Key Takeaways Antidepressant side effects often improve over time, but some patients experience worsening, leading to dropout. STAR*D trial data showed patients who dropped out reported more severe and worsening side effects than completers. Clinicians should consider alternative treatments for patients with severe side effects to prevent dropout. Research is ongoing to identify specific side effects linked to dropout and develop a tool to assess dropout risk. CLINICAL REFLECTIONS When a patient starting antidepressants for major depressive disorder voices their concerns about potential side effects, it is common for clinicians to offer patients the same reassurance that many major health agencies have advised: Stick with the medications, and your side effects should improve with time. For example, the National Institutes of Health (NIH)’s public-facing webpage on mental health medications reads: “The side effects [of antidepressants] are generally mild and tend to go away with time.” Likewise, the Centers for Disease Control and Prevention (CDC) publicly states, “Side effects usually do not get in the way of daily life‚ and they often go away as your body adjusts to the medication.” This perspective that antidepressant side effects will eventually go away is not just exclusive to the United States: The United Kingdom’s National Health Service (NHS) states on their public-facing antidepressants overview page that “the most common side effects of antidepressants are usually mild. Side effects should improve within a few days or weeks of treatment as the body gets used to the medicine.” Nevertheless, many psychiatrists and other mental health clinicians have encountered patients who report the opposite experience. Although many patients experience an improvement in side effects with time, not everyone’s side effects improve. In fact, it is not uncommon to encounter patients who report worsening side effects to the point where some decide to quit treatment. Indeed, the No. 1 self-reported reason for why patients prematurely discontinue antidepressant pharmacotherapy is side effects. One question then arises: Why does such a dichotomy exist between the clinical consensus (as publicly stated by the NIH, CDC, and NHS) that side effects improve with time and the anecdotal experiences of patients who report that their side effects do not go away or, in some cases, even worsen? We noticed that past research examining antidepressant side effects often failed to account for 1 important confounder: dropout. That is, many studies on antidepressant side effects focused on individuals who completed treatment while neglecting perhaps the most interesting group of patients: those who may have dropped out of antidepressant treatment prematurely due to side effects. We conducted a secondary analysis of side effects data from patients in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, the largest antidepressant trial ever conducted. In the first treatment step of the STAR*D trial, all patients received citalopram for an intended 12 weeks per protocol. During these 12 weeks, patients reported their side effect frequency, intensity, and burden on the Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale at weeks 2, 4, 6, 9, and 12. Additionally, patients reported which side effects they experienced in 9 organ/function systems on the Patient-Rated Inventory of Side Effects (PRISE) scale. We wanted to examine how side effect frequency, intensity, and burden on the FIBSER scale changed over the course of citalopram treatment. What we were most interested in was how side effect complaints of patients who dropped out early in treatment differed from those who completed treatment. To answer this question, we used pattern-mixture modeling to model side effect complaints at each time point (weeks 2, 4, 6, 9, and 12) for each potential treatment attrition pattern (dropout at week 2, 4, 6, or 9 or full 12-week treatment completion) while controlling for changes in depressive severity over the course of treatment. What we found does not disagree with the NIH/CDC/NHS consensus that side effects improve over time: Indeed, when examining only data from those who completed the full 12-week treatment, these patients reported decreases in side effect frequency, intensity, and burden over the course of treatment. Yet our findings also validated the experience of those patients who report that their side effects never improve. Specifically, when examining data from patients who dropped out of the trial early, a different pattern of side effects emerged: Patients who dropped out after weeks 2, 4, and 6 reported significantly more severe initial side effect complaints than those who completed treatment. And perhaps even more importantly, patients who dropped out after weeks 4 and 6 further showed a worsening of side effects over the course of treatment. Taken together, what we see in the STAR*D data are several distinct patterns in how patients experience antidepressant side effects. On the one hand, there are many patients—namely, those who complete treatment—who are able to tolerate the side effects of antidepressants. These patients not only report lower severity of side effects after antidepressant initiation but also an improvement of side effects over time. It is likely that these are the patients whom the NIH/CDC/NHS consensus guidelines refer to when they offer the reassurance that side effects will decrease over time. On the other hand, there is a nonnegligible population of patients with a much lower tolerance for side effects. These patients not only report more severe side effects immediately after antidepressant initiation, but many also report experiencing a worsening of side effects over the course of treatment—up to and until the point they drop out. These are the patients whom we and our colleagues see in clinical practice every day: those who attempt to persist with their prescribed antidepressant but ultimately drop out due to the intolerability of their side effect symptoms. What is especially surprising is that this second group of patients—those with intolerance for side effects and for whom side effects do not improve—have gone previously unnoticed in the research literature. Our analysis was not of novel data: The STAR*D trial is famous for being the largest antidepressant trial ever conducted, and the data are publicly available from the NIH. However, it seems possible that previous research on antidepressant side effects—from which the major health agencies of the NIH, CDC, and NHS may have derived their guidelines—has focused primarily on treatment completion and has neglected those who drop out of treatment early. The unfortunate part of this oversight is that this second group of patients is perhaps most affected by side effects. After all, side effects are the No. 1 self-reported reason for why patients prematurely discontinue antidepressant treatment. What do our findings mean for psychiatrists and other mental health clinicians? Past research has shown that patients who prematurely drop out of antidepressant treatment often do not return for any mental health treatment and show a poorer long-term prognosis. Consequently, it is especially important for clinicians to pay attention to patient reports of severe or worsening antidepressant side effects as potential warning signs of attrition. The next time one of your patients reports experiencing antidepressant side effects, instead of universally offering the same assurance from the NIH/CDC/NHS guidelines that their problems ought to eventually improve, it may be worth considering switching to an alternative treatment, such as a different medication or even a nonpharmacological treatment such as psychotherapy. There is another question that remains unanswered: Which side effects are more strongly linked to dropout? It is common for patients to self-report being concerned about some side effects more than others, but less is known about which effects cause patients to drop out. We are currently conducting a study to answer this question using data from the PRISE scale in the STAR*D trial and plan on developing a tool for clinicians that will flag patients for dropout risk based on their side effect profile. This tool could help inform psychiatrists in developing their treatment plans, especially for the patients at highest risk for dropout due to antidepressant side effects. We plan on validating our preliminary results in other data from clinical trials or medical records of antidepressant side effects. If you have access to such data and are interested in collaborating, please contact Colin Xu, PhD, at colinxu@uidaho.edu. Note: This article originally appeared on Psychiatric Times .

