A&E Abstracts and Extracts

Authors: Adam Gaffney, MD, MPH, et al.

Abstract: What are the probable health consequences of three US Supreme Court decisions in 2022 that invalidated COVID-19 workplace protections, voided state laws on handgun-carry restrictions, and revoked the constitutional right to abortion?

In this analytical modeling study, the model projected that:

• The Supreme Court ruling to invalidate COVID-19 workplace protections was associated with 1,402 deaths in early 2022.
• The court’s decision to end handgun-carry restrictions will result in 152 additional firearm-related deaths annually.
• The court’s decision to revoke the constitutional right to abortion will result in six to 15 deaths annually, and hundreds of additional cases of peripartum morbidity each year (an extra 782 in 13 states that had abortion bans at March 30, 2023, and 1,967 cases should other ‘high risk’ states apply abortion bans).

“These findings suggest that over a decade, the three Supreme Court decisions examined here will contribute to the loss of nearly 3,000 US lives and possibly many more,” say the analysts.

They also estimate that abortion bans will be associated with 30,440 fewer abortions annually in the 13 states that had abortion bans at March 30, 2023, (related to the driving distance to the nearest abortion facility). If other, ‘high-risk’ states also enact abortion bans, they project 76,612 fewer abortions annually.

“We elected not to model the impact of the likely increase in self-managed abortion or worsened management of ectopic pregnancy, previable preeclampsia, or miscarriage, given greater uncertainty for these outcomes,” say the analysts. “Abortion denial is also expected to force some individuals (and their family members) into poverty, an important social determinant of ill-health that we also did not model.”

Importance: Several US Supreme Court rulings have drawn criticism from the medical community, but till now their health consequences have not been quantitatively evaluated. The authors conclude: “The findings of this study suggest that these Supreme Court decisions may harm the health of US citizens for years, and possibly decades, to come.”

Availability: Published by JAMA.

Authors: Vera Feuer, MD, et al.

Abstract: In 2021, pediatric care organizations AACAP, AAP, and CHA (Children's Hospital Association) declared a national state of emergency in child and adolescent mental health.

The rate of emergency department (ED) visits for medical conditions increased 11.7% from 2006-2014, while the rate of mental health/substance use-related ED visits increased 44.1% during the same period. Visits due to suicidal ideation increased by an alarming 414.6%. At the same time, there has also been a major decrease in the number of national inpatient psychiatric beds available.

As a result, the practice of ‘boarding’ pediatric patients within emergency departments and inpatient medical floors while awaiting psychiatric admission has significantly increased.

Of the 23 participants in this study, all defined ‘boarding’ as a status when a disposition decision has been made to admit a pediatric patient to an inpatient psychiatric unit, but an inpatient psychiatric bed is not available.

The authors set out to provide consensus guidelines for the clinical care of this population.

Importance: This study highlights findings of the first national consensus panel regarding the care of youth boarding in hospital-based settings and provides promising beginnings to standardizing clinical practice while informing future research efforts.

Although long-term goals of improving access to timely mental health care while minimizing the need for boarding remain, openly acknowledging that the practice of boarding is a growing and urgent crisis which requires thoughtful guidance to inform standards of care is necessary. This is the first step to providing national consensus.

Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).

Authors: Kyungha Kim, DrPH, MHA, et al.

Abstract: Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults.

This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington DC. The sample included 195,204 adolescent and young adult patients (aged 12–25) who underwent one of 13 surgical procedures. Of these, 4.8% had prolonged opioid use.

“Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana,” say the authors. “These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.”

While opioid prescribing in the US has been decreasing, statistics on opioid prescribing to adolescents and young adults show varying trends. Data from Optum Clinformatics Data Mart suggest that any opioid prescribing to a child or adolescent declined around 50% between 2012 and 2017 among those with commercial insurance, with much of the decline being driven by reductions in the number of hydrocodone prescriptions. However, other work suggests that prescribing to adolescents and young adults in emergency and ambulatory settings has remained fairly constant.

In this study, adolescents and young adults who are prescribed opioids are shown to be at greater risk of long-term opioid use and more likely to progress to heroin use.

When prescription opioids are taken for a short period following a doctor's prescription, opioids are safe and can reduce patient pain, say the authors. “However, like illicit opioids, prescription opioids can lead to dependence and addiction when they are used for prolonged periods.”

Importance: State and federal agencies have implemented a wide range of strategies and targeted interventions to try to reduce overprescribing, including implementation and mandated use of prescription drug monitoring programs, opioid prescribing guidelines, and pain clinic regulations.

