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  1. Contingency management interventions that reward patients for abstaining from cocaine use may be a an effective treatment option for patients with cocaine use disorder, a meta-analysis published today in JAMA Network Open suggests.

    Brandon S. Bentzley, M.D., Ph.D., of Stanford University and colleagues analyzed data from 157 clinical trials that included 402 treatment groups and 15,842 participants aged 18 years or older with cocaine use disorder. Participants enrolled in the trials on average used cocaine about three days week and had been using cocaine for several years.

    The most common treatments were psychotherapy and contingency management programs. Other interventions included treatment with anticonvulsants, antidepressants, antipsychotics, dopamine agonists, opioids, psychostimulants, or placebo. The primary outcome was a negative urine test for cocaine metabolites at the end of treatment.

    Overall, 26.9% of patients completed treatment and were cocaine-free at the end of treatment.

    The researchers found that only contingency management programs were associated with an increased likelihood of having a negative urine test at the end of treatment. Patients who participated in contingency management programs were roughly twice as likely to have a negative urine test compared with those in placebo groups.

    The researchers noted that contingency management programs have been helpful in treating substance use disorders at the U.S. Department of Veterans Affairs.

    “Given the results of our study and the fact that the Department of Veterans Affairs is the largest integrated provider of addiction services in the U.S., consideration of the implementation of contingency management programs on a national level or within other major health care systems in the U.S. is warranted,” they wrote.

    Psychotherapy did not appear to have a significant impact on cocaine use. However, the researchers noted that their analysis did not take into account the type or dose (session length and frequency) of psychotherapy. They added that their approach to analyzing the data cannot rule out the benefits associated with specific approaches or doses of psychotherapy.

    For related information, see the American Journal of Psychiatry article “Searching for Treatments for Cocaine Use Disorder: The Quest Continues.”

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  2. A hospital-based smoking cessation intervention that involves motivational counseling and post-discharge follow-up helps patients maintain abstinence longer than usual care, according to a study published Wednesday in JAMA Psychiatry.

    “Individuals with serious mental illness (SMI) smoke cigarettes at disproportionately higher rates, are more likely to smoke heavily, and have lower cessation rates than the general population,” wrote Richard A. Brown, Ph.D., of the University of Texas at Austin; Nancy Rigotti, M.D., of Harvard Medical School; and colleagues. “These findings, if replicated, provide a scalable approach to achieving sustained smoking cessation in patients with SMI following a psychiatric hospital stay.”

    Brown, Rigotti, and colleagues conducted a clinical trial involving 342 participants aged 18 and older receiving inpatient treatment for SMI who smoked at least five cigarettes per day when not hospitalized. Participants’ diagnoses included depressive, anxiety, bipolar, psychotic, and personality disorders, among others. The participants were randomly assigned to one of two interventions: usual care or sustained care.

    Patients assigned to the usual care group received five to 10 minutes of smoking cessation information and advice from the admitting nurse, self-help materials, and an offer of nicotine replacement therapy to use after discharge. Those in the sustained care group received a single 40-minute motivational interview tailored for patients with SMI provided by a smoking cessation counselor; four weeks of free transdermal nicotine patches upon discharge; access to free telephone-, text-, or web-based cessation counseling after discharge provided by a counselor trained to work with callers with psychiatric diagnoses; and enrollment in an automated, interactive voice response telephone system that asked participants about their smoking and intentions to quit following discharge.

    The participants in both groups were asked about their use of smoking cessation treatment (smoking counseling and/or pharmacological interventions) at one, three, and six months after hospital discharge. At the six-month follow-up, participants were also asked about smoking in the past seven days; smoking status was also biochemically verified. Participants reported smoking an average of 17 cigarettes per day prior to hospitalization. At the six-month follow-up, those in the sustained care group had significantly higher rates of seven-day abstinence compared with the participants who received usual care (8.9% vs. 3.5%). Participants in the sustained care group were also significantly more likely to report using smoking cessation treatment over the six months following their hospitalization compared with those in the usual care group (74.6% vs. 40.5%).

