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Prenatal ART regimen with lowest risk is TDF-FTC-EFV
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.
“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.
Using data collected from August 2014 through August 2016, the researchers compared outcomes among 47,027 births by women from Botswana, average age 26 years, who reached at least 24 weeks’ gestation. The study’s data came from eight government hospitals throughout Botswana, where approximately 45% of births had occurred nationwide.
The 11,932 infants exposed to HIV, representing about a quarter of all infants in the study, had a higher risk of adverse birth outcomes: 39.6% of HIV-exposed infants had adverse outcomes, compared with 28.9% of unexposed infants.
Nearly half (48.4%) of the HIV-exposed infants had also been exposed to ART from conception. Among these 5,780 infants, those exposed to the ART regimen comprising tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV) had the lowest rate of adverse birth outcomes. The following percentages of infants exposed to different ART regimens had adverse outcomes:
- 36.4% of infants exposed to TDF-FTC-EFV.
- 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
- 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
- 47.4% of infants exposed to ZDV-3TC-NVP.
- 48.5% of infants exposed to TDF-FTC-LPV-R.
The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.
The risk of severe adverse outcomes for ART exposure from conception was as follows:
- 12.3% for exposure to TDF-FTC-EFV.
- 17.9% for exposure to TDF-FTC-NVP.
- 19.5% for TDF-FTC–LPV-R.
- 20.7% for ZDV-3TC-NVP.
- 23.4% for ZDV-3TC–LPV-R.
The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.
“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.
The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.
“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”
The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
FROM JAMA PEDIATRICS
Key clinical point: Different antiretroviral regimens pose different adverse birth outcome risks for pregnant women with HIV.
Major finding: The ART regimen with the lowest level of risk was tenofovir, emtricitabine, and efavirenz, with a 36.5% risk for adverse outcomes and 12.3% risk for serious adverse outcomes.
Data source: The findings are based on an observational study of 47,027 births to women at eight government hospitals in Botswana from 2014 to 2016.
Disclosures: The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
Improving children’s sleep may reduce internalizing problems long term
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
SAN FRANCISCO – , new research showed.
“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.
Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.
Data collection every 2 years included parent-reported sleep problems and child behavior. Behavior assessment came from the parent-reported Strengths and Difficulties Questionnaire for externalizing and internalizing difficulties. Parents reported severity of sleep difficulties and presence of specific problems at least 4 nights a week: difficulty falling asleep, night waking, sleep restlessness, and not wanting to sleep alone.
The researchers investigated the direction of influence – potential but unproven causation – between sleep problems and internalizing and externalizing problems. The analysis also assessed the extent of the associations. The first pair of analyses examined the relationship between sleeping and either externalizing or internalizing problems, independently assessed.
The findings revealed that sleeping problems were primarily associated with later internalizing difficulties, strongly suggesting that sleeping issues may cause or contribute to internalizing issues 2 years later.
With externalizing problems, however, the effect of poor sleep was inconsistent: Only at one point did it appear that sleeping difficulties contributed to externalizing difficulties. Instead, externalizing problems appeared to contribute to sleeping difficulties at three out of four time points. (The exception was that externalizing problems at ages 8-9 years did not appear to affect sleep at ages 10-11 years.) Though inconsistent, the results suggest that externalizing problems likely affect difficulty sleeping much more so than the other way around.
Then the researchers assessed the interacting associations between all three factors together. At all ages, poor sleep appeared to lead to internalizing difficulties 2 years later. Only once – at ages 6-7 years – did internalizing problems appear to influence sleep 2 years later.
The relationship between sleeping problems and externalizing problems was more complex and less consistent. Externalizing problems often, but not always, were positively associated with sleeping problems 2 years later. And only at ages 4-5 years did difficulty sleeping appear to lead to externalizing problems at ages 6-7 years.
In addition, independent of any interaction with sleeping problems, externalizing difficulties appeared to lead to internalizing problems at all time points.
Although this type of analysis can strongly suggest a direction of causality, Dr. Quach noted, the associations remain subject to the limitations of any observational data, where clearly determining causation or its direction is not possible.
