SAN DIEGO – Hyperbaric oxygen therapy, a mainstay of wound care, has a long and controversial history as a treatment for diabetic foot ulcers. Conflicting studies have spawned plenty of debate, and the most recent Cochrane Library review of existing research didn’t shed much light on the value of the treatment because the evidence was weak (Cochrane Database Syst Rev. 2015 Jun 24;[6]:CD004123).

But William H. Tettelbach, MD, a wound care specialist, told an audience at the annual scientific sessions of the American Diabetic Association that hyperbaric treatments are worth a try in certain cases. And he brought evidence to prove it – a 2015 report he coauthored that reviewed studies and offered clinical practice guidelines for hyperbaric oxygen therapy for the treatment of diabetic foot ulcers (DFUs) (Undersea Hyperb Med. 2015 May-Jun;42[3]:205-47).

“It’s an arrow that we need in our quiver to get better results,” said Dr. Tettelbach, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City and adjunct assistant professor at Duke University, Durham, N.C.

In an interview, Dr. Tettelbach discussed ideal candidates for the treatment and offered clinical advice to endocrinologists.
 

Question: What did your review of research tell you about the value of hyperbaric oxygen treatment for DFUs?

Answer: We came to the same conclusion that most of the papers have indicated over the years: Hyperbaric oxygen is effective and attains goals such as reducing rates of amputation in a select population of diabetic ulcer patients.

Patients who have Wagner grade 3 or greater ulcers or admitted for surgery due to a septic diabetic foot benefit from an evaluation by a hyperbaric medicine–trained physician and treatment when indicated. There is evidence and years of clinical experience indicating that these patients benefit and have improved outcomes when evaluated and treated appropriately with hyperbaric oxygen therapy.

In the United States, hyperbaric oxygen therapy is not indicated in Wagner grade 2, 1 or 0 diabetic foot ulcers, the ulcers that involve soft tissue but not deep structure like bone.
 

Q: Why has there been so much controversy over the value of this treatment? 

A: In the past, there have been problems with commercial outpatient wound centers that are heavily driven by profits. Financial margins in wound care clinics can be tight, and the need to remain profitable has at times resulted in patients being treated inappropriately with hyperbaric oxygen therapy (Adv Skin Wound Care. 2017 Apr;30[4]:181-90).

Q: Why does hyperbaric oxygen treatment work in some cases?

A: When you place a patient in a hyperbaric chamber where they breathe 100% oxygen under pressure, you increase the percentage of oxygen in the blood. At such a high percentage, oxygen saturates the plasma versus just being carried by red blood cells, thereby allowing the oxygen to penetrate farther into hypoxic tissues. By increasing the oxygen, you have the ability to make the environment unfavorable for rapid proliferation of anaerobic or microaerophilic bacteria that do not survive a highly oxygen-rich environment. Increasing tissue oxygen tension to 30 mm Hg or greater increases the macrophages’ ability to have an oxidative burst needed to kill bacteria. Furthermore, there are antibiotics that require certain levels of oxygen for transport across the bacterial cell wall.

Q: What should physicians understand about hyperbaric oxygen therapy for DFUs?

A: Overall, hyperbaric practitioners need to be more selective in identifying and treating patients according to what the evidence supports. Poorly designed trials with misleading results should not drive medical decisions. We should revisit diabetic foot ulcers through well-thought-out studies that target those who would benefit as suggested by current evidence. Prior trials have been heavily weighted with Wagner grade 1 and 2 candidates or ischemic diabetic ulcers that are not revascularized. These are biased toward poor outcomes since the current evidence does not strongly support treating these types of individuals with adjunctive hyperbaric oxygen therapy (Ont Health Technol Assess Ser. 2017 May 12;17[5]:1-142. eCollection 2017).

Q: What conditions should trigger endocrinologists to think about hyperbaric oxygen therapy for their DFU patients?

A: Candidates for the therapy include diabetic ulcers that have persisted for longer than 30 days, since these ulcers are at a significantly higher risk of a complicating infection, along with those that have failed treatment or are becoming more symptomatic over time (Undersea Hyperb Med. 2017 Mar-Apr;44[2]:157-60). 

At that point, it might make sense to refer those patients to a wound and hyperbaric specialist for further evaluation and management, especially to a wound center that offers hyperbaric oxygen therapy.  

These wound centers can be found in smaller towns. But some folks will have to travel, perhaps to a wound center at a hospital that has room and board like they do for cancer patients. 
 

 

Q: What about treatment after surgery?

A: Using hyperbariatric oxygen therapy to treat inpatients with septic diabetic foot ulcers – Wagner grade 3 or higher – immediately after surgery may reduce length of stay as well as lower the risk of requiring multiple surgical debridements. 

Q: What are the best-case scenarios for treatment?

A: A significant portion of what we do is limb preservation. Hyperbaric oxygen therapy often can help save a digit, forefoot, or even an extremity. 

But it’s not something that just happens overnight. It’s a long-term process. Underlying complicating osteomyelitis may require up to 40-60 adjunctive hyperbaric oxygen treatments, 5 days a week with weekends off, along with concurrent antibiotics, wound care, and vascular interventions when indicated. 
 

Q: Is insurance ever an issue for this treatment?

A: Typically, not if one follows the indications set by the Centers for Medicare & Medicaid Services and the Undersea and Hyperbaric Medical Society.

Medicare lists 15 medical indications that it will cover, and a majority of commercial insurers will cover the same 15 indications and possibly more. But commercial insurers may require prior authorization of medical necessity before preceding with hyperbaric oxygen therapy (Diving Hyperb Med. 2016 Sep;46[3]:133-4).

 

SAN DIEGO – Hyperbaric oxygen therapy, a mainstay of wound care, has a long and controversial history as a treatment for diabetic foot ulcers. Conflicting studies have spawned plenty of debate, and the most recent Cochrane Library review of existing research didn’t shed much light on the value of the treatment because the evidence was weak (Cochrane Database Syst Rev. 2015 Jun 24;[6]:CD004123).

But William H. Tettelbach, MD, a wound care specialist, told an audience at the annual scientific sessions of the American Diabetic Association that hyperbaric treatments are worth a try in certain cases. And he brought evidence to prove it – a 2015 report he coauthored that reviewed studies and offered clinical practice guidelines for hyperbaric oxygen therapy for the treatment of diabetic foot ulcers (DFUs) (Undersea Hyperb Med. 2015 May-Jun;42[3]:205-47).

“It’s an arrow that we need in our quiver to get better results,” said Dr. Tettelbach, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City and adjunct assistant professor at Duke University, Durham, N.C.

In an interview, Dr. Tettelbach discussed ideal candidates for the treatment and offered clinical advice to endocrinologists.
 

Question: What did your review of research tell you about the value of hyperbaric oxygen treatment for DFUs?