The latest surveillance data from the US Centers for Disease Control and Prevention (CDC) show a steep rise in the prevalence of autism spectrum disorder (ASD) , extending a years-long trend of increasing diagnoses. While greater awareness and improved diagnostic criteria have likely played a role, other potential contributing factors remain unclear and questions persist about what’s truly driving this phenomenon. These new surveillance data came on the heels of an April 10 announcement by US Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr, who set a September deadline to determine the cause of what he called an “autism epidemic.” “By September, we will know what has caused the autism epidemic and we’ll be able to eliminate those exposures,” Kennedy said. However, many scientists who have spent their careers studying ASD are deeply skeptical that a definitive answer could be found in just a few months — if at all. What Do the Latest Data Show? The CDC regularly compiles data on ASD prevalence through the Autism and Developmental Disabilities Monitoring (ADDM) Network. The findings are considered to be among the most reliable snapshots of autism rates in children. The CDC’s most recent data from the 2022 ADDM surveillance cycle are based on 393,353 8-year-olds across 16 US sites. The CDC report shows that ASD affects 1 in 31 children (32.2 per 1000), up from 1 in 36 in 2020 and 1 in 150 in 2000. ASD continues to be more common in boys than girls (ratio 3.4:1). ASD prevalence was higher among Asian/Pacific Islander, Black, and Hispanic children than White children, continuing a pattern first observed in 2020. Children born in 2018 were more likely to be diagnosed by age 48 months compared with those born in 2014, suggesting increased early identification consistent with historical patterns. Why Is ASD Prevalence Rising? The CDC’s latest findings have prompted renewed scrutiny over why ASD prevalence continues to rise. CDC investigators noted several factors that may be driving the increase, including broader diagnostic criteria, greater awareness among parents and pediatricians, and improved access to specialized services. Together, these shifts mean children who may have been overlooked in previous decades are now being identified. Kennedy has long expressed concern about environmental toxins and their potential role in ASD. At an April 16 press conference, he claimed that such toxins disrupt neurodevelopment and are behind the rising caseload. He described autism as “a preventable disease” and pledged to identify the environmental culprit by September. “We’re going to follow the science no matter what it says,” Kennedy said. “And we will have some of the answers by September.” In a statement, the International Society for Autism Research said referring to the condition as a “preventable disease” is “out of touch with contemporary, evidence-based understanding of autism.” “Based on current autism research, we know that there are many causes of autism, and virtually all of these occur prenatally,” the statement continued. “In other words, you are born with autism.” What’s Driving ASD: Genes, Environment, or Both? A robust body of evidence points to a substantial genetic component in ASD etiology. Studies of twins dating back to the 1970s have consistently shown that the vast majority of ASD is due to genetics, said Alexander Kolevzon, MD, clinical director of the Seaver Autism Center at Mount Sinai in New York City. “With advances in genetic technology and analytic methods, hundreds of specific genetic changes have now been identified and are commonly accepted to cause autism. Yet the same twin studies show that if one identical twin has ASD, the other may not about 10% of the time, leaving room for some environmental influence,” Kolevzon told Medscape Medical News. “Environmental effects may be acting through epigenetic mechanisms where certain factors, as of yet unidentified, influence the expression of genes. However, despite being an active area of study, no widespread environmental effects have been reliably established to date,” he added. When it comes to environmental contributors, a substantial amount of research has focused on exposures during the prenatal period — a critical window for neurodevelopment. For example, a 2019 JAMA Pediatrics population-based cohort study of 132,256 births showed that maternal exposure to nitric oxide during pregnancy was associated with increased risk for ASD in offspring. Investigators leading a 2022 study of 294,937 mother-child pairs found that exposure to particulate matter 2.5 in the first two gestational trimesters were associated with increased ASD risk in children. In addition, a 2022 study from France showed prenatal exposure to organophosphate pesticides was linked to an increase in autistic traits among 11-year-old children. Maternal metabolic conditions may also play a role. In April 2025, a meta-analysis of 202 studies including more than 56 million mother-child pairs showed that children born to mothers with gestational diabetes were 25% more likely to be diagnosed with autism. Researchers have also linked ASD risk to preterm birth and advanced parental age. It’s thought that these exposures likely act as modifiers — influencing gene expression, immune activation, or neuronal development — rather than standalone causes. Gut-Brain Link? An emerging area of autism research involves the gut microbiome and whether gut dysbiosis contributes to ASD risk. “There have been several studies showing that there is gut dysbiosis in autism, and that it correlates with autism symptoms,” Lisa Aziz-Zadeh, PhD, professor, Department of Psychology, University of Southern California, Los Angeles, told Medscape Medical News. “However, we know that any behavioral differences must be via gut microbiome/metabolite interactions with the human nervous system,” she said. In an April 2025 study published in Nature Communications, Aziz-Zadeh’s team was the first to identify links between gut microbial tryptophan metabolites, ASD symptoms, and brain activity in individuals with autism, particularly in brain regions associated with interoceptive processing. This points to a “mechanistic model by which gut metabolites may impact autism,” she said. “It’s possible that addressing gut imbalances (via diet, probiotics, prebiotics, fecal transplants) may be helpful. However, we still don’t know if there is a critical age where this may need to happen (prenatal, early life). There is still a lot of work to be done to answer this question,” she said. In another recent study, microbiota transfer therapy led to significant improvements in gastrointestinal (GI) symptoms, autism-related symptoms, and gut microbiota in children with ASD. The effects of the initial treatment on both gut microbiota and GI symptoms were maintained at the 2-year follow-up, with continued improvement in autism-like behaviors, the researchers reported. A Realistic Deadline? When Kennedy declared a September deadline for identifying the cause of autism, reaction was swift. Advocacy organizations, professional societies, and many research scientists expressed skepticism regarding the feasibility of such a deadline, noting that complexity argues against finding a single cause. “The odds of identifying a single factor that causes autism, whether genetic or environmental, is zero,” said Kolevzon. The 5-month timeline Kennedy set “gives people a false sense of hope” and risks politicizing science, the Autism Society of America said in a statement. “The Autism Society of America finds the administration’s claim that ‘we will know what has caused the Autism epidemic and we’ll be able to eliminate those exposures’ — to be harmful, misleading, and unrealistic.” Aziz-Zadeh said that 60%-90% of the causes of autism are likely due to genetic factors. “However, since that number isn’t 100%, there are also contributing environmental factors — what those might be, we still don’t know — and likely there isn’t a single one,” he said. In a letter signed by more than 130 scientists, the newly formed Coalition of Autism Scientists rejected Kennedy’s “false narrative” about the incidence and causes of ASD. “We are unified in our commitment to conduct the highest quality research and build mutual respect and trust with the public. This trust is seriously threatened by the Secretary’s interpretation of the rising prevalence rates and his plans to carry out a study that will deliver findings within a few months on an environmental toxin that causes autism,” the statement said. An ASD Registry? Equally concerning to many in the autism community was a recent announcement from the National Institutes of Health (NIH) about plans to establish a “new disease registry” focused on ASD that would collect federal and private health data for upcoming autism studies. NIH Director Jay Bhattacharya, MD, PhD, made the announcement during a presentation to the Council of Councils on April 21. However, HHS walked back that plan 3 days later, following an outcry from the autism community. HHS spokeswoman Vianca N. Rodriguez Feliciano told Medscape Medical News that the agency is not creating an autism registry but is developing a “real-world data platform” linking existing datasets “that maintains the highest standards of security and patient privacy while supporting research into autism and other areas such as chronic diseases.” NIH is also investing $50 million to launch a comprehensive research effort aimed at understanding the causes of ASD and improving treatments by leveraging large-scale data resources and fostering cross-sector collaboration, Feliciano added. Feliciano did not respond to follow-up questions from Medscape Medical News to clarify whether the data platform would include patient identifying information or such data sources as pharmacies, private insurers, and personal wearable sensors, as noted by Bhattacharya during his presentation. Autism Speaks, an advocacy group, said that research should not focus solely on the causes of autism. “We also need to invest in studies that lead to real improvements in people’s lives — like better healthcare, education, job opportunities, and support at every stage of life for autistic people and their families,” the group said in a statement. Note: This article originally appeared on Medscape .