The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
AT PAS 17
Key clinical point: Improving children’s sleep may reduce internalizing problems 2 years later.
Major finding: Externalizing problems were associated with sleep problems later on, and sleeping difficulties were linked to later internalizing problems.
Data source: The findings are based on analysis of four longitudinal, biennial questionnaires from parents of 4,983 Australian children aged 4-5 years, starting in 2004.
Disclosures: The Australian Research Council and the National Health Medical Research Council in Australia funded the research. The authors did not report any conflicts of interest.
Alcohol use, high-risk drinking increases in U.S. to ‘crisis’ levels
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
“This timely article by Grant et al. ... makes a compelling case that the United States is facing a crisis with alcohol use, one that is currently costly and about to get worse,” Marc A. Schuckit, MD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.1981). However, he said, several studies show that lowering the risk for future alcohol-related problems in 18 year olds is possible.
He said his group delivered an intervention to 500 college freshmen using Internet-based videos aimed at helping them “recognize their vulnerability toward heavy drinking.” Six and 12 months after watching four 50-minute videos, the effects on how much the students drank remained significant, he wrote. In addition, other studies have identified programs that help lower drinking during pregnancy. “These are only a few examples of ongoing hopeful developments,” Dr. Schuckit wrote.
The number in the study that is especially concerning for him, Dr. Schuckit said, is the 106% increase in AUDs among older individuals because of the many preexisting medical disorders “that can be exacerbated by heavier drinking. These drinkers are also likely to be taking multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences,” according to Dr. Schuckit.
“There is also some disturbing news,” he wrote. “The proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all. Efforts to identify risk factors for substance-related problems and to test prevention approaches take time and money and are less likely to be funded in the current financial atmosphere. … If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children … and higher costs for jails and prisons that are the last resort for help for many.”
Dr. Schuckit is affiliated with the department of psychiatry at the University of California, San Diego. He reported having no disclosures.
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.
“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.
“Mortality among alcohol-affected drivers who were simultaneously distracted also increased between 2005 and 2009 by 63%,” they wrote (JAMA Psychiatry. 2017 Aug 9. doi: 10.1001/jamapsychiatry.2017.2161).
The researchers analyzed data from 43,093 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions (April 2001-June 2002) and from 36,309 respondents to the National Epidemiologic Survey on Alcohol and Related Conditions III (April 2012-June 2013). Both surveys involved face-to-face interviews with a nationally representative sample of U.S. adults.
The findings showed that 12-month alcohol use had increased 11.2% between 2001-2002 and 2012-2013, from 65.4% to 72.7%. A substantial increase also occurred in high-risk drinking and alcohol use disorder as defined in the DSM-IV. High-risk drinking increased 29.9% during that time, from 9.7% to 12.6%, representing an increase of approximately 9.4 million Americans engaging in high-risk drinking.
Alcohol use disorder (AUD) increased 49.4%, from 8.5% to 12.7% – a percentage that accounts for an additional 12.3 million Americans with the diagnosis. That increase dwarfs the 14.8% increase in alcohol use disorder that was seen between 1991-1992 and 2001-2002, the authors pointed out. The prevalence of 12-month AUD rose significantly among adults aged 65 and older (106.7%), African American individuals (92.8%), and women (83.7%). Interestingly, all subgroups reported significant increases in AUD except for Native Americans and people living in rural areas. By comparison, the 12-month prevalence of AUD among men increased by a third (34.7%), and their high-risk drinking increased 15.5%.
“Drinking norms and values have become more permissive among women, along with increases in educational and occupational opportunities and rising numbers of women in the workforce, all of which may have contributed to increased high-risk drinking and AUD in women during the past decade,” the authors wrote. “Stress associated with pursuing a career and raising a family may lead to increases in high-risk drinking and AUD among women.”
These increases indicate potential future increases among women in alcohol-related conditions, such as breast cancer and liver cirrhosis. Increases may also occur in fetal alcohol spectrum disorder and exposure to violence, the authors wrote.
The increases in alcohol use, high-risk drinking, and AUD found among minorities may be related to increased stress and demoralization as wealth inequality widened between minorities and whites in the wake of the 2008 recession. Other inequalities, such as income and educational disparities, unemployment, residential segregation, discrimination, and less health care access may also play a role in those increases, the authors wrote.