Answer: We came to the same conclusion that most of the papers have indicated over the years: Hyperbaric oxygen is effective and attains goals such as reducing rates of amputation in a select population of diabetic ulcer patients.

Patients who have Wagner grade 3 or greater ulcers or admitted for surgery due to a septic diabetic foot benefit from an evaluation by a hyperbaric medicine–trained physician and treatment when indicated. There is evidence and years of clinical experience indicating that these patients benefit and have improved outcomes when evaluated and treated appropriately with hyperbaric oxygen therapy.

In the United States, hyperbaric oxygen therapy is not indicated in Wagner grade 2, 1 or 0 diabetic foot ulcers, the ulcers that involve soft tissue but not deep structure like bone.
 

Q: Why has there been so much controversy over the value of this treatment? 

A: In the past, there have been problems with commercial outpatient wound centers that are heavily driven by profits. Financial margins in wound care clinics can be tight, and the need to remain profitable has at times resulted in patients being treated inappropriately with hyperbaric oxygen therapy (Adv Skin Wound Care. 2017 Apr;30[4]:181-90).

Q: Why does hyperbaric oxygen treatment work in some cases?

A: When you place a patient in a hyperbaric chamber where they breathe 100% oxygen under pressure, you increase the percentage of oxygen in the blood. At such a high percentage, oxygen saturates the plasma versus just being carried by red blood cells, thereby allowing the oxygen to penetrate farther into hypoxic tissues. By increasing the oxygen, you have the ability to make the environment unfavorable for rapid proliferation of anaerobic or microaerophilic bacteria that do not survive a highly oxygen-rich environment. Increasing tissue oxygen tension to 30 mm Hg or greater increases the macrophages’ ability to have an oxidative burst needed to kill bacteria. Furthermore, there are antibiotics that require certain levels of oxygen for transport across the bacterial cell wall.

Q: What should physicians understand about hyperbaric oxygen therapy for DFUs?

A: Overall, hyperbaric practitioners need to be more selective in identifying and treating patients according to what the evidence supports. Poorly designed trials with misleading results should not drive medical decisions. We should revisit diabetic foot ulcers through well-thought-out studies that target those who would benefit as suggested by current evidence. Prior trials have been heavily weighted with Wagner grade 1 and 2 candidates or ischemic diabetic ulcers that are not revascularized. These are biased toward poor outcomes since the current evidence does not strongly support treating these types of individuals with adjunctive hyperbaric oxygen therapy (Ont Health Technol Assess Ser. 2017 May 12;17[5]:1-142. eCollection 2017).

Q: What conditions should trigger endocrinologists to think about hyperbaric oxygen therapy for their DFU patients?

A: Candidates for the therapy include diabetic ulcers that have persisted for longer than 30 days, since these ulcers are at a significantly higher risk of a complicating infection, along with those that have failed treatment or are becoming more symptomatic over time (Undersea Hyperb Med. 2017 Mar-Apr;44[2]:157-60). 

At that point, it might make sense to refer those patients to a wound and hyperbaric specialist for further evaluation and management, especially to a wound center that offers hyperbaric oxygen therapy.  

These wound centers can be found in smaller towns. But some folks will have to travel, perhaps to a wound center at a hospital that has room and board like they do for cancer patients. 
 

 

Q: What about treatment after surgery?

A: Using hyperbariatric oxygen therapy to treat inpatients with septic diabetic foot ulcers – Wagner grade 3 or higher – immediately after surgery may reduce length of stay as well as lower the risk of requiring multiple surgical debridements. 

Q: What are the best-case scenarios for treatment?

A: A significant portion of what we do is limb preservation. Hyperbaric oxygen therapy often can help save a digit, forefoot, or even an extremity. 

But it’s not something that just happens overnight. It’s a long-term process. Underlying complicating osteomyelitis may require up to 40-60 adjunctive hyperbaric oxygen treatments, 5 days a week with weekends off, along with concurrent antibiotics, wound care, and vascular interventions when indicated. 
 

Q: Is insurance ever an issue for this treatment?

A: Typically, not if one follows the indications set by the Centers for Medicare & Medicaid Services and the Undersea and Hyperbaric Medical Society.

Medicare lists 15 medical indications that it will cover, and a majority of commercial insurers will cover the same 15 indications and possibly more. But commercial insurers may require prior authorization of medical necessity before preceding with hyperbaric oxygen therapy (Diving Hyperb Med. 2016 Sep;46[3]:133-4).

 

SAN DIEGO – Hyperbaric oxygen therapy, a mainstay of wound care, has a long and controversial history as a treatment for diabetic foot ulcers. Conflicting studies have spawned plenty of debate, and the most recent Cochrane Library review of existing research didn’t shed much light on the value of the treatment because the evidence was weak (Cochrane Database Syst Rev. 2015 Jun 24;[6]:CD004123).

But William H. Tettelbach, MD, a wound care specialist, told an audience at the annual scientific sessions of the American Diabetic Association that hyperbaric treatments are worth a try in certain cases. And he brought evidence to prove it – a 2015 report he coauthored that reviewed studies and offered clinical practice guidelines for hyperbaric oxygen therapy for the treatment of diabetic foot ulcers (DFUs) (Undersea Hyperb Med. 2015 May-Jun;42[3]:205-47).

“It’s an arrow that we need in our quiver to get better results,” said Dr. Tettelbach, systems medical director of Wound Care & Hyperbaric Medicine Services at Intermountain Healthcare in Salt Lake City and adjunct assistant professor at Duke University, Durham, N.C.

In an interview, Dr. Tettelbach discussed ideal candidates for the treatment and offered clinical advice to endocrinologists.
 

Question: What did your review of research tell you about the value of hyperbaric oxygen treatment for DFUs?

Answer: We came to the same conclusion that most of the papers have indicated over the years: Hyperbaric oxygen is effective and attains goals such as reducing rates of amputation in a select population of diabetic ulcer patients.

Patients who have Wagner grade 3 or greater ulcers or admitted for surgery due to a septic diabetic foot benefit from an evaluation by a hyperbaric medicine–trained physician and treatment when indicated. There is evidence and years of clinical experience indicating that these patients benefit and have improved outcomes when evaluated and treated appropriately with hyperbaric oxygen therapy.

In the United States, hyperbaric oxygen therapy is not indicated in Wagner grade 2, 1 or 0 diabetic foot ulcers, the ulcers that involve soft tissue but not deep structure like bone.
 

Q: Why has there been so much controversy over the value of this treatment? 

A: In the past, there have been problems with commercial outpatient wound centers that are heavily driven by profits. Financial margins in wound care clinics can be tight, and the need to remain profitable has at times resulted in patients being treated inappropriately with hyperbaric oxygen therapy (Adv Skin Wound Care. 2017 Apr;30[4]:181-90).

Q: Why does hyperbaric oxygen treatment work in some cases?

