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Atypical anorexia nervosa (AN) is more prevalent among people of color and is associated with increasing anxiety and stable binge-eating trajectories over time, according to study results published in the International Journal of Eating Disorders. Atypical AN is categorized by significant weight loss and psychological symptoms that closely resemble AN, but with “normal” or higher weight relative to typical AN. Although atypical AN has become increasingly recognized as an eating disorder following its inclusion in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is still relatively understudied and underrepresented in clinical settings. To address this knowledge gap, investigators explored the natural course of atypical AN compared with AN and bulimia nervosa (BN) among college students. The investigators conducted a prospective cohort study at a public university in the United States to delineate the progression of eating disorder and internalizing symptoms among college students with and without histories of atypical AN, AN, and BN. First-year college students (18 years of age and older) were recruited to complete a self-reported questionnaire on sociodemographic information, psychiatric symptoms, and health behaviors, and follow-up assessments were conducted each year of college. Eating disorder symptoms were evaluated using the Eating Disorder Examination Questionnaire, while internalizing symptoms were assessed using the 8-item Symptom Checklist-90. The investigators included data from 989 first-year students, 1208 sophomores, 1727 juniors, and 1854 seniors. Overall, 61.4% of included students were women and 47.2% were White. Participants were categorized into 4 groups: those who met the criteria for atypical AN (n=125), AN (n=160), BN (n=617), or non-eating disorder controls (NCs, n=5876). Relative to the AN group, participants with atypical AN were significantly more likely to identify as non-White (B=0.74; P =.004). Across all groups, body mass index (BMI) significantly increased over time and BMI trajectory did not differ across groups. Relative to NCs, participants with atypical AN were significantly more likely to report fasting (P <.001), driven exercise (P =.006), purging (P =.007), anxiety (P =.002), and depression (P <.001). However, only anxiety (P =.038) and fasting (P <.001) remained elevated over time. Among the eating disorder groups, students with atypical AN had more stable binge eating trajectories (B=0.25; 95% CI, -0.21 to 0.70) relative to BN participants who displayed decreases in binge eating over time (B= -2.84; 95% CI, -3.18 to -2.49; P <.001). The atypical AN, AN, and BN groups did not significantly differ for the remaining eating disorder and internalizing symptom trajectories. “Given that atypical AN is under-represented in treatment settings and affects a greater proportion of people of color than AN, healthcare providers should be aware of biases that may delay diagnosis and care,” the investigators noted. Study authors concluded, “[Current] results improve understanding of atypical AN symptom trajectories relative to AN and BN, emphasizing the need for ongoing research in nonclinical samples beyond the context of college.” Study limitations include reliance on self-reported data, potential sample size suppression in the atypical AN group, varying assessment times, and participant attrition. Note: This article originally appeared on Psychiatry Advisor

PSYCHIATRIC VIEWS ON THE DAILY NEWS The publication of the book Dune in 1965 came at the height of the use and abuse of psychedelics in what could be called the first coming of the psychedelics in the United States. Now, years after they became federally illegal in 1970, they are being researched and used again in what could then be called their second coming. Besides their potential to help treatment-resistant depression, anxiety, and trauma, they may be beneficial for loneliness, opiate addiction, and traumatic brain injuries. We also should not forget the long world-wide use of psychedelics by the indigenous over millennia. In the “Stoned Ape Theory,” ingesting psilocybin regularly in diets is said to have potentially led to the rapid evolution of brain size and abilities. Ketamine, which seems to have some psychedelics properties, has been practically available because it had approval from the US Food and Drug Administration (FDA) as an anesthetic years ago. Research has indicated its potential usefulness for treating depression more rapidly. No wonder, then, that this promise and availability of ketamine has led to numerous so-called ketamine clinics. I was asked to consult on one locally and suggested following the American Psychiatric Association’s (APA) 2017 guidelines,2 as well as to make sure that there was a psychiatrist onsite. As far as I can tell, that has not been followed locally or nationally. No wonder, then, that the APA has recently told MedPage that those clinics are like the “wild west,” where patients do not received adequate informed consent on the downsides.3 The profit potential on refined psychedelic doses is another influence. The hope is that when other purer psychedelics receive FDA approval, that they are more carefully regulated and monitored. However, even if that proves so, underground usage will likely continue as usual. If we can skip the imagined 10,000 years to reach “Dune: Part Two,” the third coming of psychedelics seems in full swing. A highly addictive and very power psychedelic is in planetary use for producing a longer life, vitality, and awareness. At higher doses, it produces increased computational skills, making interstellar travel practical. As what seems to be a key ingredient in the poisonous narcotic Waters of Life, past memories and clairvoyant visions of the future can become available. However, in “Dune: Part 2,” we see very little, if any, of the touted cosmic connections from our current psychedelics. Instead, competition for spice seems to have escalated conflict and colonialism, once again depicting both the promise and perils of psychedelics. Although there is no formal psychiatry depicted in the movies or book, real life psychiatry has the knowledge and some power to guide our psychedelic future for the better. Note: This article originally appeared on Psychiatric Times

