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Key Points: Question: What is the association between social vulnerability and mental health and substance use disorders and related treatment in the US noninstitutionalized population of adults aged 18 years and older? Findings: In this survey study of 4674 participants from US households, large increases in several mental health and substance use disorders and corresponding decreases in treatment were found in the most socially vulnerable communities. Meaning: The findings suggest that routine measurement of social vulnerability might assist in developing more comprehensive care models that integrate medical and social care for mental health and substance use disorders. This survey study evaluates associations of social vulnerability with mental health disorders and substance use disorders in a noninstitutionalized setting. Importance: Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study. Objective: To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older. Design, Setting, and Participants: A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews. Main Outcomes and Measures: Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level. Results: The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80). Conclusions and Relevance: In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, stimulant use disorder, and OUD with corresponding decreases in treatment. These results suggest that the SVM might assist in developing more comprehensive care models that integrate medical and social care for MH disorders and SUDs. [ABSTRACT FROM AUTHOR]

This cross-sectional study estimates the proportion of US adults with lifetime suicide attempts whose first attempt occurred without or preceded the diagnosis of a psychiatric disorder. Key Points: Question: What percentage of people who attempt suicide meet criteria for a psychiatric disorder? Findings: In this cross-sectional study using data from 1948 US adults with lifetime suicide attempts from a nationally representative population-based survey, an estimated 20% reported not having met criteria for any psychiatric disorders prior to their first attempt. Meaning: The findings suggest a possible need to broaden suicide risk screening beyond psychiatric populations. Importance: Not all people who die by suicide have a psychiatric diagnosis; yet, little is known about the percentage and demographics of individuals with lifetime suicide attempts who are apparently psychiatrically healthy. If such suicide attempts are common, there are implications for suicide risk screening, research, policy, and nosology. Objective: To estimate the percentage of people with lifetime suicide attempts whose first attempt occurred prior to onset of any psychiatric disorder. Design, Setting, and Participants: This cross-sectional study used data from the US National Epidemiologic Study of Addictions and Related Conditions III (NESARC-III), a cross-sectional face-to-face survey conducted with a nationally representative sample of the US civilian noninstitutionalized population, and included persons with lifetime suicide attempts who were aged 20 to 65 years at survey administration (April 2012 to June 2013). Data from the NESARC, Wave 2 survey from August 2004 to September 2005 were used for replication. Analyses were performed from April to August 2023. Exposure: Lifetime suicide attempts. Main Outcomes and Measures: The main outcome was presence or absence of a psychiatric disorder before the first lifetime suicide attempt. Among persons with lifetime suicide attempts, the percentage and 95% CI of those whose first suicide attempt occurred before the onset of any apparent psychiatric disorders was calculated, weighted by NESARC sampling and nonresponse weights. Separate analyses were performed for males, females, and 3 age groups (20 to <35, 35-50, and >50 to 65 years). Results: In the total sample of 36 309 respondents, 1948 persons had lifetime suicide attempts; 66.8% (95% CI, 64.1%-69.4%) were female, and 6.2% (95% CI, 4.9%-7.4%) had no apparent lifetime psychiatric diagnoses when surveyed. In addition, 13.4% (95% CI, 11.6%-15.2%) made their first suicide attempt prior to psychiatric disorder onset. Thus, an estimated 19.6% of respondents first attempted suicide without an antecedent psychiatric disorder. No significant age or sex differences were detected in the percentage of those with lifetime suicide attempts absent psychiatric disorders, although females were more likely than males to attempt suicide in the year of psychiatric disorder onset (14.9% [95% CI, 12.5%-17.3%] vs 8.6% [95% CI, 6.0%-11.2%]; P <.001), and attempts were less frequent among those older than 50 to 65 years (3.9% [95% CI, 3.5%-4.4%] vs 6.1% [95% CI, 5.4%-6.8%] for 35-50 years and 6.2% [95% CI, 5.6%-6.9%] for 20 to <35 years; P <.001). Conclusions and Relevance: In this study, an estimated 19.6% of individuals who attempted suicide did so despite not meeting criteria for an antecedent psychiatric disorder. This finding challenges clinical notions of who is at risk for suicidal behavior and raises questions about the safety of limiting suicide risk screening to psychiatric populations. [ABSTRACT FROM AUTHOR]