A: When you place a patient in a hyperbaric chamber where they breathe 100% oxygen under pressure, you increase the percentage of oxygen in the blood. At such a high percentage, oxygen saturates the plasma versus just being carried by red blood cells, thereby allowing the oxygen to penetrate farther into hypoxic tissues. By increasing the oxygen, you have the ability to make the environment unfavorable for rapid proliferation of anaerobic or microaerophilic bacteria that do not survive a highly oxygen-rich environment. Increasing tissue oxygen tension to 30 mm Hg or greater increases the macrophages’ ability to have an oxidative burst needed to kill bacteria. Furthermore, there are antibiotics that require certain levels of oxygen for transport across the bacterial cell wall.

Q: What should physicians understand about hyperbaric oxygen therapy for DFUs?

A: Overall, hyperbaric practitioners need to be more selective in identifying and treating patients according to what the evidence supports. Poorly designed trials with misleading results should not drive medical decisions. We should revisit diabetic foot ulcers through well-thought-out studies that target those who would benefit as suggested by current evidence. Prior trials have been heavily weighted with Wagner grade 1 and 2 candidates or ischemic diabetic ulcers that are not revascularized. These are biased toward poor outcomes since the current evidence does not strongly support treating these types of individuals with adjunctive hyperbaric oxygen therapy (Ont Health Technol Assess Ser. 2017 May 12;17[5]:1-142. eCollection 2017).

Q: What conditions should trigger endocrinologists to think about hyperbaric oxygen therapy for their DFU patients?

A: Candidates for the therapy include diabetic ulcers that have persisted for longer than 30 days, since these ulcers are at a significantly higher risk of a complicating infection, along with those that have failed treatment or are becoming more symptomatic over time (Undersea Hyperb Med. 2017 Mar-Apr;44[2]:157-60). 

At that point, it might make sense to refer those patients to a wound and hyperbaric specialist for further evaluation and management, especially to a wound center that offers hyperbaric oxygen therapy.  

These wound centers can be found in smaller towns. But some folks will have to travel, perhaps to a wound center at a hospital that has room and board like they do for cancer patients. 
 

 

Q: What about treatment after surgery?

A: Using hyperbariatric oxygen therapy to treat inpatients with septic diabetic foot ulcers – Wagner grade 3 or higher – immediately after surgery may reduce length of stay as well as lower the risk of requiring multiple surgical debridements. 

Q: What are the best-case scenarios for treatment?

A: A significant portion of what we do is limb preservation. Hyperbaric oxygen therapy often can help save a digit, forefoot, or even an extremity. 

But it’s not something that just happens overnight. It’s a long-term process. Underlying complicating osteomyelitis may require up to 40-60 adjunctive hyperbaric oxygen treatments, 5 days a week with weekends off, along with concurrent antibiotics, wound care, and vascular interventions when indicated. 
 

Q: Is insurance ever an issue for this treatment?

A: Typically, not if one follows the indications set by the Centers for Medicare & Medicaid Services and the Undersea and Hyperbaric Medical Society.

Medicare lists 15 medical indications that it will cover, and a majority of commercial insurers will cover the same 15 indications and possibly more. But commercial insurers may require prior authorization of medical necessity before preceding with hyperbaric oxygen therapy (Diving Hyperb Med. 2016 Sep;46[3]:133-4).

Madrid – A combination of the investigational cyclin-dependent kinase 4/6 (CDK4/6) agent abemaciclib and a nonsteroidal aromatase inhibitor (AI) was associated with a near doubling of progression-free survival in postmenopausal women with previously untreated hormone-receptor positive, human epidermal growth factor receptor 2–negative (HR+/HER2-) advanced breast cancer.

At a planned 18-month interim analysis of the MONARCH 3 trial, the median investigator-assessed progression free survival (PFS), the primary endpoint, had not been reached for 328 patients assigned to receive abemaciclib with either anastrozole (Arimidex) or letrozole (Femara). In contrast, the median PFS for 165 patients assigned to an AI and a placebo was 14.7 months, translating into a hazard ratio (HR) of 0.543 (P = .000021), reported Angelo Di Leo, MD, of Hospital of Prato, Istituto Toscano Tumori, Prato, Italy.

“Abemaciclib in combination with a nonsteroidal aromatase inhibitor is superior to a nonsteroidal aromatase inhibitor alone in terms of progression-free survival, but also in terms of the objective response rate as the initial treatment of HER2-negative, endocrine sensitive advanced breast cancer,” he said at a briefing prior to his presentation of the data in a presidential symposium at the European Society for Medical Oncology Congress.

Neil Osterweil/Frontline Medical News

The efficacy of abemaciclib was consistently seen across all subgroups.

“However, we have observed that the patients deriving the largest benefit from abemaciclib are those who have adverse prognostic factors such as, for instance, the presence of liver metastases, or the fact the disease has relapsed only after a few years from the end of adjuvant endocrine therapy,” he added.

The study was stopped for efficacy at the interim analysis.

Abemaciclib has previously been shown to be active as a monotherapy in treatment-refractory HR+/HER2- breast cancer, and in combination with fulvestrant (Faslodex) in patients who had disease progression on endocrine therapy.

Dr. Di Leo and his colleagues enrolled 493 postmenopausal women with metastatic or locally recurrent HR+/HER2- breast cancer who had not received systemic therapy in this setting. Patients who had prior neoadjuvant or adjuvant endocrine therapy were allowed if they had a disease-free interval of more than 1 year since completing endocrine therapy, The patients also had to have good performance status (Eastern Cooperative Oncology Group PS score 1 or less).

They were randomly assigned on a 2:1 basis to receive abemaciclib 150 mg b.i.d. on a continuous schedule plus either anastrozole 1 mg or letrozole 2.5 mg daily until disease progression, or to placebo plus either of the two AIs.

In addition to the superior PFS with abemaciclib added to an AI, as noted before, the CDK4/6 inhibitor was associated with a significantly better objective response rate (ORR), at 48.2% compared with 34.5% for placebo (P = .002). Among patients with measurable disease at baseline, the respective ORRs were 59.2% and 43.8% (P = .004). The clinical benefit rate in this subgroup was also better with abemaciclib, at 79.3% vs. 69.2% (P = .024).

In exploratory subgroup analyses, the investigators found that patients who had indicators of poor prognosis seemed to derive “substantial” benefit from the addition of abemaciclib. However, in an exploratory analysis in patients with disease only in bone, the investigators found that adding abemaciclib did not appear to improve PFS, suggesting that this subgroup could be treated effectively with endocrine therapy alone. Dr. Di Leo cautioned against overinterpreting this finding however, as only 109 patients had bone-only disease.