    “These findings are notable, given that two-thirds of this sample could be considered economically disadvantaged (with household annual incomes less than $25,000), in addition to having SMI,” the authors wrote. “Both of these factors are associated with higher smoking rates and less success at quitting.

    “Our findings suggest that combining this evidenced-based, client-centered counseling approach with automated, proactive resources, such as [interactive voice response], text messaging, and other technology-assisted interventions … increases the likelihood of successful attempts at quitting,” the authors continued.

    For related information, see the Psychiatric News article “Psychiatrists Can Do More to Help Patients Quit Smoking.”

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  3. Neighborhood disadvantage, trauma history, and pregnancy complications are all established risk factors for psychosis. These social determinants of health are also more likely to impact minority groups in the United States, in part because of the racial discrimination these groups experience. A comprehensive review published in AJP in Advance examines how structural racism helped lead to the disproportionate risk of psychosis facing minority groups.

    “That racism has historically structured U.S. societal systems means that the neighborhood and social context may hold a significant portion of the relative contribution of risk for psychosis. This may occur through individual-level discrimination as well as through collective trauma at the community level (e.g., police and gun violence),” wrote Deidre M. Anglin, Ph.D., an associate professor of clinical psychology at the City College of New York, and colleagues. Anglin presented the review at a virtual press session at APA’s online 2021 Annual Meeting on Monday.

    Anglin and colleagues summarized multiple studies that show that common characteristics of many minority neighborhoods (including more densely populated areas and inequitable access to health care, healthy foods, clean air and water, green spaces, and employment) and exposure to trauma (including gun violence and police victimization) are associated with cumulative stress and increased risk of psychosis.

    The authors presented data showing that Black women in the United States are at substantially increased risk for many obstetric complications, as well as data showing that obstetric complications are often associated with psychotic disorders in offspring. For instance, studies show that Black women tend to have higher rates of preterm birth and infants born at low birth weights compared with other women in the United States. “Our review of obstetric complications suggests that discrimination among Black and Latina mothers may [also] contribute to … these complications because of heightened responses to stress (for example, inflammatory responses),” the authors wrote.

    The review highlighted several studies demonstrating that discrimination is not just associated with psychological distress, but also adverse biological effects including advanced cellular aging and changes in neural connections.

    “Overall, this research indicates that we need to acknowledge and treat structural racism as it is: A critical public health threat,” Anglin said during the virtual press session.

    The authors offered several recommendations for addressing the ways that racism shapes social determinants of psychosis, such as establishing a federal program to provide reliable and up-to-date estimates of psychosis prevalence across different racial and ethnic groups and incorporating more discussion of discrimination and racial trauma in mental health training.

    “To truly adopt an anti-racist framework, it is necessary to walk in the opposite direction on the path that seeks to maintain the status quo,” the AJP article concluded. “Building a critical consciousness about the ways behaviors and symptoms are connected to the contexts in which we live, including in our training programs, among providers, and in our patients, can enhance practice effectiveness.”

    For related information, see the Psychiatric News article “We Must Speak to Patients and Their Families About Racism.”

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  4. APA’s online 2021 Annual Meeting is now in the books, and highlights of Annual Meeting lectures and scientific sessions appear below. Look for additional coverage in future issues of Psychiatric News.


    Incoming APA President Outlines Specific Plan to Address Social Determinants of Mental Health
    As the country executes a massive public health effort to stop the spread of COVID-19, how can psychiatry address the systemic problems that the pandemic made obvious?

    A Pandemic Year of Chronic Stress: Robert Sapolsky Reviews Science Behind Chronic Stress and What It Is Doing to Us
    In a whirlwind lecture, seemingly extemporaneous and frequently amusing, of the science linking chronic stress to depression, anxiety, and other mental disorders, Robert Sapolsky, Ph.D., said the stresses of COVID-19 have brought out the worst and—sometimes—the best in human beings.

