones were introduced in 2007, and by 2015 fully 92 percent of teens and young adults owned a smartphone. The rise in depressive symptoms correlates with smartphone adoption during that period, even when matched year by year, observes the study’s lead author, San Diego State University psychologist Jean Twenge, PhD. Over that same time period there was a sharp spike in reports of students seeking help at college and university counseling centers, principally for depression and anxiety. Visits jumped 30 percent between 2010 and 2015, and they’ve continued to rise since the pandemic. Social media and depression One of the biggest differences in the lives of current teenagers and young adults, compared to earlier generations, is that they spend much less time connecting with their peers in person and more time connecting electronically, principally through social media. Some experts see the rise in depression as evidence that the connections social media users form electronically are less emotionally satisfying, leaving them feeling socially isolated. “The less you are connected with human beings in a deep, empathic way, the less you’re really getting the benefits of a social interaction,” points out Alexandra Hamlet, PsyD, a clinical psychologist. “The more superficial it is, the less likely it’s going to cause you to feel connected, which is something we all need.” Indeed, one exception to the depression correlation is girls who are high users of social media but also keep up a high level of face-to-face social interaction. The Twenge study showed that those girls who interact intensely offline as well as through social media don’t show the increase in depressive symptoms that those who interact less in person do. And there are some teenagers who aren’t successful in connecting with peers offline, because they are isolated geographically or don’t feel accepted in their schools and local communities. For those kids, electronic connection can be lifesaving. Social Media and Perceived Isolation Another study of a national sample of young adults (age 19-32) showed correlation between the time spent on social media and perceived social isolation (PSI). The authors noted that directionality can’t be determined. That is, “Do people feeling socially isolated spend more time on social media, or do more intense users develop PSI?” If it’s the latter, they noted, “Is it because the individual is spending less time on more authentic social experiences that would decrease PSI? Or is it the nature of observing highly curated social feeds that they make you feel more excluded?” Which brings us what we now call FOMO, or fear of missing out. Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute, observes that “FOMO is really the fear of not being connected to our social world, and that need to feel connected sometimes trumps whatever’s going on in the actual situation we’re in. The more we use social media, the less we think about being present in the moment.” Instead we might be occupied with worrying why we weren’t invited to a party we’re seeing on Instagram, or making sure we don’t miss a single post from a friend. But if we’re always playing catch-up to endless online updates, we’re prioritizing social interactions that aren’t as emotionally rewarding and can actually make us feel more isolated. Social media and self-esteem Another theory about the increase in depression is the loss of self-esteem, especially in teenage girls, when they compare themselves negatively with artfully curated images of those who appear to be prettier, thinner, more popular and richer. “Many girls are bombarded with their friends posting the most perfect pictures of themselves, or they’re following celebrities and influencers who do a lot of Photoshopping and have makeup and hair teams,” explains Dr. Hamlet. “If that’s their model for what is normal, it can be very hard on their self-confidence.” Indeed, image-driven Instagram shows up in surveys as the platform that most leads young people to report feeling anxiety, depression and worries about body image. Curation of a perfect image may not only make others feel inadequate, it’s unhealthy even for those who appear to be successful at it, notes Dr. Bubrick. “Kids spend so much time on social media trying to post what they think the world will think is a perfect life. Look at how happy I am! Look how beautiful I am! Without that they’re worried that their friends won’t accept them. They’re afraid of being rejected.” And if they are getting positive feedback from their social media accounts, they might worry that what their friends like isn’t the “real” them. Less healthy activity Another possible source of depression may be what teenagers are not doing during while they’re spending time on social media, including physical activity and things that generate a sense of accomplishment, like learning new skills and developing talents. “If you’re spending a lot of time on your phone, you have less time for activities that can build confidence, a sense of achievement and connectedness,” explains Dr. Hamlet. Kids who are spending a lot of time on devices are not getting much in return to make them feel good about themselves, she adds. “Yes, you get a little dopamine burst whenever you get a notification, or a like on a picture, or a follow request. But those things are addicting without being satisfying.” Disrupted concentration Another thing disrupted by social media is the process of doing homework and other tasks that require concentration. It’s