The safety analysis showed that patients were able to tolerate the combination fairly well. The incidence of grade 3 or 4 neutropenia was 21.1% with the combination compared with 1.2% with placebo, and grade 3 diarrhea occurred in 9.5% vs. 1.2% (no grade 4 diarrhea in either arm). The diarrhea tended to occur early in therapy and could be managed with dose adjustments and antidiarrheal medications, Dr. Di Leo said.

“What we would like to ask is, is this a practice-changing study? Do the results change standard first-line endocrine-based therapy, and then do these results change who we give endocrine therapy to?,” said invited discussant Nicholas Turner, PhD, of The Royal Marsden Hospital in London.

“The study stopped at the reported interim analysis, so at the moment the abemaciclib arm hasn’t reached the median PFS, but we can anticipate that with further follow-up we will see approximately a year improvement in median PFS by the addition of abemaciclib, which is really a substantial improvement in PFS for these patients. And importantly, this benefit was confirmed by a blinded independent central review of the investigator PFS,” he said.

Eli Lilly funded MONARCH 3. Dr. Di Leo and Dr. Turner reported receiving honoraria from the company.
 

 

[email protected]

Madrid – A combination of the investigational cyclin-dependent kinase 4/6 (CDK4/6) agent abemaciclib and a nonsteroidal aromatase inhibitor (AI) was associated with a near doubling of progression-free survival in postmenopausal women with previously untreated hormone-receptor positive, human epidermal growth factor receptor 2–negative (HR+/HER2-) advanced breast cancer.

At a planned 18-month interim analysis of the MONARCH 3 trial, the median investigator-assessed progression free survival (PFS), the primary endpoint, had not been reached for 328 patients assigned to receive abemaciclib with either anastrozole (Arimidex) or letrozole (Femara). In contrast, the median PFS for 165 patients assigned to an AI and a placebo was 14.7 months, translating into a hazard ratio (HR) of 0.543 (P = .000021), reported Angelo Di Leo, MD, of Hospital of Prato, Istituto Toscano Tumori, Prato, Italy.

“Abemaciclib in combination with a nonsteroidal aromatase inhibitor is superior to a nonsteroidal aromatase inhibitor alone in terms of progression-free survival, but also in terms of the objective response rate as the initial treatment of HER2-negative, endocrine sensitive advanced breast cancer,” he said at a briefing prior to his presentation of the data in a presidential symposium at the European Society for Medical Oncology Congress.

Neil Osterweil/Frontline Medical News

The efficacy of abemaciclib was consistently seen across all subgroups.

“However, we have observed that the patients deriving the largest benefit from abemaciclib are those who have adverse prognostic factors such as, for instance, the presence of liver metastases, or the fact the disease has relapsed only after a few years from the end of adjuvant endocrine therapy,” he added.

The study was stopped for efficacy at the interim analysis.

Abemaciclib has previously been shown to be active as a monotherapy in treatment-refractory HR+/HER2- breast cancer, and in combination with fulvestrant (Faslodex) in patients who had disease progression on endocrine therapy.

Dr. Di Leo and his colleagues enrolled 493 postmenopausal women with metastatic or locally recurrent HR+/HER2- breast cancer who had not received systemic therapy in this setting. Patients who had prior neoadjuvant or adjuvant endocrine therapy were allowed if they had a disease-free interval of more than 1 year since completing endocrine therapy, The patients also had to have good performance status (Eastern Cooperative Oncology Group PS score 1 or less).

They were randomly assigned on a 2:1 basis to receive abemaciclib 150 mg b.i.d. on a continuous schedule plus either anastrozole 1 mg or letrozole 2.5 mg daily until disease progression, or to placebo plus either of the two AIs.

In addition to the superior PFS with abemaciclib added to an AI, as noted before, the CDK4/6 inhibitor was associated with a significantly better objective response rate (ORR), at 48.2% compared with 34.5% for placebo (P = .002). Among patients with measurable disease at baseline, the respective ORRs were 59.2% and 43.8% (P = .004). The clinical benefit rate in this subgroup was also better with abemaciclib, at 79.3% vs. 69.2% (P = .024).

In exploratory subgroup analyses, the investigators found that patients who had indicators of poor prognosis seemed to derive “substantial” benefit from the addition of abemaciclib. However, in an exploratory analysis in patients with disease only in bone, the investigators found that adding abemaciclib did not appear to improve PFS, suggesting that this subgroup could be treated effectively with endocrine therapy alone. Dr. Di Leo cautioned against overinterpreting this finding however, as only 109 patients had bone-only disease.

The safety analysis showed that patients were able to tolerate the combination fairly well. The incidence of grade 3 or 4 neutropenia was 21.1% with the combination compared with 1.2% with placebo, and grade 3 diarrhea occurred in 9.5% vs. 1.2% (no grade 4 diarrhea in either arm). The diarrhea tended to occur early in therapy and could be managed with dose adjustments and antidiarrheal medications, Dr. Di Leo said.

“What we would like to ask is, is this a practice-changing study? Do the results change standard first-line endocrine-based therapy, and then do these results change who we give endocrine therapy to?,” said invited discussant Nicholas Turner, PhD, of The Royal Marsden Hospital in London.

“The study stopped at the reported interim analysis, so at the moment the abemaciclib arm hasn’t reached the median PFS, but we can anticipate that with further follow-up we will see approximately a year improvement in median PFS by the addition of abemaciclib, which is really a substantial improvement in PFS for these patients. And importantly, this benefit was confirmed by a blinded independent central review of the investigator PFS,” he said.

Eli Lilly funded MONARCH 3. Dr. Di Leo and Dr. Turner reported receiving honoraria from the company.
 

 

[email protected]

Madrid – A combination of the investigational cyclin-dependent kinase 4/6 (CDK4/6) agent abemaciclib and a nonsteroidal aromatase inhibitor (AI) was associated with a near doubling of progression-free survival in postmenopausal women with previously untreated hormone-receptor positive, human epidermal growth factor receptor 2–negative (HR+/HER2-) advanced breast cancer.

At a planned 18-month interim analysis of the MONARCH 3 trial, the median investigator-assessed progression free survival (PFS), the primary endpoint, had not been reached for 328 patients assigned to receive abemaciclib with either anastrozole (Arimidex) or letrozole (Femara). In contrast, the median PFS for 165 patients assigned to an AI and a placebo was 14.7 months, translating into a hazard ratio (HR) of 0.543 (P = .000021), reported Angelo Di Leo, MD, of Hospital of Prato, Istituto Toscano Tumori, Prato, Italy.

“Abemaciclib in combination with a nonsteroidal aromatase inhibitor is superior to a nonsteroidal aromatase inhibitor alone in terms of progression-free survival, but also in terms of the objective response rate as the initial treatment of HER2-negative, endocrine sensitive advanced breast cancer,” he said at a briefing prior to his presentation of the data in a presidential symposium at the European Society for Medical Oncology Congress.

Neil Osterweil/Frontline Medical News

The efficacy of abemaciclib was consistently seen across all subgroups.