One limitation of the study is that certain populations were not surveyed, such as homeless individuals and people who are incarcerated. This means that the prevalence of alcohol use, high-risk drinking, and AUD could be underestimated, Dr. Grant and her colleagues said. However, they said, the large sample sizes of the surveys might balance out that limitation and others.
Nevertheless, the increases found in alcohol use, high-risk drinking, and AUD “constitute a public health crisis that may be overshadowed by increases in much less prevalent substance use (marijuana, opiates, and heroin) during the same period,” Dr. Grant and her colleagues wrote. “The findings herein highlight the urgency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD.” In addition, they called for broader effors to address the “individual, biological, environmental, and societal factors” influencing high-risk drinking and AUD.
The research was sponsored by the NIAAA, and funded by the National Institutes of Health. The authors reported having no disclosures.
FROM JAMA PSYCHIATRY
Key clinical point: Drinking and alcohol use disorder have substantially increased across virtually all demographic groups, particularly racial/ethnic minorities, adults aged 65 and older, and women.
Major finding: High-risk drinking increased 9.7%, and alcohol use disorder increased 49.4% among U.S. adults between 2001-2002 and 2012-2013.
Data source: The findings are based on data from 43,093 U.S. adults in 2001-2002 and 36,309 U.S. adults in 2012-2013.
Disclosures: The research was sponsored by the National Institute on Alcohol Abuse and Alcoholism, and funded by the National Institutes of Health. The authors reported having no disclosures.
Online intervention aims to prevent teen depression
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
AT PAS 17
SAN FRANCISCO – One in eight teenagers experienced at least one major depressive episode in 2015, according to the National Institute for Mental Health. Yet the recent uptick in teen suicide rates suggests that U.S. mental health care services are not meeting their needs.
A team at the University of Illinois in Chicago, led by Benjamin Van Voorhees, MD, MPH, hopes so, and they have spent the past several years developing and testing such a program with a National Institute of Mental Health (NIMH) grant.
“Adolescents are in a really plastic moment in their psychobehavioral repertoire and brain development as they program themselves to adapt to adult life,” Dr. Van Voorhees said in an interview. “Right now we have nothing to offer those individuals other than an occasional referral to an overtaxed mental health system. The only rational strategy is a mass dissemination model, which is going to have to be technology.”
The CATCH-IT program is aimed at teens showing early signs of depression or predepressive symptoms as determined through screening during well checks or other visits for acute or chronic concerns. The study uses multiple screening tools in selecting participants, but Dr. Van Voorhees estimates that screening in practice would require about 1-2 minutes of a medical assistant’s or nurse’s time, followed by 1-2 minutes of the practitioner’s time for positive screens – “and one in five of those screens is going to be positive,” he said.
“The thing we want to convey to primary care practitioners is that these individuals are coming through your office every day, we’re doing nothing for them, and in some ways we are ignoring their enormous future potential adverse trajectory toward mental disorders,” he said.
The program includes 14 modules drawing on cognitive behavioral therapy, behavioral activation, interpersonal psychotherapy, and community resiliency. Six archetypal teens – such as teen living with a single mom or one whose parents are divorcing – are featured in each of the modules to demonstrate six ways of applying the strategies taught in that module. The archetypal teens are around 14-15 years old, but the program is aimed at teens aged 13-18 years, with a reading level at about grade 6, Dr. Van Voorhees said.
Two and a half years after those teens used the CATCH-IT intervention, they showed “a sustained reduction in automatic negative thoughts and educational impairment,” but no difference in their perceptions of support from family or friends. The lack of a control group in that pilot limits what conclusions can be drawn about the program’s effectiveness, but the researchers did learn that motivational interviewing led to greater engagement with the program, compared with teens who received a brief recommendation of it.
Therefore, in the subsequent – and still ongoing – study, physicians used motivational interviewing when offering teens the opportunity to join the program. That study does include a control group, in which participants are assigned a generic health education program online instead of CATCH-IT, and the randomized participants have been stratified by site, gender, and depression risk level.