TOPLINE: Living alone and having both depression and anxiety was associated with a 558% increase in risk for suicide compared with living with others and without these conditions, a new population-based study showed. METHODOLOGY: Researchers assessed data for more than 3.7 million adults (mean age, 47.2 years; 56% men) from the Korean National Health Insurance Service (NHIS) from 2009 through 2021 to determine the associations among living arrangements, mental health conditions (depression and anxiety), and risk for suicide. Living arrangements were categorized as either living alone (for ≥ 5 years) or living with others. Depression and anxiety were determined using NHIS claims. The primary outcome was death by suicide, identified using national death records; the mean follow-up duration was 11.1 years. Suicide cases were identified on the basis of International Statistical Classification of Diseases and Related Health Problems (10th Revision) codes. TAKEAWAY: Overall, 3% of participants had depression, 6.2% had anxiety, and 8.5% lived alone. The mortality rate was 6.3%, with suicide accounting for 0.3% of all deaths. Compared with individuals living with others and without either depression or anxiety, those living alone and with both conditions had a 558% increased risk for suicide (adjusted hazard ratio [AHR], 6.58; 95% CI, 4.86-8.92; P < .001). Living alone and having depression only was associated with a 290% increased risk for suicide (AHR, 3.91), whereas living alone with anxiety only was associated with a 90% increased risk for suicide (AHR, 1.90). The association between living alone and risk for suicide was greater among middle-aged individuals (age, 40-64 years) with depression (AHR, 6.0) or anxiety (2.6), as well as in men (AHRs, 4.32 and 2.07, respectively). IN PRACTICE: “These findings highlight the importance of considering living arrangements in individuals with depression or anxiety, especially for specific demographic groups, such as middle-aged individuals and men, in suicide risk assessments. Targeted interventions addressing these factors together are crucial to mitigate risk,” the investigators wrote. Note: This article originally appeared on Medscape .

Key points In the past, social psychiatrists were interested in mental health in rural settings. Studies found that rates of mental illness in rural settings were similar to those in urban settings. Although researchers found that social problems contributed to mental illness, they failed to call for action. If you’re not a psychiatric epidemiologist or a mental health historian, it is doubtful that you’ve heard of Stirling County, Nova Scotia. And for good reason. Stirling Country, Nova Scotia, doesn’t exist, at least in the sense that you’ll never find it named on a map. But it is a real place, and a place that played an enormous role in shaping our understanding of the social factors that contribute to mental health and illness. Why haven’t you heard of it? The answer is simple. Stirling County is a pseudonym. It stands in for a county in Nova Scotia that hosted one of the world’s longest and most important epidemiological studies, in this case focusing on mental health. Why the pseudonym? When the study began in 1948, mental illness was deeply stigmatized, even more than today. Unlike the Framingham Heart Study, which focuses on risk factors related to cardiovascular health and began in the same year (and is based in Framingham, Massachusetts), many people in “Stirling County” didn’t want to be associated with mental illness. And even though it is quite easy to identify the real name of the host county (I’ll leave you to figure that out for yourself), researchers were still keeping it a secret very recently. You might ask another question: Why situate a study about mental health in a rural setting? As my last post suggested, most people during the middle of the twentieth century were much more concerned with the threat cities posed to mental health. In a way, there’s your answer. Psychiatrists and social scientists interested in social psychiatry, or the social determinants of mental health, wondered about whether rural settings were better for mental health . Stirling County helped to provide some of the answers. The Stirling County Study was the brainchild of two prototypical social psychiatrists: husband and wife team Dorothea Cross Leighton (1908-1992) and Alexander Leighton (1908-2007). The Leightons met at Johns Hopkins, where they both earned medical degrees, specializing in psychiatry. But they were both intrigued by the social sciences and took advantage of opportunities to do field work in indigenous communities in Alaska, New Mexico, and Arizona. Their time in such places, along with their experiences in World War II, convinced both of them to switch their attention to studying mental health using methods from the social sciences. Following the Second World War, which catalysed psychiatric interest in the impact of social factors on mental health, the Leightons looked for opportunities to lead their epidemiological study. They opted for Nova Scotia in part because Alexander Leighton had spent his summers there ever since he was a boy. The Leightons received one of the first grants from the newly founded National Institute of Mental Health , which, along with other funders, paid for a team of 100 researchers, including psychiatrists, social scientists, historians, and even a photographer. As with other pioneering social psychiatry studies, including those in Manhattan and New Haven, the Leightons delved deeply into the history and social structure of Stirling County. One of the three books the study published, People of Cove and Woodlot (1960), focused exclusively on Stirling County’s historical and social context. Although Stirling County was a rural setting, it was remarkably mixed in terms of geography, ethnicity, and economy. The county was primarily made up of English Canadians, who tended to be Protestant, and French Canadians (Acadians), who were Roman Catholic, along with indigenous people, Black Canadians, and a few other ethnic minorities. It was on the sea and many people worked in the fishery, but others worked in the lumber industry or farming. People’s economic situation also varied considerably, ranging from the comfortably well-off to those living in abject poverty. Did Stirling County’s residents have better mental health than people living in cities? The short answer, to the surprise of many, was no. Statistics revealed that the rates of mental illness in Stirling County were very similar to those found in the Midtown Manhattan Study, which Leighton also ended up running in the late 1950s. Moreover, many of the risk factors in both places were similar: poverty, inequality, social isolation, and community disintegration. Simply being in a crowded city, it seemed, wasn’t problematic in itself. Interestingly, when the Leightons reassessed rates of mental illness in one of the most deprived communities, “The Road,” a decade later, they found that residents’ mental health had improved . While Alexander Leighton argued that this was due to an adult education program and more mixing with wealthier people due to the consolidation of two schools, it is also notable that new employment opportunities had come to the area. I would imagine that these new jobs lifted people out of poverty, gave their lives new meaning, and fomented new social relationships was probably more of a factor. But Alexander Leighton, much like most social psychiatrists of the period and, indeed, just like the architects of Lyndon Johnson’s “War on Poverty,” was not minded to lift people out of poverty by giving them more material resources. Rather, they believed there was something inherently wrong with the poor, that could be taught out of them (thus explaining the adult education programs). Such thinking was one of the greatest shortcomings of social psychiatry and Johnson’s Great Society policy initiative. By the 1970s and 1980s, psychiatry shifted away from social explanations for mental illness and onto neurological and genetic ones, along with psychopharmaceutical treatments. Although the Stirling County Study kept trundling on, most psychiatrists moved on from social psychiatry. These days, as we try to contend with ever-rising rates of mental illness , it is important to reassess such studies and to determine what their real lessons are. Note: This article originally appeared on Psychology Today .