“However, we have observed that the patients deriving the largest benefit from abemaciclib are those who have adverse prognostic factors such as, for instance, the presence of liver metastases, or the fact the disease has relapsed only after a few years from the end of adjuvant endocrine therapy,” he added.

The study was stopped for efficacy at the interim analysis.

Abemaciclib has previously been shown to be active as a monotherapy in treatment-refractory HR+/HER2- breast cancer, and in combination with fulvestrant (Faslodex) in patients who had disease progression on endocrine therapy.

Dr. Di Leo and his colleagues enrolled 493 postmenopausal women with metastatic or locally recurrent HR+/HER2- breast cancer who had not received systemic therapy in this setting. Patients who had prior neoadjuvant or adjuvant endocrine therapy were allowed if they had a disease-free interval of more than 1 year since completing endocrine therapy, The patients also had to have good performance status (Eastern Cooperative Oncology Group PS score 1 or less).

They were randomly assigned on a 2:1 basis to receive abemaciclib 150 mg b.i.d. on a continuous schedule plus either anastrozole 1 mg or letrozole 2.5 mg daily until disease progression, or to placebo plus either of the two AIs.

In addition to the superior PFS with abemaciclib added to an AI, as noted before, the CDK4/6 inhibitor was associated with a significantly better objective response rate (ORR), at 48.2% compared with 34.5% for placebo (P = .002). Among patients with measurable disease at baseline, the respective ORRs were 59.2% and 43.8% (P = .004). The clinical benefit rate in this subgroup was also better with abemaciclib, at 79.3% vs. 69.2% (P = .024).

In exploratory subgroup analyses, the investigators found that patients who had indicators of poor prognosis seemed to derive “substantial” benefit from the addition of abemaciclib. However, in an exploratory analysis in patients with disease only in bone, the investigators found that adding abemaciclib did not appear to improve PFS, suggesting that this subgroup could be treated effectively with endocrine therapy alone. Dr. Di Leo cautioned against overinterpreting this finding however, as only 109 patients had bone-only disease.

The safety analysis showed that patients were able to tolerate the combination fairly well. The incidence of grade 3 or 4 neutropenia was 21.1% with the combination compared with 1.2% with placebo, and grade 3 diarrhea occurred in 9.5% vs. 1.2% (no grade 4 diarrhea in either arm). The diarrhea tended to occur early in therapy and could be managed with dose adjustments and antidiarrheal medications, Dr. Di Leo said.

“What we would like to ask is, is this a practice-changing study? Do the results change standard first-line endocrine-based therapy, and then do these results change who we give endocrine therapy to?,” said invited discussant Nicholas Turner, PhD, of The Royal Marsden Hospital in London.

“The study stopped at the reported interim analysis, so at the moment the abemaciclib arm hasn’t reached the median PFS, but we can anticipate that with further follow-up we will see approximately a year improvement in median PFS by the addition of abemaciclib, which is really a substantial improvement in PFS for these patients. And importantly, this benefit was confirmed by a blinded independent central review of the investigator PFS,” he said.

Eli Lilly funded MONARCH 3. Dr. Di Leo and Dr. Turner reported receiving honoraria from the company.
 

 

[email protected]

 

SILVER SPRING, MD. – Alopecia areata patients struggle as much, if not more so, with the social and emotional challenges of the disease as with the physical challenges, according to patients and others who spoke at a public meeting on alopecia areata patient-focused drug development.

Alopecia areata affects as many as 6.8 million individuals in the United States, according to the National Alopecia Areata Foundation (NAAF). However, the particulars of alopecia can vary widely from one person to another; some patients experience total hair loss (alopecia universalis), while others retain eyebrows, eyelashes, or some body hair.

The FDA meeting, held on Sept. 11, is part of the agency’s patient-focused drug development initiative. “We wanted to hear the broader patient’s voice,” Theresa M. Mullin, PhD, director of the FDA’s Office of Strategic Programs, said in her opening remarks. Gary Sherwood, communications director for NAAF, said that the meeting was the culmination of a 5-year effort, begun in 2012 when alopecia areata was named as one of 39 disease categories under consideration for such a meeting. “It is too early to know what the exact results will be … but if the past is any indication, they may be significant. The meeting held with psoriasis yielded FDA approval of a treatment previously denied,” he added in an interview.

Two panel presentations featured patients who discussed their experiences with alopecia; each was followed by a discussion period where patients and family members in the audience were invited to share their experiences.

The “Health Effects and Daily Impacts” panel allowed several patients and their family members the opportunity to identify specific issues that may surprise clinicians.

Heidi Splete/Frontline Medical News

“I found this session to be very moving. Many of the patient stories brought me to tears,” Kalyani Marathe, MD, a dermatologist at Children’s National Health System, Washington, said in an interview. “Being exposed to the raw pain that they felt inspired me to take more time to listen to my own patients’ stories and to ask more questions about their condition and the impact it has on their lives.

“One thing I learned was how much the patients are bothered by sweating of the scalp; this can affect what type of head covering, hair piece, or hat/helmet they are able to wear, and thus limits activities,” Dr. Marathe continued. “This is not something I had focused on previously. I will be more inclined to ask about sweating and offer treatments, such as scalp botulinum toxin or aluminum chloride now that I have been alerted to this concern. Also, the challenges of facial makeup such as pencil for eyebrows was another thing that the FDA session brought home for me; I’m more inclined to suggest things such as microblading for eyebrows, or to try treatments like latanoprost for eyebrows/lashes.”

The second panel, “Current Approaches to Treatment,” included a different group of patients who shared stories of treatments that had been successful and those that had not. “The patients at the FDA meeting expressed very eloquently what our patients feel – different treatments may work temporarily and then stop working, which leads to a roller coaster of emotions of hope and disappointment,” A. Yasmine Kirkorian, MD, also a dermatologist at Children’s National Health System, said in an interview. “Patients and physicians would be interested in a treatment option with a track record for predictable efficacy with durable and sustained hair regrowth and minimal side effects.”

Dr. Marathe noted that in her experience, those who develop alopecia totalis or universalis at a younger age tend to have more recalcitrant disease. “It is still very hard for me to predict which children will regrow their hair spontaneously, or with topical therapies, versus those with more resistant disease. I hope that continued study will allow us to offer a more realistic prognosis for these patients,” she said.

Discussion after the treatment panel included testimonials from patients who reported successful treatment with tofacitinib (Xeljanz), a Janus kinase inhibitor approved for rheumatoid arthritis, which is not approved for treatment of alopecia.

“I absolutely agree with the focus on JAK inhibitors and increasing our understanding of how they work, as well as what some of the long-term effects are,” said Dr. Marathe. “The better we are able to target the pathogenesis of this condition, the more easily we can treat in a more focused fashion and reduce side effects,” but more clinical trials are needed to determine safety and efficacy for children and teens, she noted.