This cohort study uses patient data from the Medicaid and Children's Health Insurance Program to investigate if antipsychotic treatment of children and young adults without severe somatic illness or psychosis is associated with increased risk of death. Key Points: Question: Is antipsychotic treatment of children and young adults without severe somatic illness or psychosis associated with increased risk of death? Findings: In a cohort of 2 067 507 Medicaid patients aged 5 to 24 years, antipsychotic treatment was associated with increased risk of death only for patients with doses greater than 100-mg chlorpromazine equivalents. Risk was not significantly associated with lower doses or with either dose in children aged 5 to 17 years. Meaning: Antipsychotic treatment of 100-mg chlorpromazine equivalents or less or in children was not associated with increased mortality; further research is needed to better understand the increased risk of death with higher doses in young adults. Importance: Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective: To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants: This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures: Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures: Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score–based overlap weights. Results: The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, −5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance: In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article related to the higher rates of long-term benzodiazepine use among older adults in the U.S. by M. Olfson and others in a previous issue of 2015.

Importance: While access to psychotherapy has recently increased in the US, concern exists that recent gains may be unevenly distributed despite teletherapy expansion., Objective: To characterize recent trends and patterns in outpatient psychotherapy by US adults., Design, Setting, and Participants: This is a repeated cross-sectional study of psychotherapy use among adults (ages ≥18 years) in the 2018 to 2021 Medical Expenditure Panel Surveys, which are nationally representative surveys of the civilian noninstitutionalized population. Data were analyzed from March to August 2024., Main Outcomes and Measures: Age-, sex-, and distress-adjusted differences between 2018 and 2021 in use of any psychotherapy and video-based psychotherapy (teletherapy) in 2021 with tests for trend differences (interactions) across levels of sociodemographic characteristics and distress were assessed. Psychological distress was measured using the Kessler-6 scale, with scores of 13 or higher defining serious psychological distress, 1 to 12 defining mild to moderate distress, and 0 defining no distress., Results: The analysis involved 89 619 participants (47 838 female [51.5%] and 41 781 male [48.5%]; 22 510 aged 18-34 years [29.0%], 43 371 aged 35-64 years [48.8%], and 23 738 aged ≥65 years [22.2%]). Between 2018 and 2021, psychotherapy use increased significantly faster for females (931/12 270 females [7.7%] to 1207/12 237 females [10.5%]) than males (547/10 741 males [5.2%] to 655/10 544 males [6.3%]), younger (455/6149 individuals [8.0%] to 602/5296 individuals [11.9%] aged 18-34 years) than older (217/5550 individuals [3.6%] to 304/6708 individuals [4.6%] aged ≥65 years) adults, college graduates (503/6456 adults [7.6%] to 810/7277 adults [11.4%]) than those without a high school diploma (193/3824 adults [5.5%] to 200/3593 adults [7.0%]), privately insured (881/14 387 adults [6.1%] to 1154/13 414 adults [8.9%]) than publicly insured (558/6511 adults [8.8%] to 659/7453 adults [8.8%]) individuals, adults at 2 to 4 times the poverty level (370/6670 adults [5.7%] to 488/6370 adults [8.2%]) than those below the poverty level (384/4495 adults [9.7%] to 428/4760 adults [10.0%]), employed persons overall (733/13 358 adults [5.7%] to 1082/12 365 adults [8.9%]) than unemployed persons aged 65 years and younger (547/5138 adults [10.8%] to 519/4905 adults [10.5%]), and urban (1335/20 682 adults [6.5%] to 1729/20 590 adults [8.7%]) than rural (143/2329 adults [6.4%] to 133/2191 adults [5.9%]) residents. In 2021, after controlling for distress level, teletherapy use was significantly higher among younger than middle-aged (aged 35-64 years: difference, -3.7 percentage points; 95% CI, -5.1 to -2.3) or older (aged ≥65 years: difference, -6.5 percentage points (95% CI, -8.0 to -5.0 percentage points) adults, females (difference, 1.9 percentage points; 95% CI, 0.9 to 2.9 percentage points) than males, not married (difference, 2.9 percentage points; 95% CI, 1.6 to 4.2 percentage points) than married persons, college educated adults (difference, 4.9 percentage points; 95% CI, 3.3 to 6.4 percentage points) than those without a high school diploma, people with higher (eg, 400% vs <100% of the federal poverty level: difference, 2.3 percentage points; 95% CI, 1.2 to 3.5 percentage points) than lower incomes, privately than publicly (difference, -2.5 percentage points; 95% CI, -3.4 to -1.5 percentage points) insured persons, and urban (difference, 2.7 percentage points; 95% CI, 1.5 to 3.8 percentage points) than rural residents., Conclusions: This study found that psychotherapy use increased significantly faster among several socioeconomically advantaged groups and that inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and health care policies to broaden access to psychotherapy including teletherapy.