Key Takeaways Emergency psychiatry is gaining recognition with the approval of a focused practice designation by the American Board of Medical Specialties. The new designation allows both psychiatrists and emergency medicine physicians to practice in emergency psychiatry settings, addressing staffing challenges. EmPATH units are expanding, providing patient-centric care and reducing psychiatric boarding times in emergency departments. SAMHSA's recognition of emergency behavioral health centers enhances access, reimbursement, and parity with physical medical care. SPECIAL REPORT: EMERGENCY PSYCHIATRY 2025 is shaping up to be one of the most consequential years ever for the burgeoning subspecialty of emergency psychiatry. Not only are new programs and hospital departments opening seemingly on a daily basis, while even more sites begin nouveau development, there has been unprecedented ascent in the academic gravitas and clinical recognition for emergency psychiatry’s role and stature. Perhaps most compelling is the recent approval by the American Board of Medical Specialties (ABMS) of the proposal by the American Board of Emergency Medicine (ABEM) to recognize a focused practice designation (FPD) in emergency behavioral health.1 This new designation is an enormous step toward emergency behavioral health becoming a full-fledged boarded subspecialty, long a dream of many practitioners of emergency psychiatry. According to the ABMS, an FPD “recognizes the value that physicians who focus some or all their practice within a specific area of a specialty and/or subspecialty can provide to improving health care. Focused practice designation enables the ABMS Member Boards to set standards for, assess, and acknowledge additional expertise that physicians gain through clinical experience, and may include formal training.” ABEM worked in tandem with the American Board of Psychiatry and Neurology to support this new designation, which, as a result, will be available to either psychiatrists or emergency medicine physicians. This expansion of the types of physicians who will be able to practice in emergency psychiatry settings in the future is a welcome development, as one of the biggest questions in the past few years, as more and more emergency psychiatry programs have been coming online, has been: How can there be sufficient providers to staff all these new 24/7 sites? Adding emergency medicine physicians to the mix along with psychiatrists might not only address these staffing questions but also help out some practitioners with a major issue in recent years for emergency medicine: burnout. Splitting shifts between the emergency department (ED) and a psychiatric ED might be a great way for some physicians to keep themselves fresh, energetic, and optimistic. With multiple emergency psychiatry fellowships currently available to emergency medicine physicians, the opportunity for them to become trained and credentialed as emergency behavioral health providers already awaits. The timing of the new FPD could not be better, because there will be a huge demand for prescribing behavioral health providers in the coming months as dozens of new Emergency Psychiatric Assessment, Treatment, and Healing (EmPATH) units open across the US. With nearly 50 such programs already operating across the country, it is projected that more than 100 EmPATH units will be in service nationally by 2027. As described by Cooley et al in this Special Report, EmPATH units are soothing hospital-based alternatives to the medical ED where patients can quickly be moved for prompt, appropriate, noncoercive, and patient-centric care, rather than the common approach of boarding with long hours in the ED waiting for an inpatient admission. This EmPATH solution for psychiatric boarding also stabilizes most patients—even those with involuntary status—to the point of discharge home in hours, often less time than these individuals would commonly otherwise be boarding, untreated, in the ED. Speaking of which, everyone working at, constructing, or considering the creation of an EmPATH unit now has a place to share ideas for the first time. The inaugural National EmPATH Summit is taking place May 21 to 22, 2025, in Dallas, Texas, with a packed house of speakers, experts, clinicians, health care architects, and everyone whom one might imagine would participate in the development of an EmPATH unit. It looks like it will be quite the event. EmPATH units and other emergency behavioral health centers, in another substantial advancement that happened just this year, were officially recognized as the sites capable of working with patient populations with the highest acuity within the overall crisis continuum by the Substance Abuse and Mental Health Services Administration (SAMHSA). In January, SAMHSA published certified national behavioral health crisis care guidance and definitions, which appreciated the considerable need for multiple levels of crisis care, especially the take-all-comers behavioral emergency sites with low barriers to entry, such as EmPATH units, psychiatric emergency services in hospitals, and high-intensity behavioral health emergency centers in community settings. This imprimatur of the federal government is a huge milestone toward establishing parity of emergency psychiatry interventions with physical medical care, helping to improve access, reimbursement, and solvency of these necessary programs while reducing stigma and improving outcomes. With all this good news, it is a great occasion for Psychiatric Times to do this Special Report on emergency psychiatry. Note: This article originally appeared on Psychiatric Times .