One policy area that has garnered attention from researchers in recent years is medical marijuana laws. Randomized trials have documented that cannabinoids have a modest association with reduced levels of chronic pain, and studies examining the association between state medical marijuana law adoption and opioid prescribing have shown a reduced number of opioid prescriptions, daily opioid doses prescribed, spending on opioid prescriptions, and opioid prescribing rates.

“However, these effects have been found within adult populations or state-level analyses, and little attention has been given to the impact of medical marijuana laws on adolescent and young adult opioid use, particularly among postsurgical adolescents and young adults—populations likely to receive opioids for pain management,” say the authors.

These findings are the first to demonstrate potentially important age differences in sustained use of opioids. Prolonged opioid use after surgery might lead to prescription opioid misuse, so it would be especially important to prevent long-term exposure to opioids and prolonged opioid use after surgeries in this population. “Opioid prescribers should be more cautious when prescribing opioids to adolescents and young adults, and prescriber oversight and management with this vulnerable population is necessary,” say the authors.

Availability: Published by The American Journal on Addictions.

Authors: Ching-Fan Sun, MD, et al.

Abstract: This mystery shopper study examines new appointment availability within general psychiatry outpatient services in the US, including in-person and telepsychiatry appointments, comparing results between insurance types (Medicaid vs. private insurance), states, and urbanization levels.

Researchers investigated five US states (New York, California, North Dakota, Virginia, and Wyoming) selected according to Mental Health America Adult Ranking and geography to represent the US mental health care system. Clinics across these states were sampled based on urbanization levels. Collected data included contact information accuracy, appointment availability, wait time (in days), and related data.

Of 948 psychiatrists originally sampled, only 18.5% were available to see new patients. A ‘significantly longer’ wait time was provided for in-person than telepsychiatry appointments. The most frequent reason for unavailability was ‘provider not taking new patients’ (54%). The research also showed that mental health resources were unevenly distributed, favoring urban areas

Importance: Psychiatric care has been severely restricted in the US with low accessibility and long wait times. “Transitioning to telepsychiatry represents a potential solution for rural disparities in access,” say the authors. Even so, the authors also rate telepsychiatry wait times as ‘still considerable’.

Availability: Pre-publication in General Hospital Psychiatry.

Authors: Fabio Panariello, et al.

Abstract: This study investigates the connection between childhood violence exposure and violent behavior in adults with schizophrenia spectrum disorders (SSDs). It includes 398 SSD patients: 221 cases with a history of severe interpersonal violence in the past, and 177 controls with no history of violence.

More than one-third of the general population report to being exposed to at least one violent act during their childhood; physical abuse is the most frequent form of childhood maltreatment by adults, affecting about one-quarter of all children. In the US, more than 28% of adults report they were exposed to physical abuse; nearly 21% report some form of sexual abuse; and more than 10% report emotional abuse in their childhood.

Childhood maltreatment, whether physical, sexual, or emotional, is associated with a wide range of later adverse outcomes in adults. These include an increased likelihood of a range of mental and physical disorders, substance use disorders, and other maladaptive behaviors that include self-harm and suicide.

Childhood maltreatment that includes experiencing physical abuse, witnessing domestic violence and suffering various forms of emotional neglect is associated with an increased likelihood of being diagnosed with mood and anxiety disorders, personality disorders, and substance use disorder.

Being exposed to violence in childhood may also increase the risk of being diagnosed with schizophrenia and other psychotic disorders. A meta-analysis of retrospective studies found that patients with schizophrenia were 2.72 times more likely to report violence exposure in their own childhood.

Three developmental pathways for violence in people with schizophrenia have been identified:

• ‘Early start offenders’—who exhibit stable antisocial behavior before the onset of acute symptoms.
• Adults who engage in violent behavior only once their illness has begun.
• A small subset who commit serious violence despite not showing prior violent behavior in the context of their illness.

The aim of this study—part of a large multicentre European study on Risk Factors for Violence in Mental Disorder and Forensic Care—was to investigate the possible links between exposure to violence in childhood and violence later in life in patients with SSDs.

Importance: This study did not find statistically significant differences between the number of violent cases and non-violent control patients with SSD who reported any exposure to violence during their childhood. On the other hand, the number of episodes of childhood violence reported by violent cases was significantly higher than in non-violent controls.

Availability: Pre-publication in Psychiatry Research.