The researchers first assessed the baseline characteristics of the population, recruited from 38 clinics in two cities. The study enrolled 369 teens aged 13-18 years – 248 in Chicago and 121 in Boston. All were identified as high risk for depression based on elevated scores on the Center for Epidemiological Studies Depression (CES-D) scale or the Kiddie Schedule for Affective Disorders Scale (K-SADS). Two thirds (68%) of participants are female, and most (63%) are in high school. About a third (34%) are in middle school. The racial/ethnic breakdown of the sample is 21% Hispanic, 26% black, 43% white, 4% Asian, 6% multiracial, and 1% other (which adds up to 101% due to rounding). More than half of the participants’ mothers (60%) and fathers (53%) were college graduates.
The teens completed the CES-D, the Screen for Child Related Anxiety Disorders (SCARED), the Beck Hopelessness Scale (BHS), the CRAFFT screening for adolescent substance misuse and the Disruptive Behaviors Disorder Scale (DBD-A). A parent of each teen also filled out the CES-D and DBD-A.
The baseline results did not suggest any concerns about substance use, hopelessness, or disruptive behaviors such as ADHD or conduct disorder. But the average scores on the CES-D and SCARED sat just at the threshold for a potential depressive or anxiety disorders. A CES-D score of at least 16 suggests a possible depressive disorder, and a SCARED score of at least 25 suggests a possible anxiety disorder. The mean scores on the teens’ CES-D were 17.7 in the Chicago cohort, 15.4 in the Boston cohort and 16.9 for the whole group. Similarly, the SCARED mean scores were 26.3 in the Chicago cohort, 23.5 in the Boston cohort and 25.3 overall.
Scores from K-SADS showed subthreshold levels of depressed mood in 36% of teens in both cities, and a nearly identical subthreshold level of irritability. Subthreshold anhedonia was identified in 20% of the overall population. One percent of the overall population had current suicidal ideation.
The next steps are to analyze outcomes among the participants, as the team is doing currently. They have just passed the 1-year anniversary of the trial and are analyzing the data they collected over the past year. The study will run an additional year for longer-term data collection.
One of the abstracts presented at PAS explored the economic implications of incorporating CATCH-IT in primary care.
“The cost for implementation is where the challenge is,” Dr. Van Voorhees said. “Screening takes time, and calling people takes time.” But when spread across a practice’s overall clientele in a year, the costs drop considerably, he said, and savings from effective identification and depression prevention may outweigh costs. The researchers have not yet conducted a cost-effectiveness study because they still are analyzing data on outcomes.
But Dr. Van Voorhees is optimistic about the possibilities of the program.
“What this entire model is about is, how do we understand what’s going on in the environment of the primary care clinic to find these people, identify them, and motivate them, and how can we give them something relevant enough to actually complete,” Dr. Van Voorhees said in the interview. “Then, let’s actually see if it changes their behavioral trajectory.”
The National Institute of Mental Health funded the research. Dr. Van Voorhees has consulted for Prevail Health Solutions, Mevident, Social Kinetics, and Hong Kong University on development of Internet-based interventions.
Office visit conversations are clues to teens’ predepressive symptoms
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
SAN FRANCISCO – if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.
“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”
To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.
The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.
Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.
The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.
“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”
The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.
The researchers identified four main categories of sadness expression:
• Feeling stressed, sad, or down, often involving crying and interfering with their lives.
• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”
• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”
• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.
“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”
For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”
The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.
The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.
“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”
The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
AT PAS 17
Key clinical point: Dialogue with teens at each visit may reveal predepressive symptoms indicating an opportunity for depression prevention.
Major finding: The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.
Data source: The findings are based on a qualitative analysis of 37 K-SADS interviews with teens aged 13-18 years from Chicago and Boston community pediatric clinics.
Disclosures: The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.
Prenatal methadone maintenance linked to poorer child neurodevelopment
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
SAN FRANCISCO – Infants born to mothers receiving methadone maintenance treatment show poorer-than-average neurodevelopment outcomes, a retrospective study found.