    NIMH Director Highlights Institute’s Response to Joint Crises of COVID-19 and Systemic Racism
    The long-term mental health landscape in the COVID-19 era is still unfolding, but NIMH is responding to the fact that members of minority groups are bearing the brunt of the social and economic impacts of the pandemic.

    Substance Use Rises as Isolation Takes Toll on People With Substance, Opioid Use Disorders During Pandemic
    Social distancing and limited access to peer-support groups increase the risk of relapse and fatal overdose, says NIDA Director Nora Volkow, M.D.

    Black People in U.S. Have Been Victims of ‘Caste’ System for Centuries, Says Pulitzer Prize–Winning Author
    Most Americans associate a caste system with countries like India, but it applies to the United States as well—from the time of slavery, Black people have been stratified to the bottom of American society, says author Isabel Wilkerson.

    Changing the Way People at Risk for Suicide Think: Using CBT to Provide Hope
    CBT specifically focuses on the way patients with suicidal behavior perceive themselves and their world and offers alternatives to those perceptions using an actionable safety plan that patients can employ to avert a crisis in the future.

    Societal, Systemic Change Is Key to Addressing Mental Health Impact of Climate Change
    Psychiatrists are in an excellent position to educate their communities and advocate for sound environmental policies.

    Mental Illness Too Often Wrongly Associated With Gun Violence
    People with mental illness are more likely to be the victims of violence than perpetrators, but mass shootings are often incorrectly associated with psychiatric illnesses. Psychiatrists can help educate the public about evidence-based strategies that reduce gun violence.

    MDMA-Assisted Psychotherapy Found Superior to Placebo in Phase 3 Trial
    The trial of 90 adults with chronic PTSD revealed a good safety profile and potential benefits of combining MDMA and psychotherapy. A second phase 3 trial is currently underway.

    Treating Family Members Can Help Break the Cycle of Depression
    Depression is often a family affair. Studies show that successfully treating mothers can vastly improve children who have depressive symptoms.




    Annual Meeting Doesn’t Have to End Now!
    Continue your learning experience and earn CME credits by purchasing APA Annual Meeting On Demand 2021. It includes the 135 sessions presented at this year’s Annual Meeting and more than 250 new sessions. You can access the content anytime, anywhere, from any device.

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  5. Even as COVID-19 vaccines become more widely available to people across the United States, Americans continue to express concerns about the impact the pandemic has had on their mental health and the mental health of their children, according to the results of an APA poll released on Sunday.

    The findings were based on an online survey conducted March 26 to April 5 of 1,000 adults 18 years and older.

    According to the survey, 43% of adults reported that the pandemic has had a serious impact on their mental health, up from 37% in 2020. Adults aged 18 to 29 years were more likely to report the pandemic has had a serious impact on their mental health than those 30 and older.

    More than half of adults (53%) with children under 18 in their household said they were concerned about the mental state of their children, and almost half (48%) said the pandemic has caused mental health problems for one or more of their children. Twenty-six percent of parents said they sought or are currently seeking professional mental health help for their children because of the pandemic, and 22% reported they had difficulties scheduling appointments for their children with mental health professionals.

    “This poll shows that even as vaccines become more widespread, Americans are still worried about the mental state of their children,” said APA President Jeffrey Geller, M.D., M.P.H., in a news release. “This is a call to action for policymakers, who need to remember that in our COVID-19 recovery, there’s no health without mental health.”

    Slightly fewer adults reported that the coronavirus pandemic is affecting their day-to-day life now compared with a year ago; for example, the percentage of adults reporting sleep problems fell from 22% to 19%, and those having difficulties concentrating fell from 20% to 18%. In contrast, the percentage of adults consuming more alcohol or other substances/drugs than normal increased from 14% to 17%. Additionally, 33% of adults reported gaining weight during the pandemic.

    “While most people, including most children, will likely adapt and recover well as we emerge from the pandemic, we know from previous research that for some, the mental health impacts of this trauma and distress will continue to have repercussions into the future,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We need to be prepared to help those who need it in the coming months and years.”

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