New Research, Treatment Issues Featured at Annual Meeting

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With the theme “Innovate. Collaborate. Motivate: Charting the future of mental health,” the 2023 American Psychiatric Association Annual Meeting featured new research and clinical discussions May 20-24, 2023, in San Francisco, California. For complete coverage, including videos and additional articles and insights, visit PsychiatricTimes.com/apa. (Make sure you are don’t miss late-breaking news, clinical insights, and conversations with your colleagues by subscribing to our e-newsletters: www.psychiatrictimes.com/enews.)

ABIS to Address Suicide Risk

A therapeutic alliance is key for all patients, and especially for patients with self-destructive and suicidal behaviors, Eric M. Plakun, MD, told attendees. Plakun, medical director and chief executive office the Austen Riggs Center, shared his clinical experience and lessons learned in explaining the 9 practical principles of the Alliance Based Intervention for Suicide (ABIS) (Table).

Table. 9 Principles of ABIS

Setting the foundation of the therapeutic relationship is the first step, and that is why a distinct consulting phase before the therapy phase is important, Plakun said. During the consultant phase, which allows the patient and clinician to negotiate the terms of an alliance, he might spend a few sessions exploring their background and what brought them to care. He also looks for their buy-in. “I need you alive to do the work,” he tells them. “Can you agree to this? If so, we can see where this takes us.”

As the process unfolds, it is important to consider the meanings of any self-destructive behavior as well as their impact on others. Possible meanings include atonement or self-punishment, fusion with another, aggressive assault, marking a boundary, or even a substitute for actual suicide. He spoke of a patient with suicidal ideation and self-cutting behaviors. As part of an initial treatment discussion, her therapist asked her to cease cutting, without understanding that behavior. Unfortunately, the patient was using the cutting behaviors as a substitute for suicidal urges, and without that outlet, the patient was lost.

Plakun also detailed the story of “Daisy,” a patient he encountered who had attempted suicide seemingly out of nowhere after a family event. Daisy was raised in the Bible Belt, and she had limited education. She reported being unhappy at home as a teen and said she would often go to hang out with friends and others in the woods. Daisy reported being hospitalized in high school following a panic attack. Eventually she moved north, got married. At time of presentation, she had a 14-year-old son. She was placed on 150 mg amitriptyline in addition to the therapy.

Treatment continued and was unremarkable until the patient was a no-show on Christmas eve. That day Plakun received a call from Daisy’s husband looking for her. The police were alerted and, shortly thereafter, Daisy was found in a van in a parking lot, somnolent after overdosing on her medication.

Plakun’s initial reactions included intense fear and even anger toward the patient. He then pulled in 1 of the ABIS’ principles: to contain and metabolize the countertransference to resume empathetic neutrality. He engaged Daisy in the hospital: “We had an agreement to keep yourself safe. You seem to have made a decision to end our work,” referencing the attempt. “I can continue to consult with you, but our commitment to weekly sessions has ended.”

Two months later, Daisy returned to Plakun’s office to process the events. At that point, Daisy shared new and vitally important information about her previous psychiatric hospitalization: While hanging out in the woods in her youth, she had been drugged, beaten, and gang raped. She was too afraid to divulge the attack to her religious parents, so she kept it to herself. She was later triggered in high school when a boy cornered her to ask her out, and the resulting panic attack landed her in the hospital. As part of outpatient treatment, the therapist asked Daisy to show him the sexual experimentation she had encountered in the woods, which further victimized Daisy. Scared and ashamed, she considered hurting the therapist, but was unable to do so. Instead, she convinced her family she no longer needed those sessions, and kept these experiences to herself.

Daisy explained those negative experiences came crashing down on her shortly before the holiday as a result of a few events: Her husband asked her if she was sleeping with Plakun, reminding her of her previous victimization by a therapist; Plakun made what he thought was a seemingly benign comment about their lack of treatment progress but their good connection, again reminding her of the previous negative experiences; and Plakun noted he would be unavailable for a week, making her feel all alone. Together, these events led to her most recent suicide attempt.

The benign comment falls in line with another principle, Plakun told attendees, and one that psychiatrists often overlook: consider a perceived injury from the therapist that may have precipitated self-destructive behavior.