Delays or difficulties in motor abilities appeared first in these children, followed by evidence of cognitive problems in their second year of life, reported Cristina Borradori Tolsa, MD, of University Hospital, Geneva.
“Higher methadone doses during pregnancy can have a detrimental effect on neonatal characteristics and children’s psychomotor development,” Dr. Borradori Tolsa said at the Pediatric Academic Societies meeting. She noted the need for long-term follow-up of children prenatally exposed to methadone maintenance therapy to evaluate their cognitive abilities and school readiness at preschool ages.
Only 38% of the women had exclusively used methadone, while the other 62% had used a variety of substances, including cocaine, alcohol, benzodiazepine, marijuana, and antidepressants. The women had a low average socioeconomic status based on their level of education and the occupations of the children’s fathers.
The researchers drew children’s development data from their scores on the Bayley Scales of Infant Development, Second Edition (BSID-II), at 6 months and 18-24 months. The BSID-II has an average score of 100 and includes a mental development index for language and cognitive development, and a psychomotor development index to assess fine and gross motor skills.
At age 6 months, 75% of the 40 children assessed showed some level of motor skills delay, and 33% had a moderate to severe delay in psychomotor skills. A quarter had no delay at all (a score of at least 85). The average psychomotor score at 6 months was 76, and the average cognitive score was 88. Most of the children (60%) did, however, show mental development within the normal range at 6 months.
By the age of 18-24 months, half of the 36 children assessed showed no motor delays, and half showed no cognitive delays. One in five (20%) showed a moderate to severe psychomotor delay, and 14% showed a moderate to severe mental development delay. Mild delays in mental development occurred in 36% of the toddlers assessed, and 30% showed mild delays in psychomotor skills.
A dose-response effect was seen with mothers’ higher doses of methadone at birth and their children’s psychomotor scores at 6 months. No similar association existed for mental development, and the psychomotor association disappeared by 18-24 months. At this older age, however, 68% of children born to mothers taking a high dose of methadone showed cognitive delays, compared with 29% of children born to mothers on a low dose.
Although no differences were seen in newborns’ average gestational age (an average of 37.8 weeks overall) or birth weight between the high-dose and low-dose methadone groups, infants born to mothers with high doses were more likely to be small for gestational age (P = .01) and to need longer treatment duration for neonatal abstinence syndrome (NAS) (P = .03). Overall, 44% of the newborns were small for gestational age, 28% were born microcephalic, and all but three required pharmacologic treatment for NAS. NAS treatment lasted an average 54 days for the cohort, and the average hospital stay for the babies was 76 days.
The researchers did not report having any external funding or relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: Three-fourths of methadone-exposed infants showed psychomotor delays at 6 months, and 50% showed cognitive delays and/or psychomotor delays at 18-24 months.
Data source: A retrospective analysis of neurodevelopment scores of children born to 61 mothers in Geneva who received methadone maintenance therapy during pregnancy.
Disclosures: The researchers did not report having any external funding or relevant financial disclosures.
Teen suicide risk significant among screened nonresponders
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
SAN FRANCISCO – Teens who answered “no response” for one or more questions during a standard suicide screening in the ED typically have a risk of suicide nearly on par with those who answered “yes” to at least one question, results of a study showed.
“Risk for suicidality was substantial among both groups,” Tricia Hengehold of the University of Cincinnati reported at the Pediatric Academic Societies meeting. “About half of each group fit the medium-risk category, although the yes group had more teens in the high-risk category comparatively.”
In their study, she and her coinvestigators compared all teens who answered yes or no response (NR) to any question on the Ask Suicide-Screening Questions (ASQ). A total of 3,386 adolescents, aged 12-17 years, were screened when each presented to the ED with a complaint other than a psychiatric one. The data came from a preexisting study not initially designed for studying nonresponders.
The majority of teens (93%) answered no to all ASQ questions: 5% answered yes to at least one ASQ question, regardless of other answers, and 2% answered no response on at least one of the ASQ questions, but did not answer yes to any of them.
The average age of participants was 14 years among all response groups, but females were overrepresented in the yes and NR groups: 74% of females answered yes to one of the ASQ questions, compared with just 26% of males. Similarly, 79% of females were classified as nonresponders, vs. 21% of males. In the negative screen group, however, females (54%) and males (46%) were much more evenly represented.