Higher body mass index (BMI) at 7 years of age is associated with increased body dissatisfaction in late childhood and greater depressive symptoms in adolescence, according to study results published in Lancet Psychiatry. However, body dissatisfaction in late childhood was independent of BMI as a risk factor for depressive symptoms in adolescence. The prevalence of depressive symptoms among adolescents is increasing, highlighting the need for effective preventative interventions and a better understanding of potential modifiable risk factors. The current study sought to explore the relationship between childhood BMI, late childhood body dissatisfaction, and adolescent depressive symptoms. Investigators utilized data from the Millennium Cohort Study, an ongoing UK longitudinal birth cohort study involving over 18,000 families with children born between 2000 and 2002. The primary outcome was depressive symptoms at 14 years of age, assessed using the 13-item Short Mood and Feelings Questionnaire (sMFQ). Objective BMI measurements were recorded at 7 years of age by trained interviewers and were standardized by age and sex. Body dissatisfaction was measured at 11 years of age using a single-question scale from 0 to 6, derived from a broader happiness questionnaire. A total of 13,135 children with available BMI data at 7 years of age were included in the analysis, of which 49.6% were girls and 84.4% were White. Our findings suggest that greater body dissatisfaction in late childhood is an important risk factor for adolescent depression, regardless of the child’s BMI. In univariable models, higher BMI at 7 years of age was associated with greater depressive symptoms at 14 years of age (β, 0.38; 95% CI, 0.25-0.50; P <.0001) and with greater body dissatisfaction at 11 years of age (β, 0.17; 95% CI, 0.14-0.19; P <.0001). Greater body dissatisfaction at 11 years of age was also associated with higher depressive symptoms at 14 years of age (β, 0.83; 95% CI, 0.74-0.92; P <.0001). All associations were higher in magnitude among girls relative to boys and all sensitivity analyses were consistent with results from the main analyses. In mediation analyses, the investigators found that 26% of the association between BMI and depression was mediated by body dissatisfaction. This relationship varied by sex, with body dissatisfaction accounting for 43% of the relationship between BMI and depression in girls (P =.005), and 39% in boys (P =.822). These findings indicate that children with higher BMI in childhood have greater body dissatisfaction at 11 years of age and higher depressive symptoms in adolescence. Additionally, children who were more dissatisfied with their appearance at 11 years of age had greater depressive symptoms by 14 years of age. Study authors concluded, “Our findings suggest that greater body dissatisfaction in late childhood is an important risk factor for adolescent depression, regardless of the child’s BMI.” Study limitations include the reliance on a single-item question to measure body dissatisfaction and a lack of information on disordered eating behaviors. Note: This article originally appeared on Psychiatry Advisor

Long-acting injectable (LAI) antipsychotics reduce 30-day rehospitalizations relative to oral antipsychotics, according to study results published in the Journal of Clinical Psychopharmacology. Hospital inpatient free trial programs were also found to aid in LAI antipsychotic acquisition. Prior literature has demonstrated the efficacy of LAI antipsychotics over oral formulations in diminishing the frequency of readmissions. However, there is limited evidence supporting the role of LAI antipsychotics in the prevention of rehospitalizations. To address this knowledge gap, investigators conducted a single-center retrospective cohort study to compare psychiatric readmission rates among patients with schizophrenia or schizoaffective disorder who were prescribed either LAI or oral antipsychotics upon discharge between August 1, 2019, and June 30, 2022. The study also evaluated the benefits of leveraging pharmaceutical free trial programs for LAI medications. Screening a total of 1574 patients, researchers identified 343 individuals who were discharged with prescriptions for at least 1 oral or LAI antipsychotic. Within this cohort, 62.7% were diagnosed with schizophrenia and 37.3% with schizoaffective disorder. On average, patients were 40.3 years of age, 55.4% were male, and 32.9% were African American. Patients discharged from an inpatient psychiatric unit on LAI medications had a statistically significant decrease in 30-day readmission rates as compared with patients discharged on oral antipsychotics. In the study, 30% of patients were discharged on an LAI antipsychotic, while 70% were on oral antipsychotics. The LAI antipsychotic prescriptions included aripiprazole lauroxil (45.6%), haloperidol decanoate (35%), paliperidone palmitate (15.5%), extended-release aripiprazole injection (2.9%), fluphenazine decanoate (1%), and risperidone long-acting injection (1%). Among patients discharged on oral antipsychotics, the majority were prescribed risperidone (27.5%) or olanzapine (21.3%). The investigators also found that the average chlorpromazine equivalent dose was higher for the LAI group (477.3 mg/d) compared with the oral group (278.6 mg/d, P <.001). Additionally, 64% of LAI antipsychotics were accessed through hospital inpatient free trial programs. The investigators observed a 6.4% readmission rate for schizophrenic or schizoaffective exacerbation within 30 days following discharge. Patients on a LAI antipsychotic had a significantly lower rate of readmission at 1.9% compared with 8.3% for the oral antipsychotic group (P =.03; 95% CI, 1.05–20.02). Of those readmitted, 43% were diagnosed with schizophrenia and 57% with schizoaffective disorder. The researchers concluded, “Patients discharged from an inpatient psychiatric unit on LAI medications had a statistically significant decrease in 30-day readmission rates as compared with patients discharged on oral antipsychotics.” Study limitations include the retrospective study design, small sample size, and incomplete accounting of patient history and admissions to other facilities. Note: This article originally appeared on Psychiatry Advisor

Grandparent care is associated with increased internalizing, externalizing, and overall mental health problems among children, according to study results published in the Journal of Child Psychology and Psychiatry. These findings indicate that grandparental care may be a risk factor for children’s mental health. Previous research has demonstrated that parental characteristics exert a major impact on children’s mental health outcomes. Given the global increase in the number of children residing in grandfamilies, investigators conducted a systematic review and meta-analysis to characterize and evaluate the effect of grandparental care on children’s mental health. The investigators searched publication databases in November 2021 and a second-round search in June 2023 for studies that focused on grandparental care and reported at least 1 mental health outcome for grandchildren. The primary outcome of interest was children’s mental health outcomes, including internalizing problems, externalizing problems, overall mental problems, and socioemotional well-being. Additionally, the investigators evaluated potential moderators in the effects of grandparental care. A total of 38 studies (cross-sectional: k =27; longitudinal, k =11) were included for analyses, for a pooled sample