Plakun noted the Group for the Advancement of Psychiatry as well as the American Psychiatric Association’s Psychotherapy Caucus were good resources for clinicians who want to learn more. For those who want to “work at the top of their license,” these psychotherapeutic tools are essential, Plakun noted.—HAD

Disparities in LAI Use

There is a statistically significant difference in racial and ethnic use of long-acting injectable antipsychotics (LAIs), according to research presented at the meeting.¹

The study leveraged data from the 2018-2019 Chronic Conditions Warehouse 100% Medicare Parts A, B, and D claims as well as summary files from the Centers for Medicare and Medicaid services. Inclusion criteria was at least 1 inpatient and/or at least 2 outpatient claims noting an ICD-10 diagnosis of schizophrenia as well as continuous fee-for-service coverage via Medicare Parts A, B, and D in 2018 and 2019. Patients with more than 1 inpatient and/or more than 2 outpatients claims detailing a bipolar diagnosis were excluded. To control for sociodemographic and clinical history variables, logistic regression models were used to calculate adjusted outcomes by race and ethnicity categories.

Patients (n=210,686) were at least 18 years old, with a mean age of 56.1 years. A slight majority were male (60.6%) and white (66.4%). Approximately one quarter (22.6%) of the patients used an LAI, with the majority (66.4%) receiving second generation LAIs. Although initial data found large differences between any LAI use among white, Black, Hispanic, and other patients (19.3%, 30.7%, 26.0, and 25.8%, respectively), the differences narrowed substantially after the adjustment was made (22.2%, 23.5%, 23.0%, and 229%, respectively). Differences remained more substantial when considering second generation LAI use, with lower rates of use among Black patients (60.1%) and Hispanic patients (64.9%) versus white patients (69.9%). Subgroup and sensitivity analyses supported these findings.

The investigators noted the study had some limitations, including lack of nuanced clinical information in claims data and the findings’ generalizability to fee-for-service Medicare populations. The study was funded by Janssen Scientific Affairs, LLC.

“Given that several [second generation] LAIS are now available with longer dosing intervals (every 2, 3, or 6 months) that may facilitate improved antipsychotic adherence, future research should examine reasons for these disparities and could assist in the development of appropriate interventions,” the researchers concluded. “Future research should examine reasons for these disparities and their impact on clinical and economic outcomes,” they added.—HAD

Reference

1. Patel C, Benson C, Li P, et al. Racial/Ethnic Disparities in Long-Acting Injectable Antipsychotic Use in a National Sample of Medicare Beneficiaries With Schizophrenia. Poster presented at the 2023 American Psychiatric Association Annual Meeting; May 20-24, 2023. San Francisco, CA.

Behavioral and Psychological Symptoms of Dementia: Management and More

“Recognition is the first and most important step,” said Rajesh R. Tampi, MD, MS, DFAPA, DFAAGP. “Treatment must always be individualized—it is not one-size-fits-all.”

In his well-attended session, “A Clinician’s Guide to the Management of Behavioral and Psychological Symptoms of Dementia in the Era of Boxed Warnings,” Tampi discussed emerging data on various important aspects of dementias, the most common neurodegenerative conditions in human beings. As he noted, there are more than 5 million individuals with dementias in the United States, and this number is projected to rise to over 11 million over the next 30 years. Despite increased prevalence, the diagnosis and management of these disorders is not standardized. How can clinicians address behavioral and psychological symptoms of dementia (BPSD)?

Common symptoms of BPSD include¹:

• Anxiety (21% to 60%)
• Apathy (48% to 92%)
• Delusions (16% to 70%)
• Depression (30% to 50%)
• Disinhibition/impulsivity (30% to 35%)
• Hallucinations (4% to 76%)
• Inappropriate sexual behaviors (7% to 25%)
• Mood lability (30% to 40%)
• Sleep disturbance (20% to 25%)
• Stereotyped behaviors (12% to 84%)
• Weight loss (15% to 20%)

If you suspect a patient has BPSD, you can follow Tampi’s recommended assessment¹ to confirm diagnosis:

1. Obtain the patient’s history: medical, psychiatric, medications, premorbid personality, cognition, function, and so on.