Patients who answered yes or NR also were more likely to have Medicaid or Medicare than commercial insurance or a self-pay arrangement. Within the yes group, 56% had public insurance, and 39% had private insurance. In the NR group, 43% had public insurance, and 53% had private insurance.
Any teens who answered yes or NR should have undergone evaluation by a mental health professional, but those answering yes were more likely to get this evaluation than nonresponders. Nearly all (93%) of those answering yes received the evaluation, compared with 79% of nonresponders. Yet half of the nonresponders who were evaluated were recommended for further follow-up, not far behind the 65% recommended from among the yes group.
A clinically significant risk of suicide existed among 93% of those answering yes and 85% of nonresponders, the investigators found. About a third (33%) of the yes group were classified as high risk – suicidal ideation within the past week or no treatment after a previous attempt – while 16% of the nonresponders were.
“The NR group was more often in an earlier stage of change than the yes group, presenting with a greater percentage of teens in the precontemplation category,” Ms. Hengehold said. The precontemplation category, which included 27% of the NR group and 17% of the yes group, referred to teens who did not believe they would benefit from working with a mental health professional.
The contemplation category referred to teens who said they were still thinking about whether to meet with a mental health professional or that they would seek treatment if their suicidality worsened. This category included 9% of yes responders and 14% of nonresponders.
A higher proportion of yes responders (56%) than nonresponders (41%) had reached the preparation stage, which meant they had agreed to set up treatment or had received a referral within a month after their ED visit. A similar percentage of yes responders and nonresponders were currently in treatment, seeing a mental health professional intermittently, or had successfully received therapy.
“The sociodemographic characteristics of teens that endorse a no response are very similar to those of positive endorsers,” she concluded. She noted the potential importance of including an NR option on suicide-screening instruments.
Although nonresponders had clinically significant mental health concerns that indicated a need for further evaluation, these adolescents were less ready to engage in mental health services than those answering yes.
“This may be important when designing suicide risk interventions for each group,” she reported.
The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: Eighty-five percent of teens who were nonresponders on at least one suicide-screening question had a clinically significant risk of suicide, compared with 93% of those answering yes.
Data source: The findings are based on an analysis of responses from 3,386 adolescents screened for suicidality during a nonpsychiatric emergency department visit.
Disclosures: The research was funded by the National Institutes of Health. Ms. Hengehold and her associates reported no relevant financial disclosures.
Adoptions increasingly involve special needs, prenatal drug exposures
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
SAN FRANCISCO – International adoptions today almost exclusively involve children with special needs, and domestic adoptions are far more likely to involve children exposed prenatally to marijuana, opiates, or another drug, Lisa Prock, MD, MPH, found in a study.
“Pediatric health care providers reviewing referrals for adoption should be knowledgeable about the changing demographics of this population and the long-term implications of prenatal substance exposure, given increasing opiate and marijuana use nationally,” said Dr. Prock of Boston Children’s Hospital.
During the initial flood of international adoptions in the 1990s, families sought preadoption consultations, often centering on infectious disease, at an increasing number of adoption clinics. Even with the decline of international adoptions, however, prospective parents still frequently seek information from pediatric providers about children they are considering adopting, whether internationally or domestically.
Prospective parents can receive medical record reviews of children they are considering adopting, provided by adoption agencies or attorneys. Dr. Prock retrospectively reviewed all the preadoptive charts submitted to one adoption clinic during 2 years a decade apart: 63 charts in 2006 and 91 charts in 2016.
Domestic records for both years usually included information about family history, prenatal history, maternal substance abuse history, lab results, and, for newborns, a physical exam. International records, however, generally included only lab results and a physical exam, sometimes with limited information on substance abuse as well, at both time points.
The records reveal just how dramatically referrals have flipped from an international focus to a domestic one in the past decade. International adoption referrals dropped from 84% in 2006 to 29% in 2016 as domestic ones increased from 16% to 71%.