size of 344,860 children. On average, children were 10.29 years of age and there was a generally balanced gender distribution. Most studies evaluated internalizing problems (k =18), followed by externalizing problems (k =14), overall mental problems (k =10), and socioemotional well-being (k =7). Additionally, mental health outcomes were reported through child self-report (k =17), caregiver report (k =11), mental health professional report (k =3), and teacher report (k =3). Our findings also call for more supportive preventions and early mental health interventions for children living in grandfamilies. The investigators found that children who were cared for by their grandparents had more internalizing (d = -.20; 95% CI, -0.31, -.09; P=.001), externalizing (d = -.11; 95% CI, -0.21 to -.01; P =.03), and overall mental problems (d = -.37; 95% CI, -.70 to -.04; P =.03) and poorer socioemotional well-being (d = -.26; 95% CI, -.49 to -.03; P = -.03), relative to children without parental care. However, the wide confidence intervals suggest variability in the association between grandparental care and child mental health across populations. When evaluating potential moderators to this relationship, the investigators observed that study design (Q =4.97; P =.03) and child gender (Q =5.96; P =.02) contributed significantly to effect size variance. Specifically, there were larger negative effects of grandparental care associated with longitudinal studies (d = -.08; 95% CI, -.53 to -.19) relative to cross-sectional studies (d = -.29; 95% CI, -.41 to -.18) and for girls (d = -.10; 95% CI, -.25 to .04) compared with boys (d = -.10; 95% CI, -.25 to .04). Recruitment setting, child age group, study region, cultural context, living area, and family type did not significantly moderate the effects of grandparental care. “These results underscore the need for additional research on grandparental care with more nuanced and comprehensive measurements of the context and extent of grandparental care,” the investigators noted. “Our findings also call for more supportive preventions and early mental health interventions for children living in grandfamilies,” study authors concluded. These findings may be limited by the lack of information on parental factors and family dynamics, inability to establish causal relationships, and small sample size. Note: This article originally appeared on Psychiatry Advisor

Ed. The US Department of Health and Human Services (HHS) announced on February 6 the launch of 2 grant programs through the Substance Abuse and Mental Health Services Administration (SAMHSA) intended to expand substance use disorder (SUD) treatment services. What does this mean for the future of SUD treatment? Psychiatric Times® Substance Use Section Editor Roueen Rafeyan, MD, DFAPA, FASAM, weighs in. It is nice to have the support of the Biden-Harris Administration in recognizing the tremendous need for SUD treatment and mental health services. Our patients with SUD also have high psychiatric comorbidities. It is never sufficient to treat one disorder and overlook the other. We need resources; our patients need access to resources. Grants provide the opportunity for many of us to create or expand on our resources to help those seeking treatment. This grant also helps with addressing mental health issues and providing treatment to patients involved in our legal system due to SUDs. Let us not forget the old saying: “An ounce of prevention is worth a pound of cure.” We know treatment works and saves lives. However, we all need to invest in prevention before the disease becomes deadly. We need to educate the public, we need to educate our youth, and we need to prevent access and use. I am personally grateful that this grant also recognizes the need for treatment for pregnant patients with SUDs—another area with scarce resources and expertise. Let us keep in mind that alcohol and SUDs cost around $500 billion a year. The National Institute on Drug Abuse (NIDS) has an annual budget of $1 billion a year. The numbers are high, but it is not hard to see the disproportion and to feel the weakness against the $500 billion giant. Any amount dedicated to fighting this battle is better than none—however, we need more. Twenty-eight million dollars is just not enough, but it is a start. Those of us in the trenches appreciate any help we can get to continue saving lives. This article originally appeared on Psychiatry Advisor

When treating opioid use disorder (OUD) during pregnancy, the risk for major congenital malformations is lower with buprenorphine than methadone. These study results, published in JAMA Internal Medicine, may help inform prescribing decisions for physicians treating pregnant individuals with OUD. Given the escalating prevalence of opioid misuse and long-term opioid use among pregnant patients in the United States, there is a critical need to optimize treatment for OUD during pregnancy to mitigate risks like overdose, opioid exposure, and withdrawal symptoms. Despite clinical evidence favoring buprenorphine over methadone for reducing the risk for neonatal abstinence syndrome, preterm birth, and low birth weight, data regarding the risk for congenital malformations associated with these treatments during pregnancy are limited. The current study sought to assess the comparative risk for congenital malformations among infants exposed to buprenorphine vs methadone during the first trimester. Researchers used data from a nationwide cohort of Medicaid-insured pregnancies and linked infant records between 2000 and 2018. The researchers used dispensing records in the first trimester to identify buprenorphine-exposed pregnancies and administration codes in the first trimester to identify pregnancies exposed to methadone. The primary outcome of interest was the composite outcome of all major congenital malformations. The researchers also evaluated specific malformations previously associated with opioid use and potential confounders, including OUD history, OUD severity, nonopioid dependence, demographics, and comorbid conditions. It should be highlighted that any opioid agonist therapy — either buprenorphine or methadone — is strongly recommended over untreated OUD during pregnancy. Overall, 9514 pregnancies were exposed to buprenorphine in the first trimester and 3846 were exposed to methadone. The researchers observed that the risk for any major congenital malformation was 50.9 (95% CI, 46.5-55.3) per 1000 pregnancies in the buprenorphine group and 60.6 (95% CI, 53.0-68.1) per 1000 pregnancies in the methadone group. After adjusting for confounders, buprenorphine was associated with a lower relative risk (RR) for malformations compared with methadone (RR, 0.82; 95% CI, 0.69-0.97). For specific malformations associated with opioid exposure, those exposed to buprenorphine had a decreased risk for central nervous system (RR, 0.51; 95% CI, 0.30-0.89), urinary (RR, 0.62; 95% CI, 0.37-1.04), and limb (RR, 0.53; 95% CI, 0.34-0.83) malformations, relative to methadone-exposed infants. However, buprenorphine was associated with a higher risk for gastrointestinal malformation (RR, 1.98; 95% CI, 1.15-3.39). Data from this large cohort of Medicaid beneficiaries indicates that buprenorphine use for the treatment of OUD in the first trimester of pregnancy is associated with a decreased risk for major congenital malformations relative to methadone. Study authors concluded, “It should be highlighted that any opioid agonist therapy — either buprenorphine or methadone — is strongly recommended over untreated OUD during pregnancy.” Study limitations include the potential underreporting of medications for opioid use disorder not covered by Medicaid, a lack of methadone dose data, and small event counts for certain malformations. Note: This article originally appeared on Psychiatry Advisor