One of her hesitations in prescribing tofacitinib to her patients is that she cannot provide them with a sense of how long they will need to be on the treatment. “Current data show that the hair growth on the medication is usually lost upon stopping it; the question I still struggle with is whether it is realistic to put a 4- or 5-year-old on a medication that has no estimated or anticipated stop date,” she said.

As for what she offers patients in terms of resources for emotional support, Dr. Kirkorian said the psychosocial aspects of alopecia areata are always discussed at patient visits. “Psychosocial needs vary based on age, personality, and personal philosophy. We offer the gamut of outside resources from local support groups, the National Alopecia Areata Foundation, referral to psychology/psychiatry and, very importantly, referral to Camp Discovery. Children have told us across the board how important and meaningful it was to them to be able to just be themselves around other children who look like them.”

Dr. Marathe and Dr. Kirkorian were attendees at the meeting; they had no relevant disclosures. They are members of the Dermatology News Editorial Advisory Board.

 

SILVER SPRING, MD. – Alopecia areata patients struggle as much, if not more so, with the social and emotional challenges of the disease as with the physical challenges, according to patients and others who spoke at a public meeting on alopecia areata patient-focused drug development.

Alopecia areata affects as many as 6.8 million individuals in the United States, according to the National Alopecia Areata Foundation (NAAF). However, the particulars of alopecia can vary widely from one person to another; some patients experience total hair loss (alopecia universalis), while others retain eyebrows, eyelashes, or some body hair.

The FDA meeting, held on Sept. 11, is part of the agency’s patient-focused drug development initiative. “We wanted to hear the broader patient’s voice,” Theresa M. Mullin, PhD, director of the FDA’s Office of Strategic Programs, said in her opening remarks. Gary Sherwood, communications director for NAAF, said that the meeting was the culmination of a 5-year effort, begun in 2012 when alopecia areata was named as one of 39 disease categories under consideration for such a meeting. “It is too early to know what the exact results will be … but if the past is any indication, they may be significant. The meeting held with psoriasis yielded FDA approval of a treatment previously denied,” he added in an interview.

Two panel presentations featured patients who discussed their experiences with alopecia; each was followed by a discussion period where patients and family members in the audience were invited to share their experiences.

The “Health Effects and Daily Impacts” panel allowed several patients and their family members the opportunity to identify specific issues that may surprise clinicians.

Heidi Splete/Frontline Medical News

“I found this session to be very moving. Many of the patient stories brought me to tears,” Kalyani Marathe, MD, a dermatologist at Children’s National Health System, Washington, said in an interview. “Being exposed to the raw pain that they felt inspired me to take more time to listen to my own patients’ stories and to ask more questions about their condition and the impact it has on their lives.

“One thing I learned was how much the patients are bothered by sweating of the scalp; this can affect what type of head covering, hair piece, or hat/helmet they are able to wear, and thus limits activities,” Dr. Marathe continued. “This is not something I had focused on previously. I will be more inclined to ask about sweating and offer treatments, such as scalp botulinum toxin or aluminum chloride now that I have been alerted to this concern. Also, the challenges of facial makeup such as pencil for eyebrows was another thing that the FDA session brought home for me; I’m more inclined to suggest things such as microblading for eyebrows, or to try treatments like latanoprost for eyebrows/lashes.”

The second panel, “Current Approaches to Treatment,” included a different group of patients who shared stories of treatments that had been successful and those that had not. “The patients at the FDA meeting expressed very eloquently what our patients feel – different treatments may work temporarily and then stop working, which leads to a roller coaster of emotions of hope and disappointment,” A. Yasmine Kirkorian, MD, also a dermatologist at Children’s National Health System, said in an interview. “Patients and physicians would be interested in a treatment option with a track record for predictable efficacy with durable and sustained hair regrowth and minimal side effects.”

Dr. Marathe noted that in her experience, those who develop alopecia totalis or universalis at a younger age tend to have more recalcitrant disease. “It is still very hard for me to predict which children will regrow their hair spontaneously, or with topical therapies, versus those with more resistant disease. I hope that continued study will allow us to offer a more realistic prognosis for these patients,” she said.

Discussion after the treatment panel included testimonials from patients who reported successful treatment with tofacitinib (Xeljanz), a Janus kinase inhibitor approved for rheumatoid arthritis, which is not approved for treatment of alopecia.

“I absolutely agree with the focus on JAK inhibitors and increasing our understanding of how they work, as well as what some of the long-term effects are,” said Dr. Marathe. “The better we are able to target the pathogenesis of this condition, the more easily we can treat in a more focused fashion and reduce side effects,” but more clinical trials are needed to determine safety and efficacy for children and teens, she noted.

One of her hesitations in prescribing tofacitinib to her patients is that she cannot provide them with a sense of how long they will need to be on the treatment. “Current data show that the hair growth on the medication is usually lost upon stopping it; the question I still struggle with is whether it is realistic to put a 4- or 5-year-old on a medication that has no estimated or anticipated stop date,” she said.

As for what she offers patients in terms of resources for emotional support, Dr. Kirkorian said the psychosocial aspects of alopecia areata are always discussed at patient visits. “Psychosocial needs vary based on age, personality, and personal philosophy. We offer the gamut of outside resources from local support groups, the National Alopecia Areata Foundation, referral to psychology/psychiatry and, very importantly, referral to Camp Discovery. Children have told us across the board how important and meaningful it was to them to be able to just be themselves around other children who look like them.”

Dr. Marathe and Dr. Kirkorian were attendees at the meeting; they had no relevant disclosures. They are members of the Dermatology News Editorial Advisory Board.

 

SILVER SPRING, MD. – Alopecia areata patients struggle as much, if not more so, with the social and emotional challenges of the disease as with the physical challenges, according to patients and others who spoke at a public meeting on alopecia areata patient-focused drug development.

Alopecia areata affects as many as 6.8 million individuals in the United States, according to the National Alopecia Areata Foundation (NAAF). However, the particulars of alopecia can vary widely from one person to another; some patients experience total hair loss (alopecia universalis), while others retain eyebrows, eyelashes, or some body hair.

The FDA meeting, held on Sept. 11, is part of the agency’s patient-focused drug development initiative. “We wanted to hear the broader patient’s voice,” Theresa M. Mullin, PhD, director of the FDA’s Office of Strategic Programs, said in her opening remarks. Gary Sherwood, communications director for NAAF, said that the meeting was the culmination of a 5-year effort, begun in 2012 when alopecia areata was named as one of 39 disease categories under consideration for such a meeting. “It is too early to know what the exact results will be … but if the past is any indication, they may be significant. The meeting held with psoriasis yielded FDA approval of a treatment previously denied,” he added in an interview.

Two panel presentations featured patients who discussed their experiences with alopecia; each was followed by a discussion period where patients and family members in the audience were invited to share their experiences.