Children with special needs also account for a larger proportion of all adoption referrals today. Just a quarter of international adoption referrals in 2006 involved children with special needs, including cleft lip and/or palate and congenital heart disease, but nearly all international referrals (96%) involved special needs in 2016.
Similarly, domestic adoption referrals in which the child is known to have prenatal exposure to alcohol or drugs doubled from 30% in 2006 to 66% in 2016, driven predominantly by maternal use of marijuana and opiates, Dr. Prock found. It’s important both for providers and for prospective parents to be aware of the higher likelihood that an internationally adopted child will have significant medical and/or developmental needs and that domestically adopted children are more likely to have experienced prenatal drug or alcohol exposures.
“Prospective adoptive parents may benefit from increased understanding of the long-term impact of prenatal substance exposure to marijuana, opiates and other substances,” Dr. Prock said. She also noted the need for prospective parents to be aware of the mental health concerns that can co-occur with substance use even though they may not be reported in preadoptive medical records.
No external funding was used for the research. Dr. Prock had no relevant financial disclosures.
AT PAS 17
Key clinical point:
Major finding: International adoption referrals with special needs increased from 25% to 96% from 2006 to 2016; domestic referrals with prenatal substance exposure increased from 30% to 66% over the same time period.
Data source: A retrospective review of all preadoptive medical records at a single adoption clinic in 2006 and 2016.
Disclosures: The researchers did not receive external funding. Dr. Prock had no relevant financial disclosures.
More states require coverage of 1-year supplies of contraception
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Each semester, Sarah Prager, MD, runs through a familiar yet arduous routine: trying to prescribe a 6- to 12-month supply of oral contraceptives for her college student patients. For those young women who study abroad for one or two semesters, the usual 1-month or 3-month supply won’t be enough.
“I even had two patients who had unplanned pregnancies while studying abroad for this very reason,” said Dr. Prager, associate professor of obstetrics and gynecology at the University of Washington, Seattle. “It’s previously been a real challenge to write the letters, and it takes an absurd amount of time to even fail at getting them 6 months, or to make a plan for them to travel some place to get them.”
This type of policy has been in effect in California since Jan. 1, 2017, and a new study estimates that the measure will save the state nearly $43 million in health care costs while preventing thousands of unintended pregnancies, miscarriages, and abortions (Contraception. 2017 May;95[5]:449-51).
“Awareness of this change in policy will be key in determining how much of an impact it will have,” said Sara McMenamin, PhD, MPH, assistant professor of public health at the University of California, San Diego, and the study’s lead author.
Dr. McMenamin and her colleagues project that 38% of current users of the contraceptive pill, patch, and ring will begin receiving 12-month prescriptions at a time, leading to 15,000 fewer unintended pregnancies, 2,000 fewer miscarriages, and 7,000 fewer abortions every year. Health care costs would be reduced by 0.03%, translating to approximately $42.8 million annually.
There are potential environmental concerns to pill wastage as well, such as keeping it out of river systems and drinking water, Dr. Prager noted.
The California law’s effects will not happen immediately, so there may be a delay in reaching the study’s projections. “These results likely represent an overestimation in the short term, as it will likely take some time to change provider and patient behavior and increase awareness of the new policy,” Dr. McMenamin said.
But the idea is catching on. In 2016, Oregon, Hawaii, Illinois, Maryland, Vermont, and the District of Columbia enacted legislation requiring insurers to cover extended supplies of contraception. Since then, Washington state, Colorado, Virginia, and Nevada have approved similar laws and more than a dozen other states have introduced similar legislation.
Importantly, the effects of this type of coverage cut across demographics, Dr. Prager said.
“I think there’s this perception by many that these are challenges experienced by women who are underresourced or poor or teenagers, and they’re not,” Dr. Prager said. “People are busy, and it’s rare for working adults to have to think about getting to a pharmacy on a regular basis. Contraception is the exception.”
In addition, some women may experience coverage gaps that prevent refills during a job change or other insurance change. Women who travel a lot, for college or work, can have a harder time getting their refills, as well. And women in rural areas may need to drive up to an hour for a pharmacy.
“These are real-life concerns for people of all socioeconomic strata of all ages,” Dr. Prager said. “If you’re off by even a day, then a woman is at risk of pregnancy.”