Riding on a judicial victory challenging the US Drug Enforcement Administration's (DEA's) denial of a petition to move psilocybin from schedule I to schedule II, the plaintiffs said they will soon be back in court to try to force the agency to allow the use of the psychedelic under state right-to-try laws, which aim to provide terminally ill patients with access to experimental treatments that have not yet been fully approved by the US Food and Drug Administration (FDA). The petition is just one avenue being pursued by the Seattle, Washington-based AIMS Institute, which is seeking to use the drug to help ease anxiety in patients with cancer. Last fall, in a scathing response to the DEA, a three-judge panel of the US Court of Appeals for the Ninth Circuit told the agency that it had failed to follow its own procedures and had obfuscated how it came to the conclusion that the petition, filed in 2022 by Sunil Aggarwal, MD, and AIMS, should be denied. The court said the DEA needed "to either clarify its pathway for denying Aggarwal's petition" or, alternatively, to "reevaluate Aggarwal's petition on an open record." The Ninth Circuit response renders moot a lawsuit filed by Aggarwal to force a DEA explanation of its refusal to reschedule psilocybin. Shane Pennington, an attorney with Porter Wright who is representing AIMS, said, "it's a huge deal to have DEA's denial of a rescheduling petition declared unlawful and set aside." "The only thing we didn't get is we wanted the court to direct them to send the petition to the FDA as the statute requires," Pennington told Medscape Medical News. The 'Right Thing' to Do The court also did not order the DEA to respond or to do so within any set period. But if the DEA delays "too much," AIMS has the right to go back to court and demand action, Pennington said. "I suspect that if they haven't done anything in 6 months to a year, the court would be frustrated by that," he added. Attorney Kathryn Tucker, director of advocacy for the National Psychedelics Association, who has also been representing AIMS, said her clients are happy with the Ninth Circuit response. However, they wish the judges had been more directive with the DEA, Tucker told Medscape Medical News. "We are at a moment where one would hope that the agency will finally stop obstructing and delaying and do the right thing," she said. Mason Marks, MD, project lead of the Project on Psychedelics Law and Regulation at Harvard Law School's Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, said he does not expect the DEA to approve the rescheduling petition, but that the agency may provide "a more detailed response that actually has some more substance to it." Marks cites the DEA's long history of refusing to reschedule cannabis, saying it "doesn't really bode well for people who are advocating to reschedule psilocybin." The agency will likely only reconsider psilocybin when there is an FDA-approved product that it can reschedule, said Marks. For instance, when the FDA approved the cannabis-derived drug Epidiolex in 2018, the DEA moved it to schedule V several months later. Compass Pathways is developing a psilocybin product, which is currently being tested in trials for treatment-resistant depression. That drug may not be approved until 2027 at the earliest, said Marks. If it were to be approved, "the DEA would reschedule that particular formulation of psilocybin, but that formulation alone," he said. "It just doesn't seem like there's any possibility that the agency would willingly do anything else before then," said Marks. Next Best Chance Tucker said that the next best chance to pressure the agency is through another suit brought by AIMS that seeks to allow use of psilocybin under state right-to-try laws. In 2021, the DEA denied AIMS' request to waive Controlled Substances Act prohibitions against psilocybin use, citing right-to-try laws. AIMS then sued, and the Ninth Circuit in 2022 threw out the case on a technicality. But AIMS had an avenue to reframe its arguments, and the case is now again pending before the Ninth Circuit, which is one of the courts that adjudicates administrative law. AIMS and the federal government are submitting briefs, and arguments could be heard as soon as summer 2024, said Tucker. For a treatment to be eligible for right-to-try, it must have completed an FDA-approved phase 1 clinical trial; be in an active trial that would form the basis of an application for approval or already is part of an approval application; and be in ongoing active development or production and not discontinued by the manufacturer or placed on clinical hold. Psilocybin meets all of these conditions, said Tucker. "A single guided treatment with psilocybin therapy for a dying cancer patient has been shown time and again to bring immediate, substantial, and sustained relief. The right to try argument is very strong," she said. Forty-one states have passed right-to-try laws. Pennington said that AIMS will argue that the federal right-to-try law, which sets a template for states, trumps the Controlled Substances Act. The plaintiffs are asking the court to declare the DEA's refusal to create a pathway for psilocybin use under those right-to-try statutes to be unlawful, said Pennington. "I believe we will prevail," said Tucker. However, Tucker is also a realist. "There is no quick path to victory here," she said. Easing Psychological Suffering She also noted that several pieces of legislation have been introduced in the US Congress that could help facilitate research and allow compassionate use of psychedelic therapies like psilocybin and 3,4-methylenedioxy methamphetamine (MDMA). The Breakthrough Therapies Act (Senate Bill 689) would expedite the transfer of substances that receive breakthrough therapy designation from the FDA from schedule I to schedule II. So far, both psilocybin and MDMA have been designated as breakthrough therapies. The bill has not received any congressional action since its March 2023 introduction. Similarly, the Right-to-Try Clarification Act (House Bill 1825) has not