The “Health Effects and Daily Impacts” panel allowed several patients and their family members the opportunity to identify specific issues that may surprise clinicians.

Heidi Splete/Frontline Medical News

“I found this session to be very moving. Many of the patient stories brought me to tears,” Kalyani Marathe, MD, a dermatologist at Children’s National Health System, Washington, said in an interview. “Being exposed to the raw pain that they felt inspired me to take more time to listen to my own patients’ stories and to ask more questions about their condition and the impact it has on their lives.

“One thing I learned was how much the patients are bothered by sweating of the scalp; this can affect what type of head covering, hair piece, or hat/helmet they are able to wear, and thus limits activities,” Dr. Marathe continued. “This is not something I had focused on previously. I will be more inclined to ask about sweating and offer treatments, such as scalp botulinum toxin or aluminum chloride now that I have been alerted to this concern. Also, the challenges of facial makeup such as pencil for eyebrows was another thing that the FDA session brought home for me; I’m more inclined to suggest things such as microblading for eyebrows, or to try treatments like latanoprost for eyebrows/lashes.”

The second panel, “Current Approaches to Treatment,” included a different group of patients who shared stories of treatments that had been successful and those that had not. “The patients at the FDA meeting expressed very eloquently what our patients feel – different treatments may work temporarily and then stop working, which leads to a roller coaster of emotions of hope and disappointment,” A. Yasmine Kirkorian, MD, also a dermatologist at Children’s National Health System, said in an interview. “Patients and physicians would be interested in a treatment option with a track record for predictable efficacy with durable and sustained hair regrowth and minimal side effects.”

Dr. Marathe noted that in her experience, those who develop alopecia totalis or universalis at a younger age tend to have more recalcitrant disease. “It is still very hard for me to predict which children will regrow their hair spontaneously, or with topical therapies, versus those with more resistant disease. I hope that continued study will allow us to offer a more realistic prognosis for these patients,” she said.

Discussion after the treatment panel included testimonials from patients who reported successful treatment with tofacitinib (Xeljanz), a Janus kinase inhibitor approved for rheumatoid arthritis, which is not approved for treatment of alopecia.

“I absolutely agree with the focus on JAK inhibitors and increasing our understanding of how they work, as well as what some of the long-term effects are,” said Dr. Marathe. “The better we are able to target the pathogenesis of this condition, the more easily we can treat in a more focused fashion and reduce side effects,” but more clinical trials are needed to determine safety and efficacy for children and teens, she noted.

One of her hesitations in prescribing tofacitinib to her patients is that she cannot provide them with a sense of how long they will need to be on the treatment. “Current data show that the hair growth on the medication is usually lost upon stopping it; the question I still struggle with is whether it is realistic to put a 4- or 5-year-old on a medication that has no estimated or anticipated stop date,” she said.

As for what she offers patients in terms of resources for emotional support, Dr. Kirkorian said the psychosocial aspects of alopecia areata are always discussed at patient visits. “Psychosocial needs vary based on age, personality, and personal philosophy. We offer the gamut of outside resources from local support groups, the National Alopecia Areata Foundation, referral to psychology/psychiatry and, very importantly, referral to Camp Discovery. Children have told us across the board how important and meaningful it was to them to be able to just be themselves around other children who look like them.”

Dr. Marathe and Dr. Kirkorian were attendees at the meeting; they had no relevant disclosures. They are members of the Dermatology News Editorial Advisory Board.

 

BOSTON – The ratio of serum calcitonin to the serum level of carcinoembryonic antigen in patients with medullary thyroid cancer can predict which patients have a better chance for survival following thyroidectomy, based on retrospective findings from 164 presurgical patients at one U.S. center.

A lower serum calcitonin–to–serum carcinoembryonic antigen (CEA) ratio following thyroidectomy is a second marker of good postsurgical survival, Tania Jaber, MD, said at the World Congress on Thyroid Cancer.

Although Dr. Jaber cautioned that these findings are preliminary and need validation in prospective studies run in different patient populations, the association she and her coworkers at MD Anderson Cancer Center found was compelling enough to convince them to begin measuring the calcitonin-to-CEA ratio routinely in medullary thyroid cancer patients and use the results in counseling patients.

“Patients want to know whether surgery will cure them, and we have had no prognostic markers to predict this. Depending on the ratio, we can now tell patients whether or not they have a good chance of cure,” said Dr. Jaber, an endocrinological oncologist at MD Anderson in Houston. “Surgery remains the standard of care, so the ratio does not affect the decision of whether to undergo surgery, but it helps patients know what to expect” after surgery, she said in an interview.

“If their ratio is favorable it can be reassuring, and if their ratio is unfavorable it helps set expectations. We are also studying whether the ratio can be a marker for the need for systemic therapy following surgery. Right now, our prognostic tools for medullary thyroid cancer are very limited, so any additional information we can give patients based on their calcitonin-to-CEA ratio is very valuable.”

Her study included 164 patients treated at MD Anderson who had their serum drawn before thyroidectomy, and 187 patients with specimens taken 3-9 months after surgery. Median patient follow-up after surgery was 5 years. Calcitonin levels were measured as pg/mL and CEA levels as ng/mL; despite this difference in unit size the researchers calculated the ratios by a direct numerical comparison that ignored the units.

Among the preoperative patients and specifically among those with a low serum CEA level of less than 25 ng/ML a calcitonin-to-CEA ratio of less than 43 had the best survival rate, Dr. Jaber reported. Among preoperative patients with a CEA level of 25 ng/mL or greater a ratio of less than 18 flagged patients with the best survival rate following thyroidectomy.

Among postoperative patients the ratios that linked with better survival also depended on the CEA level. In patients with a low postoperative CEA a ratio of less than 149 linked with better survival. In patients with a high CEA level a ratio of less than 12 linked with better postoperative survival.

[email protected]

On Twitter @mitchelzoler

 

BOSTON – The ratio of serum calcitonin to the serum level of carcinoembryonic antigen in patients with medullary thyroid cancer can predict which patients have a better chance for survival following thyroidectomy, based on retrospective findings from 164 presurgical patients at one U.S. center.

A lower serum calcitonin–to–serum carcinoembryonic antigen (CEA) ratio following thyroidectomy is a second marker of good postsurgical survival, Tania Jaber, MD, said at the World Congress on Thyroid Cancer.

Although Dr. Jaber cautioned that these findings are preliminary and need validation in prospective studies run in different patient populations, the association she and her coworkers at MD Anderson Cancer Center found was compelling enough to convince them to begin measuring the calcitonin-to-CEA ratio routinely in medullary thyroid cancer patients and use the results in counseling patients.