become common for teenagers to engage with friends on social media at the same time they are studying. They take pride in being able to multi-task, but evidence shows that it cuts down on learning and performance. “Basically, multitasking isn’t possible,” Dr. Hamlet notes. “What you end up doing is really just switching back and forth between two tasks rather quickly. There is a cost to the brain.” And with poorer concentration and constant interruption, homework takes substantially longer than it should, cutting into free time and adding to stress. Sleep deprivation and depression Some of the ways in which social media use impacts mood may be indirect. For instance, one of the most common contributors to depression in teenagers is sleep deprivation, which can be caused, or exacerbated, by social media. Research shows that 60 percent of adolescents are looking at their phones in the last hour before sleep, and that they get on average an hour less sleep than their peers who don’t use their phones before bed. Blue light from electronic screens interferes with falling asleep; on top of that, checking social media is not necessarily a relaxing or sleep-inducing activity. Scrolling on social media, notes Dr. Hamlet, can easily end up causing stress. “Social media can have a profound effect on sleep,” adds Dr. Bubrick. “You have the intention to check Instagram or watch TikTok videos for 5 minutes, and the next thing you know 50 minutes are gone. You’re an hour behind in sleep, and more tired the next day. You find it harder to focus. You’re off your game, and it spirals from there.” How to minimize negative effects of social media use While we don’t yet have conclusive evidence that social media use actually causes depression, we do have plenty of warning signs that it may be affecting our kids negatively. So it’s smart for parents to check in regularly with kids about their social media use, to make sure it’s positive and healthy, and guide them towards ways to change it, if you think it’s not. Also, be alert for symptoms of depression. If you notice signs that your child might be depressed, take them seriously. Ask your child how they are doing, and don’t hesitate to set up an appointment with a mental health provider. Steps you can take to ensure healthy social media use: Focus on balance: Make sure your kids are also engaging in social interaction offline, and have time for activities that help build identity and self-confidence. Turn off notifications: App developers are getting more and more aggressive with notifications to lure users to interrupt whatever they’re doing to engage constantly with their phones. Don’t let them. Look out for girls at higher risk of depression: Monitor girls who are going through a particularly tough time or are under unusual stress. Negative effects of social media can have more impact when confidence is down. Teach mindful use of social media: Encourage teenagers to be honest with themselves about how time spent on social media makes them feel, and disengage from interactions that increase stress or unhappiness. Model restraint and balance in your own media diet: Set an example by disengaging from media to spend quality family time together, including phone-free dinners and other activities. Kids may resist, but they’ll feel the benefits. Phone-free time before sleep: Enforce a policy of no smartphones in the bedroom after a specific time and overnight. Use an old-fashioned alarm clock to wake up. Frequently Asked Questions

Keypoint: On average, primary care providers diagnose ASD 1 year earlier than other health care providers. Although primary care providers (PCPs) diagnose children with autism spectrum disorder (ASD) 1 year earlier than psychiatrists and psychologists, the likelihood of a PCP diagnosing a child with ASD has decreased every year from 2004 to 2019, according to study findings published in Autism. Further research is needed to understand this discrepancy and improve efficient diagnoses among children with ASD. An early diagnosis of ASD can be essential for initiating treatment during critical periods of development. Early interventions often lead to better long-term outcomes by addressing core challenges in childhood and connecting patients to necessary supports that improve their quality of life. A significant factor in achieving an earlier diagnosis is primary care appointment attendance, as PCPs are in a unique position to consistently monitor a patient’s development from infancy to childhood. Yet, the diagnostic tools required for an ASD diagnosis require extensive training and are often only used in specialized treatment centers. To determine whether PCP diagnoses of ASD have changed over time, investigators conducted a secondary analysis of data from the National Survey of Children’s Health (NSCH), a caregiver-report survey of the health and well-being of United States children from birth to 17 years of age. The goal of the analysis was to determine the rate of PCPs diagnosing ASD over time and children’s ages at diagnosis. Caregivers reported if a health care professional had ever diagnosed their child with ASD and were then asked to retroactively report which type of provider was the first to diagnose their child with ASD. The investigators collapsed the responses of provider type into PCP and non-PCP. A total of 5296 caregiver-reported diagnoses of ASD were included in the current study. On average, children were 5.13 (SD, 3.32) years of age at diagnosis, 76.8% of participants were