seen any action since its introduction. That legislation would specifically exempt drugs eligible for right-to-try from restrictions under the Controlled Substances Act (CSA). Congressional pressure will not likely move the needle, said Marks. He has argued for reform of the CSA. It would make more sense "to have a public health agency making decisions that at least in theory should primarily be directed at improving public health," he noted. Arguably, scheduling does not prevent the harms associated with substance use, Marks added. "Scheduling hasn't prevented opioid overdose deaths. I don't know that there's any evidence to suggest that scheduling improves safety in any meaningful way. It does, however, inhibit the ability to do research." Tucker said she will keep pushing on every available front. "The obvious gap in the palliative care toolbox is a tool for the relief of nonphysical suffering, and psilocybin is that tool." "It's really essential that everyone in patients' rights, hospice and the palliative care movement stand up and insist that it be available sooner rather than later," Tucker added. Note: This article originally appeared on Medscape

COMMENTARY The trauma inflicted during the Hamas attack on October 7, 2023, is being experienced by vulnerable individuals worldwide, as Ofrit Shapira-Berman, PhD, a psychoanalyst supporting victims and their families, explains in our conversation. In the immediate area of conflict, not only Israelis but also Palestinians are being held hostage by Hamas and the perpetrators of the violent attacks, as they continue to bring death and destruction on the residents of Gaza and the individuals in Israel mourning their losses and waiting for the 136 men, women, and children being held hostage. Adding insult to injury, many Jewish individuals have felt the impact of rising antisemitism worldwide. The hate and the rhetoric have caused harm to innocent individuals on both sides and impact humanitarian relief and healing. The trauma is multiplied by history of the Holocaust (many Holocaust survivors live in Israel, some of whom were victims of the October 7 attacks and/or witnessed the violence in a land they had deemed safe), and the shocking willingness of much of the world to look away from the genocide that was perpetrated against the Jews. The widespread, ideologically fueled denial of sexual violence perpetrated by Hamas as well as the International Court of Justice taking up a charge of genocide against Israel with no probable cause has added to the trauma. An expert on international law who has represented Palestinian interests has noted that sometimes an accusation of genocide becomes an incitement to genocide.1 This undoubtedly adds to fear and trauma. Fostering resiliency involves acknowledging the trauma and finding ways to move forward. Fortunately, there are outlets. For those seeking legal recourse against hate speech misrepresented as free speech, there is a movement to seek civil damages for the harms caused by such speech. For those treating or consulting to clinicians treating victims and survivors, in addition to the therapeutic approaches outlined by Dr Shapira-Berman, engaging patients in creativity can be one way of helping them grieve.3 Hyman Bloom’s Child in the Garden, painted in the immediate aftermath of the Holocaust, can serve as a model for such therapeutic exploration through art. Harold J. Bursztajn, MD: What has been the impact on the bereaved, families of hostages, and traumatized victims of kidnapping, rape, and humiliation? Ofrit Shapira-Berman, PhD: The trauma is so profound and unprecedented—it seems to be very different from “regular” losses normally endured by people. It is partly because each of the victims had endured multiple traumas, simultaneously. For example, people at the kibbutzes were locked in their shelters for hours. They heard terrorists outside their homes shout in Arabic, they heard the shooting all around them, they were shot at, and their homes were invaded. They witnessed their loved ones being shot, wounded, and killed. At the extreme, their loved ones were abused and slaughtered right before their eyes. Many houses were burned with the victims in them as an attempt to make them run out—then they were murdered. In the community WhatsApp group, members of the community were texting—crying for help and reporting what was going on—so everyone was exposed to all the various atrocities that took place. People who survived the attack emerged with their world shattered, in terms of their trust and morals. Everything they have ever believed in was completely shattered. Terrorists were able to invade their homes, the army did not appear for hours on end, so their trust is totally shattered. In terms of morals, the fact that human beings could be so cruel—abuse, slaughter, cutting off people’s limbs, gouging their eyes, and burning children alive, then eating, drinking, and laughing before and after—is something no human mind can contain. The effects of such horrific acts lead the survivors not only to doubt the possibility of living with their neighbors, but to doubt humanity as a whole. The same can be said for the survivors of the NOVA Festivals. The things they witnessed and experienced are outside of one’s imagination, and 2 of the things they refer to are 1) the extent of the terrorists’ cruelty and 2) the fact that the terrorists were smiling as they were slaughtering people. It seems that the Hamas’ sadism was one of the main factors that extinguished Israelis’ trust in humanity. I presume that it goes as far as “humanity” because the atrocities were so horrific. It magnifies one’s shattered trust. Bursztajn: What has been the impact of denial of the Hamas attack (eg, the refusal—including from feminist organizations around the world—to acknowledge the rape of Israeli women and the United Nations’ delay in investigating Hamas)? Is such denial and suppression of conversation foreseeably harmful to survivors? Shapira-Berman: The Holocaust is a fundamental aspect of the Jewish and Israelis’ ethos. This ethos has 3 basic components: 1) the hatred of Jews merely for being Jewish, 2) the determination and cruelty of the Nazis, and 3) the silence of the world, at least for a long time. Jews were left to be burned, murdered in the gas chambers, and prisoned and tortured in the camps. Eventually, the world stepped in, but for many, it was too little and too late. The events of October 7, 2023, brought to the surface the Holocaust as a common metaphor. Of course, there are significant differences. Jews have a state and an army, and the Hamas, however vicious they are, are not an existential danger. However, the silence of the world and the apparent antisemitism is a dark reminder of those days. Surviving such horrific violence, only to be blamed for it, is an additional trauma to what was already suffered by the victims. The world’s avoidance and reluctance to condemn the Hamas