2. Complete a physical examination so as to rule out underlying medical or neurological disorders.

3. Order investigations, such as blood tests, urine examinations, vitamin B12 and folate levels, neuroimaging, and more.

4. Complete standardized rating scales and/or neuropsychological testing.

5. If there are underlying medical or neurological disorders, treat them.

6. If any medications have adverse effects, remove the offending drug.

7. Confirm the patient has BPSD.

Tampi also provided attendees with evidence-based nonpharmacological interventions. According to data from systematic reviews, psychoeducation and staff instruction were effective in reducing BPSD symptoms.² Additionally, person-centered care, communication skills training, and adapted dementia care mapping reduced agitation in care homes immediately and for up to 6 months.³ Activities and music therapies also saw some effect in reducing overall agitation.³

As to pharmacological treatments, Tampi shared with attendees that if monotherapy fails, clinicians should use judicious combinations of medications, such as antidepressants with antipsychotics or mood stabilizers. He also stated that clinicians should frequently assess the efficacy and adverse effects of any and all medications, specifically controlling modifiable cerebrovascular and cardiovascular risk factors.4

“It’s how we prescribe that matters,” said Tampi.—LK

References

1. Tampi RR, Bhattacharya G, Marpuri P. Managing behavioral and psychological symptoms of dementia (BPSD) in the era of boxed warnings. Curr Psychiatry Rep. 2022;24(9):431-440.

2. Livingston G, Johnston K, Katona C, et al; Old Age Task Force of the World Federation of Biological Psychiatry. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry. 2005;162(11):1996-2021.

3. Livingston G, Kelly L, Lewis-Holmes E, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014;18(39):1-226, v-vi.

4. Tampi RR, Williamson D, Muralee S, et al. Behavioral and psychological symptoms of dementia: part II—treatment. Clinical Geriatrics. 2011;2-10. Accessed May 30, 2023. https://medicine.yale.edu/intmed/geriatrics/fellowships/medicine/bpsd_part%202_clinical%20geriatrics_101891_284_38753_v1.pdf

Insights on New Onset Psychosis Post—COVID-19

With increased interest in the link between COVID-19 infection and neuropsychiatric abnormalities, researchers sought to better understand the differences between new onset psychosis following COVID-19 infection as compared with patients without concurrent infection.¹

The study included a systemic review of 57 case reports of new-onset psychosis in patients with COVID-19 infection; a first-episode psychosis study with 462 patients was used as comparison. The investigators also leveraged a study of 104 participants to ascertain effects of age of onset, and 8 unique case reports were examined for potential conclusions. All studies were identified as a result of searches via PubMed, British Journal of Psychiatry, BMJ Case Reports, Journal of the American Medical Association, and Psychiatric Times.

The investigation found symptoms differed between the groups, with paranoia, acute mania, and auditory hallucinations more common among the patients with infection. For those without COVID-19 infection, the symptoms trended differently between early- versus late-onset psychosis. Patients without infection and with early-onset psychosis displayed both positive and negative symptoms and greater levels of cognitive impairment. Meanwhile, less severe negative symptoms and less severe deficits in learning were found among the non-COVID infected individuals who had late-onset psychosis.

Antipsychotics were employed to manage acute symptoms across the patient populations. On the whole, treatment was required in the non-infected participants after stabilization, as symptoms tended to persist. In those with infection, long-term management was determined based on need.

Importantly, the investigation found that psychosis did not necessarily resolve after recovery from COVID-19. “The psychotic symptoms tend to persist post-COVID–19 infection, highlighting the need for long-term psychiatric follow-up in these patients,” the poster concluded.

The interplay between infectious disease and psychosis is not new, with links found in patients with influenza, H1N1, and other coronaviruses like SARS and MERS.² Yet, researchers have noted that associations are not causality.³ Nevertheless, this poster further emphasizes the need for vigilance in detecting psychosis in patients with COVID-19 infection as well as continued research in this area. —HAD

References

1. Anthony J. Investigation into differences of clinical presentation of new onset psychotic symptoms in patients infected With COVID-19. Presented at the 2023 American Psychiatric Association Annual Meeting. San Francisco, California. May 20, 2022.

2. St. Victor G, Azubuogu C, Liss MM, Manickam S, Thakurathi N. Psychosis in the patient with COVID-19: an emerging psychopathology? Psychiatric Times. 2022;39(6).

3. Moccia L, Kotzalidis GD, Bartolucci G, et al. COVID-19 and new-onset psychosis: a comprehensive review. J Pers Med. 2023;13(1):104.