The California study was supported by the California Health Benefits Review Program. Dr. Prager reported being an unpaid trainer for Nexplanon (Merck).
Telemedicine visits after NICU discharge improved care, processes
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
SAN FRANCISCO – Using telemedicine for a follow-up appointment 1 week after discharge of medically complex infants reduced extra visits or calls to a clinic or emergency department, a recent study found.
The telemedicine visits also helped providers identify ways to improve the neonatal ICU (NICU) discharge process while assessing infants’ home care and answering parents’ questions.
The researchers assessed whether telemedicine visits could ease the transition from neonatal intensive care to home care, respond adequately to caregivers’ needs during that transition, reduce emergency department visits and readmissions, and detect and address any potential problems. The visits also provided an opportunity for feedback on caregivers’ experiences during discharge.
The 92 patients all were medically complex infants who went home with respiratory or feeding equipment, surgical sites and/or complex medication administration. For example, 28 infants had been sent home with a nasogastric tube, 13 had a gastrostomy tube, and 13 had an apnea monitor. Overall, participants had been discharged with an average 2.3 medications and 4.8 scheduled subspecialty follow-up appointments.
The most common conditions among the participants were gastrointestinal disease, neurologic disease, and congenital diaphragmatic hernia or lung lesions. Other conditions included omphalocele, genetic disorders, tracheoesophageal fistula or esophageal atresia and chronic lung disease, or another respiratory disease, Dr. Brant reported at the Pediatric Academic Societies meeting.
Families could enroll in the study only if they had a smart device (such as a tablet) and wireless Internet access at home. One week after the infant’s discharge from the NICU, the caregivers received one telemedicine visit with a team that included neonatologists, neonatal fellows, nurse practitioners, and a telemedicine coordinator or support staffer. During the visit, the providers observed the infant and the home environment, and evaluated care practices, including tube feedings, respiratory support, management of surgical wound sites, and administration of medications.
The providers also reviewed how to use the medical equipment, gathered follow-up information about the child’s health, and answered caregivers’ questions. The providers did not bill for telemedicine visits since it was part of a pilot study, but the participants did need to reside in Pennsylvania or New Jersey to meet provider licensing regulations.
Among the 93 telemedicine visits, half (50%) prevented the family from calling or visiting a provider, and 12% of them led to an earlier follow-up appointment for the child. During the video observations, providers addressed 14 issues related to the child’s sleep environment, respiratory status, surgical sites, or dermatological issues. Among 78 total concerns identified in the visits, 35% related to the surgical site, 33% related to feeding, 19% related to respiratory concerns, and 13% related to medication administration.
The provider team also asked families during the visit about their experiences during discharge. A quarter of the families (26%) said they needed more parental education during discharge. In addition, 14% mentioned problems with scheduling follow-up appointments, and 12% had problems related to case management and insurance. Other issues raised by parents related to home equipment, early intervention, home feeding or medications, and diagnostic logistics.
In subsequent satisfaction surveys filled out by caregivers about the telemedicine visit itself, the median rating was 94.5 on a scale of 0 (not at all satisfied) to 100 (extremely satisfied). The overall intervention was 92% successful in its completion. The only follow-up telemedicine visits that did not occur resulted from malfunctioning wireless connection or a mobile app problem. On a scale of 1 to 100 (best), caregivers rated the video quality as an average 78, the Internet reliability as 79, and the ease of using the camera as 91. One of the biggest benefits of the intervention, Dr. Brant pointed out, is that using telemedicine bypasses some of the geographic and time-related obstacles that can occur with follow-ups.
Dr. Brant had no relevant financial disclosures and did not report using any external funding.
FROM PAS 17
Key clinical point:
Major finding: Telemedicine visits prevented 50% of participants from calling or visiting a provider and led 12% of families to bring infants in sooner than originally scheduled.
Data source: The findings are based on a pilot project at the Children’s Hospital of Philadelphia involving 93 medically complex infants discharged from the NICU with medical equipment, surgical sites, and/or complex medication administration.
Disclosures: Dr. Brant had no relevant financial disclosures and did not report external funding.