and other terrorists, and to acknowledge brutal rape, adds to what the Hamas did on October 7. It is not an exaggeration to suggest that this silence is an additional act of killing of the survivors’ minds and psyches. Bursztajn: How have victims of the Hamas attack, and Israelis in general, shown resilience? How can such resilience be effectively supported? Shapira-Berman: The civilians’ resilience and resourcefulness were extraordinary—both from those exposed to the atrocities and from those who lived elsewhere. People in the kibbutzes fought fiercely and with endless courage, often endangering their own lives, in their attempts to save other members of their community. For hours, they fought thousands of terrorists who invaded their homes, all alone, until the Israel Defense Forces (IDF) special forces arrived. The resilience could be seen in some of the most famous footage that was published of an 84-year-old woman who was kidnapped and taken to Gaza and was seen sitting among her kidnappers with a thin, serene, almost smile on her face. It was such an extraordinary sight that people wondered whether she was suffering from dementia. Her children said she was as lucid as possible and that this was an expression of her strengths and resilience. The civilian population showed its resilience by organizing, immediately, and setting up a war room, replacing almost all of the formal authorities, within hours of Saturday morning. Thousands of civilians not only joined the army, but started gathering food, clothing, and all other necessities for the victims of the attack who had been evacuated from their homes. Some of them went to the south to save the injured. Civilians, who were on the verge of a civil war for 10 months prior to October 7 after the political coup of Netanyahu’s government, united immediately in their support of the victims, the survivors, the bereaved families, and the combat soldiers fighting in the south. The victims themselves were able to hold in their rage and express their unity with the rest of the Israeli society and the IDF, although they did feel betrayed by the “state” and the army. With much dignity, they have been able to postpone whatever needs to be examined until after the war. Israelis’ reliance can, and should, be supported by a global recognition of the atrocities and the horrible suffering they endured. Such recognition and acknowledgment act as empathic witnessing—the opposite of the ignorant and indifferent bystander. Bursztajn: What are effective treatments for trauma like this? Can individuals who have suffered in different ways benefit from different forms of treatment? Shapira-Berman: Therapists have mainly been using the following interventions: Support: recognition and acknowledgement of the atrocities, their effects, and the individuals’ attempts to survive them -Short-term therapy: both dynamic and cognitive behavioral therapy (CBT)/eye movement desensitization and reprocessing (EMDR) Long-term therapy: both analytic and trauma informed; survivors, bereaved family members, and the hostages who are back are just beginning these therapies now For NOVA Festival survivors, specific locations were opened in which various kinds of alternative methods were combined with the more classical ones. In addition to these methods, these places employed therapies that focus on psychedelic drug usage, as many of the NOVA survivors had been using them at the party. Bursztajn: How has the denial of Hamas horrors, including the systematic rapes of Israeli women, impacted victims of sexual violence worldwide and of other recent genocides (ranging from the Shoah to Biafra and beyond), as well as emboldened antisemitism and racism? What can be done to detoxify this worldwide impact? Shapira-Berman: I think this is one of the most painful aspects of the October 7 events. I find this issue of sexual abuse to be the most difficult of all for the Israeli citizens to contain. Most say, “I cannot handle this. This is too much for me.” I think its effect on women in general, but especially Jewish women, is horrible. What can we think now, other than that our lives do not matter, women’s lives do not matter, and Jewish women’s lives do not matter at all? I cannot believe that if American women were raped, as a war crime, the world would react in the same way. This is being understood in Israel as another manifestation of antisemitism, and it should be addressed as such. I think it is not only women’s organizations that should be approached. I refuse to see sexual violence as a “women’s issue.” It is a human issue and should be addressed as one. Men who rape women (and other men as well, as was the case on October 7) should be perceived and judged as war criminals, and those who perceive themselves as the gatekeepers of the moral civilization should all stand up and shout, no more. The violence that took place on October 7 should not be regarded as a problem of the Israelis, but as a problem of the whole world. World leaders who permit such violence are bringing the world nearer to its end. How to detoxify the effects of double standards relative to Israeli self-defense efforts? For instance, what does it mean to the survivors you are treating that some American politicians insist that conditions be placed on military assistance to Israel that were not placed in instances such as aid to the Iraqi army in liberating Mosul from ISIS? Bursztajn: How can restorative justice be helpful in the face of such trauma? How might restorative justice be achieved? Shapira-Berman: I cannot see it happening in the near future. No survivor will be able to forgive the Hamas and those who support them for any of the horrific things that took place on October 7. Bursztajn: Is there anything else you would like to share with your colleagues in the United States? Shapira-Berman: No therapist can allow herself, or himself, to stay silent or to remain an innocent/ignorant bystander when children are being burned alive; people are having their limbs cut off while they are still alive; women are being raped, abused, and then murdered; men’s genitals are being cut off; and innocent people are being kidnapped and taken to Gaza. This amounts to keeping silent while another Holocaust takes place. No nation should ever suffer such atrocities. Therapists who dedicate their lives to the suffering and healing of others but do not stand with the people of Israel at the moment are hypocrites, to say the least. They should all remember: Not reaching out for the victims is strengthening the abusers. On October 7, the abusers were the Hamas and other terrorists, and the victims were the people of Israel. There is no justification, and there should never be any justification, for such atrocities. Note: This article originally appeared on Psychiatric Times®. The opinions expressed in commentaries are those of the participants and do not necessarily reflect the opinions of Psychiatric Times®.