White, 87.3% were non-Hispanic/Latinx, 80.0% of the children were boys, and 14.3% of the study group were first diagnosed with ASD by their PCP. From 2004 to 2019, the investigators found the likelihood of a PCP diagnosing a child with autism decreased by about 2% every year (odds ratio [OR], 0.98; 95% CI, 0.96-1.00). In a binary logistic regression model that controlled for demographic characteristics, the year in which a child was diagnosed with ASD was a significant, negative predictor of being diagnosed by a PCP (β, –0.02; P =.02). On average, children diagnosed with ASD by their PCP were about 1 year younger (4.10 years; SD, 2.67) than children diagnosed by a non-PCP (5.30 years; SD, 3.38; P <.001). The investigators wrote, “The present findings support the role PCPs play in early access to diagnosis, as age at first diagnosis of [ASD] was approximately [1] year earlier among children whose [ASD] was first diagnosed by their PCP as compared with non-PCPs.” Study authors concluded, “Overall, the current results indicate that more widespread access to diagnosis in primary care settings may have the potential to greatly reduce diagnostic delays in the years to come.” These study findings may be limited, as the investigators did not account for changes in ASD diagnostic criteria over the study period. Additionally, there was a lack of specificity in the survey questions and an inability to account for potential covariates (ie, living in an urban vs rural area, insurance type, and diagnostic features). Note: This article originally appeared on Psychiatry Advisor

The US Food and Drug Administration (FDA) has cleared Rejoyn (CT-152), the first prescription digital therapeutic authorized for the treatment of major depressive disorder (MDD) symptoms as an adjunct to clinician-managed outpatient care for adult patients with MDD aged 22 years and older who are on antidepressant medication. Rejoyn is a medical device with a novel approach to management of symptoms of depression. Rejoyn offers a 6-week treatment program with clinically-proven cognitive emotional training exercises for the brain, along with short therapeutic lessons. It is theorized to target the neural networks affected by depression and potentially use the brain’s inherent neuroplasticity to alter emotional connections, thus leading to a reduction in symptoms over time. “Rejoyn represents a novel and exciting adjunctive treatment option to address MDD symptoms that complements the current standard of care,” said John Kraus, MD, PhD, executive vice president and chief medical officer at Otsuka. “While traditional approaches are often effective, many are left with only a partial response to treatment. Otsuka has a long, unwavering commitment to addressing the unmet needs of people living with mental illnesses and the clearance of Rejoyn is an example of delivering on that promise. We are deeply grateful to the trial participants, clinicians, and everyone at Otsuka and Click Therapeutics, who helped Rejoyn reach this important milestone.” This clearance is based on data from a 13-week pivotal, multicenter, remote, double-blinded, randomized, controlled trial of 386 participants aged 22 to 64 who were diagnosed with MDD and on antidepressants. Participants were randomized to receive either Rejoyn or a sham control app. Those treated with Rejoyn showed an improvement in depression symptom severity from baseline and symptom improvement was consistently observed across multiple patient and clinician-reported scales, including the Montgomery-Åsberg Depression Rating Scale (MADRS), Patient Health Questionnaire 9-item depression scale (PHQ-9), and the Clinical Global Impression – Severity scale (CGI-S). Participants in the Rejoyn arm showed continued improvement 1 month after completing the 6-week treatment program. No adverse effects from Rejoyn were observed during the trial. “Only a third of patients diagnosed with depression and who receive antidepressants as their first-line treatment, are successful. These patients need new options that capitalize on proven-effective treatment strategies,” said David Benshoof Klein, cofounder and chief executive officer at Click Therapeutics. “The clearance of Rejoyn signals a fundamental change in how clinicians can treat symptoms of major depressive disorder. It provides hope for those who are looking for new treatment options, especially one that is easily accessible through the device in the palm of your hand.” Rejoyn introduces Emotional Faces Memory Task (EFMT) exercises2—designed to help participants appropriately process emotions—that were created by a team of psychologists, psychiatrists, and neuroscientists. The coinventor of EFMT, assistant professor in the department of psychiatry at the Icahn School of Medicine at Mount Sinai, and scientific advisor at Click Therapeutics, Brian Iacoviello, PhD, had this to say on the new digital therapeutic: “Rejoyn has a neuromodulatory mechanism designed to act like physical therapy for the brain by delivering personalized, consistent brain-training exercises designed to help improve connections in the brain regions affected by depression. When stronger and more balanced connections are created, the regions of the brain responsible for processing and regulating emotions are better able to work together and symptoms of depression can improve.” Rejoyn is expected to be available for download from app stores for iOS and Android operating systems later in 2024. This article originally appeared on Psychiatric Times