The gut-brain axis is a bidirectional communication network that links the enteric and central nervous systems. According to an article published in Integrated Medicine: A Clinicians Journal, this network is not only anatomical, but it extends to include endocrine, humoral, metabolic, and immune routes of communication as well. The autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and nerves within the gastrointestinal tract, all link the gut and the brain, allowing the brain to influence intestinal activities, including activity of functional immune effector cells; and the gut to influence mood, cognition, and mental health. Gut microbiota are well known to support tight junction integrity between enterocytes . It should therefore come as no surprise that dysbiosis and associated increases in intestinal permeability are now recognized features of rheumatoid arthritis, Alzheimer’s disease, asthma, autism spectrum disorders, and other systemic conditions both inflammatory and otherwise. In recent years, there has been a tremendous amount research validating the mechanisms and role of the microbiome and probiotics in managing inflammatory conditions, particularly IBD. Depression is increasingly recognized as having an inflammatory component; indeed, anti-inflammatory drugs, such as COX-2 inhibitors, have previously demonstrated efficacy in major depression A new class of probiotics, known as psychobiotics or psychomicrobiotics , has emerged in the last decade and is being fervently embraced by many health care practitioners as a nontoxic intervention for various psychiatric conditions. Several clinical trials have now documented effects, or lack thereof, of certain probiotics for depression and anxiety. In a 2017 systematic review by Wallace and Milev of 10 clinical trials, most of the studies found positive results on measures of depressive symptoms. Because clinical trials on probiotics for depression and anxiety have been heterogeneous in terms of dosing, probiotic strain selection, and length of treatment, further randomized controlled clinical trials are warranted to validate the efficacy of this promising intervention. Studies from animal models conducted by independent research groups have corroborated findings of gut dysbiosis and its relation to monoamine disruptions seen in clinical depression, connecting gut microbiota with mood.44-48 In addition, intestinal permeability defects are thought to underlie the chronic low-grade inflammation observed in stress-related psychiatric disorders.49 Those with symptoms of depression frequently exhibit increased expression of proinflammatory cytokines, such as IL-1β, IL-6, tumor necrosis factor-α, as well as interferon gamma, and C-reactive protein.50-51 , 52 Gut microbiota influence transcription of these same cytokines, with dysbiosis triggering the so-called inflammasome pathway, whereas beneficial metabolites (SCFAs in particular) reduce production of proinflammatory cytokines, such as NF-κB.53

On July 16, 2022, the Lifeline transitioned away from the National Suicide Prevention Line reached through a 10-digit number to the three-digit 988 Lifeline. Psychiatric Times provides a year end review of their progress below: A year ago, the National Suicide Prevention Lifeline switched to its new 3-digit number, 988. Since its launch, the Lifeline has received a startling number of contacts: over 5 million, including more than 1.43 million calls, 416,000 chats, and 281,000 texts.1 But is it effective in saving lives? “The transition to the 988 Suicide & Crisis Lifeline has sparked a transformational moment in behavioral health care in this country. For the first time in my 26-year career history, every state and territory is talking about improving their behavioral health crisis systems,” said Monica Johnson, MA, director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration (SAMHSA). “While we know that there is still much work to do to achieve a robust response system for mental health and substance use crisis care across the country, we have accomplished a lot in the past year. The data show that, since the transition to 988, more people are reaching out for help, and they are getting a response much faster than ever before to get the help that they need in a time of crisis.” Figure 1. May 2023 Contacts According to SAMHSA, the Lifeline receives an average of approximately 350,000 contacts per month. During May 2023 alone, contacts increased by more than 40% in calls, chats, and texts alike compared with the previous year ( Figure 1 ).2 “We are seeing this increase in contacts, and I do not think that is a failure of the system; I think that’s showing it’s a success. Increasing numbers means that we might be catching some folks before they get to that terrible stage,” said Scott Zeller, MD, vice president of acute psychiatry at Vituity, assistant clinical professor of psychiatry at the University of California, Riverside School of Medicine, and Psychiatric Times editorial board member. “Anything we can do to reduce suicide is a win.” Let’s take a look at the Lifeline, still in its infancy, and evaluate the current benefits and potential areas for improvement. Decreased Wait Times Figure 2. Monthly Comparison of Average Answer Speeds2 National overall answer rates have increased to 91% as of December 2022, compared with 64% from December 2021, meaning—no matter the outcome—more individuals in need of help are being connected to a counselor. Additionally, individuals who contact 988 are spending much less time waiting for a counselor; the average overall wait time decreased from 2 minutes and 52 seconds to just 44 seconds.1 Monthly average wait times are even shorter in 2023 ( Figure 2 ).2 “Seconds count when somebody is in crisis. If someone finds themselves on a long hold, waiting for an answer, that could lead to frustration or hanging up the phone, and that is when bad things start to happen. The more quickly we can get them access, the better,” said Zeller. According to research, 24% of suicide survivors aged 13 to 24 years said it took them less than 5 minutes between deciding to attempt suicide and trying.3 Data from another study showed that of 82 patients referred to a psychiatry department post suicide attempt, nearly half (47.6%) reported their suicidal deliberation lasted 10 minutes or less.4 Better Text Response Prior to 988’s launch, the Lifeline could only sufficiently process 56% of the text messages and 30% of the chats received. In contrast, although text volume has now increased by over 700%,1 the text answer rate in May 2023 was an impressive 99%.2 Connecting via text may be more important to youth who contact the Lifeline. With the average teenager sending and receiving 5 times more text messages a day than a typical adult, this may be their preferred method of communication.5 “One of the biggest impacts that 988 is having, when you look at the data, is the dramatic increase of texting services,” said Margie Balfour, MD, PhD, chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. “You should be able to provide services in ways that people like to communicate, and it really shows that there was an unmet need in this area.” Target Group Specificity Figure 3. Lifeline Specialized Services The Lifeline also now offers specialized services for various populations ( Figure 3 ). Other pilot programs are expected to follow, with potential Lifeline subnetworks for individuals who are hearing impaired and for American Indian/Alaska Natives.6 Area Code Issues Ideally, 988 calls should be answered as locally as possible. A national backup crisis center handles any calls that local crisis centers cannot answer, but how exactly is an individual’s local center determined? Unlike 911, 988 does not geolocate those who contact the Lifeline. Instead, 988 uses their area code to determine the closest call center.7 Unfortunately, this means if an individual living in New York has a Texas area code, the call center will be directed to the closest center in Texas, which will not be able to deploy a mobile team to a New York location. More on 988 Inside 988 Lifeline: Conversations with a Crisis Counselor Leah Kuntz; Jennifer Lang 988: The 1-Year Anniversary Bob GebbiaTherein lies the problem. Although geolocation would help in providing localized services, some callers may not want their location to be known. “I think there is a really good argument from the advocate side, saying ‘We do not want to be tracked.’ What if I just want to call and talk to you and say that I feel hopeless? It does not mean that I want you to know where I am to send cops, which is really what this all comes down to. There is not an easy solution here. Ethically and philosophically, this is one of the most interesting components of the 988 rollout so far,” said Tony Thrasher, DO, MBA, DFAPA, medical director of crisis services at Milwaukee County Behavioral Health Division, Wisconsin. Lack of Quality Consistency Every 988 call center is unique in how it responds to crisis callers. Some states had robust crisis lines prior to 988. Arizona, for example, is being looked at as an example model, Balfour told Psychiatric Times . Built on the backbone of Medicaid rather than telecommunication fees, this preexisting system has established trust in the community over the past 2 to 3 decades. However, some call centers do not have the privilege of a preexisting system. “When you ask what happens when you call 988, in Arizona, you are going to get a crisis line that has been active for years. They have the infrastructure and resources to be able to dispatch 24/7 clinician mobile crisis teams, who can do interventions in the field and then resolve many of those crises. If needed, they can bring individuals to crisis stabilization centers, or crisis receiving centers that can then provide crisis care,” said Balfour. “ If you call 988 in a community that does not have that… What actually happens is very local resource dependent. Different communities carry much different loads and are at different stages of development.” Another example is Montgomery County, Ohio. Before the launch of 988, the county created Crisis Now, a 3-pronged approach to delivering crisis services that included a hotline and mobile response teams. In the initial 6 months of Crisis Now, 89% of calls to the hotline were resolved over the phone and 77% of the mobile crisis responses were resolved in the community. Upon 988’s launch in July, the already-in-place hotline also began taking local 988 calls, and felt better prepared to handle the switchover.8 Compare this with Hanover in York County, Pennsylvania. Prior to 988’s launch, the rural center, TrueNorth Wellness Services, reported difficulty hiring counselors and were uncertain they would be able to handle an influx of contacts.9 Uncertain Expectations When you call 911, you know exactly what you are getting: an ambulance, a firetruck, or police, or maybe a combination depending on the situation. What do callers get when they call 988? “It comes down to supply and demand,” said Thrasher. “What type of workers can each area find to respond to calls? There is a large push for less law enforcement presence and higher mental health presence. The hard part is, from a supply and demand focus, there are markedly more law enforcement workers, and they are paid significantly better than mental health workers. That is no knock on law enforcement —I think they earn what they get. But if we as a culture want to bring the mental health after-hours response 24/7, 365 days, on holidays, we need to pay them. One reason law enforcement and fire do that is because they are compensated to do so.” To build these expectations, we must know: Who is running that response team? What is their supply and demand? What is their funding? Do they have enough funds to have a 24/7 mental health work? The Need for More Funding The federal government has invested close to $1 billion into the 988 Lifeline, including a little more than $500 million in the federal spending bill.10 In May 2023, the US Department of Health and Human Services announced an additional $200 million in new funding for states, territories, and tribes to build local capacity for the 988 Suicide & Crisis Lifeline and related crisis services.11 Figure 4. States With Enacted Legislation to Sustain 98812 However, as contacts continue to pour in, some local Lifeline call centers may not be able to maintain their coverage when federal funding decreases. As of early June 2023, just 26 states had enacted legislation to maintain 988, and only 5 of those states had enacted legislation to sustainably fund 988 through telecommunications fees, as enabled by the National Suicide Hotline Designation Act of 2020 ( Figure 4 ).12 “I think we need to have parity of these 4 services: fire, EMS, law enforcement, and mental health. To do so, they should all be in the same room and should all have the same sort of requirements of staffing and quality of care. But then we also must get the same degree of funding,” said Thrasher. “Mental health is not near those other 3 in anything resembling sustainable funding. The public does not see a mental health call like a fire or a police call.” Looking Ahead Comparisons are often made between 988 and 911. Notably, 911 took 13 years to reach a modicum of stability; the first 911 call was placed in 1986, but 911 was not designated the nationwide emergency telephone number until 1999.13Furthermore, there are more than 5700 primary and secondary Public Safety Answering Points to answer 911 calls, as compared with approximately 200 988 centers.1,14 911’s success was not built in a year, and to expect otherwise for 988 is irrational. Our experts agreed: “Emergency psychiatry is all about taking care of people in their most vulnerable moments on their worst days. 988 has now led to more access to services to help them with that, including services that do not necessarily culminate in the emergency department,” Thrasher told Psychiatric Times . “It is not to the scale that I think we want to see it yet, but it is a really good start.” “It is a first step in what I think is a longer journey. It has been a catalyst for both the federal government and for communities to start to look at what we need,” said Balfour. “The promise of 988 is not there yet, but I think it is effective in getting us closer.” In a Psychiatric Times online poll, 70% of responders said they had discussed 988 with their patients.15 Have you discussed 988 with patients or their families? Source: Psychiatric Times Updated 7/13/23 to reflect new statistics. References 1. Saunders H. Taking a look at 988 suicide & crisis lifeline implementation. KFF. February 23, 2023. Accessed May 31, 2023. https://www.kff.org/other/issue-brief/taking-a-look-at-988-suicide-crisis-lifeline-implementation/ 2. 988 Lifeline performance metrics. SAMHSA. Accessed May 31, 2023. https://www.samhsa.gov/find-help/988/performance-metrics 3. Simon OR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide attempts and attempters. Suicide Life Threat Behav . 2001;32(suppl 1):49-59. 4. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry . 2009;70(1):19-24. 5. Lenhart A. Part four: a comparison of cell phone attitudes & use between teens and adults. Pew Research Center. September 2, 2010. Accessed June 14, 2023. https://www.pewresearch.org/internet/2010/09/02/part-four-a-comparison-of-cell-phone-attitudes-use-between-teens-and-adults/ 6. Stracqualursi V, Howard J. Forthcoming 988 suicide prevention hotline plans pilot program specifically for LGBTQ community. CNN. July 9, 2022. Accessed June 14, 2023. https://www.cnn.com/2022/07/09/politics/988-national-suicide-prevention-lifeline-lgbtq-subnetwork-wellness/index.html 7. 988 Geolocation Report — National Suicide Hotline Designation Act of 2020. Federal Communications Commission. April 15, 2021. Accessed June 14, 2023. https://docs.fcc.gov/public/attachments/DOC-371709A1.pdf 8. Six months after launch, how is 988 doing? National Association of Counties. January 13, 2023. Accessed June 14, 2023. https://www.naco.org/articles/six-months-after-launch-how-988-doing 9. Mencia A. Pennsylvania gears up for launch of new 988 mental health hotline. Axios Philadelphia. July 13, 2022. Accessed June 14, 2023. https://www.axios.com/local/philadelphia/2022/07/13/988-mental-health-hotline-pennsylvania 10. Chatterjee R. 988 Lifeline sees boost in use and funding in first months. GBH. January 16, 2023. Accessed June 14, 2023. https://www.wgbh.org/news/national-news/2023/01/16/988-lifeline-sees-boost-in-use-and-funding-in-first-months 11. HHS announces additional $200 million in funding for 988 Suicide & Crisis Lifeline. US Department of Health and Human Services. May 17, 2023. Accessed June 14, 2023. https://www.hhs.gov/about/news/2023/05/17/hhs-announces-additional-200-million-funding-988-suicide-crisis-lifeline.html 12. State legislation to fund and implement the 988 Suicide and Crisis Lifeline. National Academy for State Health Policy. Updated June 6, 2023. Accessed June 14, 2023. https://nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/ 13. 911 and E911 Services. Federal Communications Commission. Accessed June 14, 2023. https://www.fcc.gov/general/9-1-1-and-e9-1-1-services#:~:text=The%20official%20emergency%20number%20in,States%20for%20all%20telephone%20services 14. 10 things you might not know about the United States’ 911 emergency telephone number. Walden University. Accessed June 14, 2023. https://www.waldenu.edu/online-masters-programs/ms-in-criminal-justice/resource/ten-things-you-might-not-know-about-the-united-states-911-emergency-telephone-number 15. What have you heard about 988? Psychiatric Times . May 25, 2023. https://www.psychiatrictimes.com/view/what-have-you-heard-about-988