Benzodiazepines are known to lead to dependency quickly and have numerous side effects. Long-term use is not recommended. However, if there is a long-term prescription, the goal should be to end therapy with these tranquilizers. However, discontinuation could have unexpected consequences, as US researchers reported in JAMA Network Open. In a registry study, patients who discontinued benzodiazepines after long-term therapy had an increased risk for death in the following 12 months. Whether there is a causal relationship between discontinuation of therapy and increased mortality rate or whether it is just the temporal coincidence of two phenomena cannot be answered by the study. Risks Are Downplayed "Under no circumstances should it be concluded from the results of this study that it is appropriate to continue long-term benzodiazepine therapy," warned Dirk Wedekind, MD, head of the Addiction Medicine Department the University Medical Center Göttingen's Department of Psychiatry and Psychotherapy in Germany, in response to inquiries from Medscape Medical News. "Long-term use of benzodiazepines is associated with risks that, in my opinion, are downplayed in this study," he said. In addition to rapid tolerance development and associated dependency, benzodiazepines carry the risk for various physical, psychological, and cognitive side effects. Sedation, daytime drowsiness, and sleepiness with impaired attention and reaction time, muscle weakness, lethargy, ataxia, confusion, depression, and dizziness are frequent. The risk for falls is significantly increased. A connection with the onset of Alzheimer's dementia is also frequently discussed. "Only in individual cases, when other drug strategies are not an option at all, is it indicated to treat with benzodiazepines long-term. Otherwise, these substances, as useful as they are acutely, must be discontinued after a few weeks," Wedekind emphasized. Long-Term Prescriptions The US Food and Drug Administration and German professional associations strictly advocate that benzodiazepines not be used as permanent medication. However, long-term therapy is "often medical reality," said Wedekind. "There are also many patients in Germany with long-term prescriptions that are not appropriate." The Federal Joint Committee has greatly restricted the ability to prescribe at the expense of statutory health insurance funds. A prescription is only possible for short-term therapy. "Therefore, the prescription of benzodiazepines on a private prescription in Germany is enormously high," said Wedekind. Benzodiazepine Dependence Unnoticed Estimates suggest that there are 1.2-1.5 million people with benzodiazepine dependence in Germany. "The number of benzodiazepine-dependent individuals whose addiction was induced by medical prescription over too long a period is estimated to be about half as high as that of alcohol-dependent individuals in Germany. This is a relevant problem that is little discussed, also because a patient taking benzodiazepines permanently does not appear intoxicated when handled," said Wedekind. For their registry study, Donovan T. Maust, MD, of the Department of Psychiatry at the University of Michigan in Ann Arbor, and his colleagues relied on US health insurance data for more than 350,000 patients who underwent long-term medically prescribed therapy with benzodiazepines. If patients did not refill a prescription for the tranquilizers within 31 consecutive days within 6 months, this was considered the termination of therapy. How to Discontinue? There was no evidence about the circumstances under which the medication was terminated, however. "These medications must be tapered slowly to avoid causing severe withdrawal symptoms, which can lead to impaired consciousness, confusion, and delirium. Abrupt discontinuation of long-term, even low-dose benzodiazepine therapy is a health risk, which understandably would be associated with increased mortality and would be a medical error," said Wedekind. The research group at the University of Michigan reported that the mortality risk of insured individuals who discontinued benzodiazepine therapy was 1.6 times higher in the following year than in those who continued therapy. Whether the patients were simultaneously treated with opioids did not play a role. The absolute increase in risk was 2.1% without and 2.4% with concurrent opioid use. "People who take sedatives such as benzodiazepines for the long term are also much more likely to take high-potency pain medications such as opioids," said Wedekind. Suicide Attempts and Overdoses The researchers observed comparable increases in risk for other endpoints such as nonfatal overdoses, suicide attempts or self-inflicted injuries, suicidal ideation, and treatments in an emergency department. Given the increased risks for overdoses and mortality associated with the prescription of benzodiazepines, especially when prescribed concurrently with opioids, the researchers assumed that discontinuing the sedatives would be associated with a reduction in mortality risk. This hypothesis was not confirmed. Rather, the study suggests that discontinuing benzodiazepine therapy in patients who have been prescribed them long term is associated with unforeseen risks. Efforts to promote the discontinuation of these medications should carefully weigh the potential risks of discontinuation against the continuation of treatment, wrote Maust and his colleagues. Qualified Detoxification "Simply continuing to prescribe benzodiazepines cannot, of course, be a medical standard," said Wedekind. It is important to identify patients with long-term use or dependence on benzodiazepines and refer them to qualified medical treatment. Withdrawal effects may emerge if detoxification is not slow enough. Or patients may resort to other sedative substances such as cannabis or alcohol after stopping benzodiazepines, the US authors wrote. "Therefore, these patients need qualified detoxification and rehabilitation therapy in a suitable institution," said Wedekind. This detoxification must last long enough for patients with long-term use, because "the longer and higher the dosage, the longer and more problematic the detoxification process." This article originally appeared on Medscape

Psychotherapy for posttraumatic stress disorder (PTSD) is as effective in cases involving multiple traumatic events as it is in those with a single trauma, a new meta-analysis of randomized clinical trials (RCTs) showed. Investigators said this is the first study of its kind to compare the efficacy of psychological interventions in single-event PTSD vs multiple-event PTSD. When compared with control conditions at the treatment endpoint, moderate benefits were reported in both groups of patients, with little difference between the two. Researchers also found that trauma-focused cognitive behavioral therapy (CBT) was more effective than non-trauma–based psychotherapy for PTSD with multiple traumatic events. "Some therapists believe that trauma-focused interventions are not appropriate for individuals who have been through multiple traumas," investigators, led by Thole Hoppen, PhD, of the University of Münster in Münster, Germany, said. "The finding of this meta-analysis could be used in therapist training to highlight the large body of evidence that contradicts such misconceptions." A Vulnerable Population Hoppen and his team analyzed the results of 137 RCTs with 10,600 individuals (54% female, mean age, 40). The trials compared the efficacy by time — short-term or treatment endpoint, mid-term or ≤ 5 months, or long-term or > 5 months — of different types of psychotherapy vs one another or vs control treatment on PTSD symptoms stemming from single or multiple events. Trials involving individuals with comorbid PTSD and substance abuse orders or comorbid traumatic brain injury were excluded from the analysis, and clinician-administered PTSD outcome assessments were prioritized over self-report-based ones when both were reported. At treatment endpoint, psychotherapy was highly efficacious for PTSD when compared with passive control conditions in both samples with single-trauma events and multiple trauma events, with no statistically significant difference in efficacy. When analyzing benefits of specific psychotherapies in multiple trauma trials, trauma-focused CBT and eye movement desensitization and reprocessing therapy offered similar short-term results, while trauma-focused CBT yielded larger efficacy than non-trauma–focused interventions. Investigators noted that because multiple traumas can be associated with worse PTSD presentation, "the finding that this vulnerable population nevertheless responds well to intervention is encouraging." Dispelling Misconceptions In an accompanying editorial, Maria Bragesjö, PhD, Karolinska Institutet, Stockholm, Sweden, noted that the study advances clinicians' understanding of PTSD treatment and "serves as a powerful catalyst, challenging prevailing stigmas and misconceptions." She added that by "dispelling misconceptions about the efficacy of trauma-focused interventions for individuals with multiple trauma histories, this meta-analysis contributes substantially to reshaping the landscape of PTSD treatment strategies, fostering a more comprehensive and inclusive treatment approach." Limitations of the meta-analysis included a shortage of studies that reported the number of total traumatic events and more detailed information about treatment effects. This article originally appeared on Medscape

Childhood trauma, such as sexual, physical, or emotional abuse, or neglect, is associated with chronic pain later in life. Adults with a history of childhood trauma such as sexual, physical, or emotional abuse, or neglect, have a higher risk for both pain and pain-related disability, according to study findings published in the European Journal of Psychotraumatology. Adverse childhood experiences (ACEs) have been previously associated with pain in adulthood, but it has remained unclear what types and degrees of exposure to ACE may increase the risk for chronic pain and pain-related disability later in life. Previous analyses have included small sample sizes, unclear exposure and outcome definitions, and inconsistent inclusion of comparison groups. To evaluate the associations between exposure to ACEs and chronic pain and pain-related disability in adults, researchers conducted a systematic review and meta-analysis. The researchers identified 85 cross-sectional observational studies, of which 57 were included in meta-analyses, with a population of 826,452 individuals (mean age, 44). The studies reported on ACEs during childhood including abuse and neglect (direct exposure) to other household and socioeconomic (indirect) exposures. The studies further reported musculoskeletal disorders and/or nonmusculoskeletal chronic pain, such as headache, migraine, fibromyalgia, and irritable bowel syndrome, as defined by the International Association for the Study of Pain (IASP), and quantified any associated disability. The likelihood of reporting chronic pain conditions later in life was significantly higher among individuals exposed to direct childhood ACEs (adjusted odds ratio [aOR], 1.45; 95% CI, 1.38-1.53), including neglect (aOR, 1.38; 95% CI, 1.15-1.66), sexual abuse (aOR, 1.37; 95% CI, 1.25-1.49), and emotional abuse (aOR, 1.56; 95% CI, 1.36-1.78) compared with those with ACE. Individuals who had experienced childhood physical abuse were more likely to report not only chronic pain (aOR, 1.50; 95% CI, 1.39–1.64) but also pain-related disability (aOR, 1.46; 95%CI, 1.03–2.08). This result was not influenced by sensitivity analysis. The researchers also found that exposure to any ACE, including indirect exposures, had higher odds of developing any of a variety of musculoskeletal and nonmusculoskeletal pain conditions (aOR, 1.53; 95% CI, 1.42–1.65), as well as pain-related disability (aOR, 1.29; 95% CI, 1.01–1.66), in adulthood. No significant association was identified between pooled estimates for chronic pain or pain-related disability outcome and measured covariate such as country, setting, or year of publication. Study limitations included the potential lack of accuracy of self-reported ACEs and the cross-sectional designs of the included studies that did not differentiate between cause and effect and are prone to selection and recall bias. The researchers suggested that these results underscore the need for trauma-informed care for chronic pain in adults. They concluded, “Over 1 billion children — half of all children in the world — are exposed to physical, sexual, or emotional violence or neglect each year. The endemic magnitude of ACEs, their health consequences, and their combined attributable costs … compel urgent action.” Note: This article originally appeared on Psychiatry Advisor