NeuroStar Advanced Therapy has received clearance from the US Food and Drug Administration (FDA) as an adjunct in the treatment of major depressive disorder (MDD) in adolescent patients aged 15 to 21 years. This clearance marks NeuroStar as the first and only transcranial magnetic stimulation (TMS) treatment that is FDA-cleared for this age group. MDD in adolescent patients is also the fourth FDA-cleared indication for NeuroStar,1 along with treatment of MDD in adults, treatment of obsessive-compulsive disorder in adults, and anxiety symptoms in adults with MDD. “The prevalence of depression in adolescents and young adults has been accelerating since the COVID-19 pandemic,” said Kenneth Pages, MD, medical director of TMS of South Tampa, in a press release. “The current treatment options available for adolescents are extremely limited, compared to those available for adults. NeuroStar’s TMS therapy now offers a promising first-line treatment for adolescents, backed by real-world data and impressive response rates consistent with response rates for adults. This advancement has the potential to set a new treatment paradigm for how we address depression in our youth.” The FDA’s decision to grant clearance for this indication is informed by an analysis of real-world data collected through NeuroStar’s proprietary TrakStar® platform. Among the 1169 adolescents analyzed, 78% showed clinically meaningful improvement in depression severity. The FDA reviewed this data set alongside clinical literature and concluded that NeuroStar TMS, when used as an adjunct to antidepressant therapy, is substantially equivalent in terms of safety and effectiveness compared to antidepressant therapy alone in this population. The coil design versatility of NeuroStar also allows providers to address the immediate treatment needs of adolescents with MDD symptoms without requiring additional hardware upgrades or purchases. This feature gives adolescent patients and their families a new option when weighing alternative treatments for depression. Access to effective treatment for MDD is important for all patient populations, as MDD is the fourth leading cause of disease burden globally. “Receiving FDA clearance to treat the adolescent segment aged 15 and up is a treatment solution that is long overdue in the mental health industry,” said Keith J. Sullivan, president and CEO of NeuroStar developer Neuronetics Inc, in a press release. “We are excited to offer NeuroStar TMS therapy as a new option for young people and for their concerned parents who have struggled to find a treatment they can be confident in. As a company, we will be focused on driving even more awareness and education about NeuroStar given that this new clearance grows our total advdnhfjshydfdressable market in MDD by 35%.” Note: This article originally appeared on Psychiatric Times

PSYCHIATRIC VIEWS ON THE DAILY NEWS But I do see a way. There is a narrow way through.” - Paul Atreides in “Dune” “All the world is a narrow bridge, and most important is not to be overwhelmed by fear.” - Rabbi Nachman of Breslov One of the definitions of a prophet is one who foretells future events correctly. We have had a few such possibilities lately. One is the featured character Paul Atreides in the movie “Dune.” As a possible Messiah, and with the help of the psychedelic spice, he foresees various future scenarios involving planetary war. The Free Press began a weekly series on past prophets in the United States. First, on March 2, featured Marshall McLuhan of “the medium is the message” fame. Decades ago, he seemed to foresee our internet age and its profound rewiring of our society and brains. Next, on March 11, was Bayard Rustin, the civil rights advocate and ally of the Rev. Dr Martin Luther King Jr. He predicted that psychologically traumatizing White individuals to increase their guilt would be likely to backfire, as perhaps may be now happening with diversity, equity, & inclusion consultants. March 16 featured D.A. Henderson who, back in 2006, warned against a global shutdown in an epidemic because it would lead to economic and social disruption. Even though I was way off in predicting how long the COVID-19 pandemic would last, as discussed in my last column, these portraits of prophets inspired me to responsibly see how I did so far in a series of predictions starting just about a year ago. One might assume that since psychiatrists have some expertise in understanding human behavior, that our prediction ability would increase. Therefore, in ensuing columns, I will try to fairly cover my previous predictions about psychiatry and artificial intelligence, psychedelics, politics, naming, social psychopathologies, indigenous individuals, eulogies, and predictions. My prediction is that I will complete them on April 1, April Fool’s Day 2024. Wouldn’t that be fitting? Note: This article originally appeared on Psychiatry Times

A diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults was associated with a 7-year reduction in life expectancy, on average, compared to the general population, findings from a large study show. Compared with peers without ADHD, males with ADHD in the matched retrospective UK study died an estimated 7 years earlier, and females with the diagnosis died around 9 years earlier. "We believe that this is unlikely to be because of ADHD itself and likely caused by modifiable factors such as smoking, and unmet mental and physical health support and unmet treatment needs," the authors wrote, adding "The findings illustrate an important inequity that demands urgent attention." The findings were published online January 23 in The British Journal of Psychiatry . Consequences of Impaired Executive Function Previous research has shown that adults with ADHD experience more unemployment, financial problems, contacts with the criminal justice system, and homelessness than those without the condition. ADHD has also been linked to a higher risk of suicide, and an earlier meta-analysis of eight studies found that people with ADHD are twice as likely as those in the general population to die prematurely. They are also more likely to engage in risky behaviors, such as smoking, drug use, and drinking, investigators noted. To learn more about ADHD and life expectancy, investigators examined electronic medical records from 794 UK primary care practices. The analysis included data on 30,039 adults diagnosed with ADHD at any point in their lives and 300,390 matched controls. The primary outcome was all-cause death. In the UK, primary care offices are updated with patients' deaths by the National Health System Personal Demographic Service. Investigators used a Poisson model to estimate the mortality rate by single year-of-age for those with ADHD and the control group. They then used the modelled rates to estimate life expectancy at age 18 years using the period life table method as described by the Office for National Statistics. The median age at cohort entry for males was 18.95 years and 22.10 years for females. Shorter Lifespans Mortality rates were higher in the ADHD group (males, 0.83%; females, 2.22%) compared to the control group (males, 0.52%;females, 1.35%). Among those with ADHD, death was 1.89 times more likely in men (95% CI,1.62-2.19) and 2.13 times more likely in women (95% CI, 1.79-2.53) during follow up compared to controls. ADHD was associated with a reduction in total life expectancy of 6.78 years in males (95% CI, 4.50-9.11) and 8.64 years in females (95% CI, 6.55-10.91). Average age at death for the ADHD group was 73 years in men (95% CI, 71.06-75.41) and 75 years (95% CI, 72.99-77.11) in women. For the control group, average age at death was 80 years (95% CI, 79.34-80.74) for men and 84 years for women (95% CI, 83.12-84.44). The authors called the findings "extremely concerning," adding that for individuals with ADHD, there are often associated mental health challenges, including substance use, smoking, or compulsive behavior that may contribute to premature death. “Only a small percentage of adults with ADHD have been diagnosed, meaning this study covers just a segment of the entire community," lead author, Elizabeth O’Nions, PhD, epidemiologist at the Bradford Institute for Health Research, University College of London, said in a press release. “More of those who are diagnosed may have additional health problems compared to the average person with ADHD. Therefore, our research may over-estimate the life expectancy gap for people with ADHD overall, though more community-based research is needed to test whether this is the case,” she continued. Study limitations include the lack of information about cause of death and wide confidence intervals around certain point estimates, likely due to the relatively small number of participants with ADHD. In addition, the findings are probably not generalizable to other countries, settings, or time periods, the authors wrote. Experts Weigh In Several experts who were not part of the study weighed in on the findings in a statement from the UK-based nonprofit and independent Science Media Centre. Philip Asherson, PhD, professor of molecular psychiatry at King's College London, said the study illuminated the impact of an ADHD diagnosis on life expectancy. While the causes of early death are not yet confirmed, he noted, ADHD has been linked to cardiovascular disease and cancer and may be linked to autoimmune and other physical health disorders. "ADHD is increasingly recognized as a serious condition in adults associated with poor health outcomes," Asherson said. Of particular concern are limited access to diagnosis and treatment including psychosocial support, he said, adding, "until this is addressed, the shorter life expectancy demonstrated in this study is likely to continue.” Also commenting on the study was Oliver Howes, PhD, MBBS, professor of molecular psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London. “The study adds to lots of other evidence that people with other mental illnesses die sooner than people without mental illness to show this for ADHD as well," he said. The study's use of a large UK database is a strength, but a limitation was that investigators were unable to study how participants' ADHD diagnosis date was related to comorbid conditions or treatment efficacy. "More work is needed to understand what underlies the link between ADHD and premature death,” he said. Note: This article originally appeared on Medscape .

TOPLINE: Common childhood stressful life events like starting a new school, moving homes, or having a new sibling are associated with an increased risk for atopic dermatitis (AD) activity and severity in children, a study suggests. METHODOLOGY: Researchers conducted a longitudinal cohort study of 13,972 children aged 1-8.5 years from the Avon Longitudinal Study of Parents and Children in the United Kingdom; 4454 had AD. Primary caregivers completed standardized questionnaires on about 15-17 age-appropriate stressful life events over the past year at 7 timepoints (18, 30, 42, 57, 69, 81, and 103 months). Study outcomes were prevalence and severity of AD. Median follow-up was 81 months from birth. Those with AD were more likely to be women, have a higher socioeconomic status, and have mothers who experienced more prenatal stress. TAKEAWAY: The annual period prevalence of AD ranged from 18% to 21%, and 5% to 8% of individuals with AD reported having “quite bad” to “very bad disease” at any given timepoint. The most common stressful life events were starting school (91%), starting a new school (75%), pet dying (54%), moving homes (54%), and having a new sibling (45%). Each SD increase in stressful life events was associated with a 4% increase in the odds of active AD (odds ratio [OR], 1.04; 95% CI, 1.01-1.07), with the highest risk for children with moderate to severe AD (OR, 1.13; 95% CI, 1.03-1.23). Of all life events, starting school was associated with a lower risk for active AD (OR, 0.93; 95% CI, 0.88-0.98). Each SD score increase in cumulative stress scores was associated with a higher risk for active AD (OR, 1.11; 95% CI, 1.07-1.16) and severe disease (OR, 1.17; 95% CI, 1.05-1.31). IN PRACTICE: "In a longitudinal, population-based study, we found associations between the perceived impact of childhood stressful life events and AD," the authors wrote. The results “suggest that parents and providers may anticipate and proactively moisturize or treat to prevent potential AD flares around life events," they added, noting that stress-reducing modalities may also be helpful. SOURCE: The study was led by Katrina Abuabara, MD, MA, MSCE, Department of Dermatology, University of California, San Francisco, and was published online on January 28 in the Journal of Investigative Dermatology. LIMITATIONS: Study limitations included potential measurement error and bias in both exposure and outcome. The stressful life events scale used was not independently validated. Caretaker-reported AD activity and severity may have introduced bias. Validated AD severity scores were unavailable for key timepoints. Potential missing data and selection bias were also a concern. DISCLOSURES: The study was supported by the National Institutes of Health and the Wellcome Trust. Abuabara reported receiving consulting fees and grants from pharmaceutical companies. Another author received grants and fellowships from various government organizations; other authors had no disclosures. Note: This article originally appeared on Medscape .

Exposure to officer-involved killings of unarmed Black individuals is associated with worse sleep health among Black adults in the United States, according to new research published in JAMA Internal Medicine. Specifically, Black adults reported significant increases in short and very short sleep following nationally prominent and state-specific officer-involved killings. Previous research has demonstrated racial disparities in sleep health, as Black individuals are more likely to report short sleep durations than White individuals. However, relatively few studies have identified explanations for these disparities. Therefore, the current study examined the extent to which structural racism, in the form of police violence, may contribute to sleep health among Black adults in the US. Researchers gathered individual-level data on sleep duration from 2 nationally representative, cross-sectional surveys: the US Behavioral Risk Factor Surveillance Survey (BRFSS) and the American Time Use Surveys (ATUS). To identify officer-involved killings of unarmed Black individuals, the researchers used information from Mapping Police Violence (MPV), an online database that has tracked officer-involved killings since 2013. The primary outcomes of interest were self-reported total sleep duration (average house of sleep), short sleep (duration <7 hours), and very short sleep (duration <6 hours) among Black adults. For the primary exposure, the researchers used a binary indicator for whether an officer-involved killing of an unarmed Black person occurred in the respondent’s state of residence in four 90-day intervals before the BRFSS or ATUS surveys. Responses from the BRFSS survey included a total of 181,865 Black adults distributed across 50 US states and the District of Columbia and ATUS responses consisted of 9958 Black adults distributed across 44 states and the District of Columbia. For BRFSS and ATUS respondents, the mean duration of sleep was 6.8 (SD, 1.7) and 8.8 (SD, 2.5) hours, 45.9% and 22.6% reported short sleep, and 18.4% and 11.3% reported very short sleep, respectively. Overall, 331 officer-involved killings of unarmed Black individuals were recorded in the MPV database during the study period. Greater than one-third of participants in both surveys (BRFSS, 35.8% vs ATUS, 35.5%) were exposed to an officer-involved killing of an unarmed Black person in their state of residence in the 90 days before their survey interview. The researchers found a 1.3 (95% CI, 0.5-2.2; P =.003) percentage point increase in short sleep and 1.1 (95% CI, 0.13-1.97; P =.03) percentage point increase in very short sleep among Black adults in the 91 to 180 days after officer-killings. When Black adults were exposed to nationally prominent officer-involved killings, these percentage point increases rose to 2.1 (95% CI, 0.02-4.08; P =.047) for short sleep and 2.1 (95% CI, 0.57-3.71; P =.01) for very short sleep. No adverse outcomes on sleep health were found for White respondents exposed to officer-involved killings of unarmed Black individuals. These findings support the notion that sleep health may be influenced by structural racism in the US. Study authors concluded, “These findings further underscore the need for evidence-based institutional reforms to eliminate officer-involved killings in the Black community and other manifestations of biased policing.” The primary limitations of the study include the reliance on self-reported sleep duration rather than polysomnography, potential data inaccuracy from the use of the crowd-sourced MVP database, and a lack of data on the effect of nonfatal police encounters. Note: This article originally appeared on Psychiatry Advisor