“Patients want to know whether surgery will cure them, and we have had no prognostic markers to predict this. Depending on the ratio, we can now tell patients whether or not they have a good chance of cure,” said Dr. Jaber, an endocrinological oncologist at MD Anderson in Houston. “Surgery remains the standard of care, so the ratio does not affect the decision of whether to undergo surgery, but it helps patients know what to expect” after surgery, she said in an interview.

“If their ratio is favorable it can be reassuring, and if their ratio is unfavorable it helps set expectations. We are also studying whether the ratio can be a marker for the need for systemic therapy following surgery. Right now, our prognostic tools for medullary thyroid cancer are very limited, so any additional information we can give patients based on their calcitonin-to-CEA ratio is very valuable.”

Her study included 164 patients treated at MD Anderson who had their serum drawn before thyroidectomy, and 187 patients with specimens taken 3-9 months after surgery. Median patient follow-up after surgery was 5 years. Calcitonin levels were measured as pg/mL and CEA levels as ng/mL; despite this difference in unit size the researchers calculated the ratios by a direct numerical comparison that ignored the units.

Among the preoperative patients and specifically among those with a low serum CEA level of less than 25 ng/ML a calcitonin-to-CEA ratio of less than 43 had the best survival rate, Dr. Jaber reported. Among preoperative patients with a CEA level of 25 ng/mL or greater a ratio of less than 18 flagged patients with the best survival rate following thyroidectomy.

Among postoperative patients the ratios that linked with better survival also depended on the CEA level. In patients with a low postoperative CEA a ratio of less than 149 linked with better survival. In patients with a high CEA level a ratio of less than 12 linked with better postoperative survival.

[email protected]

On Twitter @mitchelzoler

 

BOSTON – The ratio of serum calcitonin to the serum level of carcinoembryonic antigen in patients with medullary thyroid cancer can predict which patients have a better chance for survival following thyroidectomy, based on retrospective findings from 164 presurgical patients at one U.S. center.

A lower serum calcitonin–to–serum carcinoembryonic antigen (CEA) ratio following thyroidectomy is a second marker of good postsurgical survival, Tania Jaber, MD, said at the World Congress on Thyroid Cancer.

Although Dr. Jaber cautioned that these findings are preliminary and need validation in prospective studies run in different patient populations, the association she and her coworkers at MD Anderson Cancer Center found was compelling enough to convince them to begin measuring the calcitonin-to-CEA ratio routinely in medullary thyroid cancer patients and use the results in counseling patients.

“Patients want to know whether surgery will cure them, and we have had no prognostic markers to predict this. Depending on the ratio, we can now tell patients whether or not they have a good chance of cure,” said Dr. Jaber, an endocrinological oncologist at MD Anderson in Houston. “Surgery remains the standard of care, so the ratio does not affect the decision of whether to undergo surgery, but it helps patients know what to expect” after surgery, she said in an interview.

“If their ratio is favorable it can be reassuring, and if their ratio is unfavorable it helps set expectations. We are also studying whether the ratio can be a marker for the need for systemic therapy following surgery. Right now, our prognostic tools for medullary thyroid cancer are very limited, so any additional information we can give patients based on their calcitonin-to-CEA ratio is very valuable.”

Her study included 164 patients treated at MD Anderson who had their serum drawn before thyroidectomy, and 187 patients with specimens taken 3-9 months after surgery. Median patient follow-up after surgery was 5 years. Calcitonin levels were measured as pg/mL and CEA levels as ng/mL; despite this difference in unit size the researchers calculated the ratios by a direct numerical comparison that ignored the units.

Among the preoperative patients and specifically among those with a low serum CEA level of less than 25 ng/ML a calcitonin-to-CEA ratio of less than 43 had the best survival rate, Dr. Jaber reported. Among preoperative patients with a CEA level of 25 ng/mL or greater a ratio of less than 18 flagged patients with the best survival rate following thyroidectomy.

Among postoperative patients the ratios that linked with better survival also depended on the CEA level. In patients with a low postoperative CEA a ratio of less than 149 linked with better survival. In patients with a high CEA level a ratio of less than 12 linked with better postoperative survival.

[email protected]

On Twitter @mitchelzoler

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

I have to give a talk. Get this – the topic is how to give a good talk. Very meta.

I’ve given a hundred or so presentations in my career, including a couple of TEDx talks. With each one, I try to get a little better. Effective speaking is always simple but never easy. Let me share with you a few things I’ve learned.

Even if you don’t want to become a TEDMED phenom, you should know a few fundamentals. Giving good talks enhances your reputation and can jump-start your practice or career. For any talk, you must master three things: preparation, content, and delivery.

First, prepare. Just as no football team, no matter how dominant, would play without exhaustive preparation, no presenter should speak without thoroughly preparing. No matter how slick your slides, if the audience is not interested, you’ll lose. The purpose of a presentation is to affect your audience – to teach them, to move them, to inspire them. Therefore, you must know your audience. A seasoned private practice dermatologist will care about different issues than a second-year resident or an academic psoriasis expert. Ask yourself, Who will attend? Why are they coming? What do they hope to get out of your lecture? Perusing the agenda and seeing other speakers’ topics can also help you understand your audience. These factors should help determine both your content and delivery style.

Just as we choose movies with actors we like, people choose speakers they want to see. Who you are matters. If you are introduced by an emcee, then be sure he or she bills you as a star. However, don’t try to be someone you aren’t – If I gave a talk on robotic prostate surgery, I’d be sure to lose no matter how witty I was. That’s why writing your own intro can sometimes be your best option.

Next up: content. It’s the king of speaking as well as marketing. Although you can pick up points for style, if you want to be remembered, you have to deliver something worth remembering. This starts with your preparation. Resist the temptation to focus exclusively on your slides. As in writing, it is best to brainstorm what you want to cover, then outline your ideas, then fill in content with slides.

Most presentations require visuals; however, there are times when you can do without. Go for it! Nothing is more freeing or more intimate than you one-on-one with your audience. If you must have slides, then follow the one-idea one-slide rule. Slides crammed with information actually detract from your presentation. Here’s a tip: Write only what you can fit with a marker on a Post-it pad. Then, laying out the Post-its, you can rearrange slides getting a feel for the flow or argument of the talk.

Did you ever wonder why headlines like, “Why I never use this suture” and “How I cut my EMR documentation time in half” work so well? They tap into a core human instinct: curiosity. Your opening should introduce some sense of wonder. What is she going to share? Really, how does he do that? Starting with a problem and taking them to a solution is also a great game plan that will often yield success.

When it comes to slides, be clean and concise. Taking a cue from wildly popular TED talks, use images and art instead of words. Use sentence fragments, not sentences, and limit content to the width of the slide (no easy feat). Sometimes you need the slide to prompt your talking point. Put only the data or fact you need and leave the rest at the bottom in your notes section.

Humor is almost always a good idea and more difficult to execute than most realize. Cartoons with captions don’t work. I know that’s hard for many of you to hear, but it’s true. Delete them from your decks. Go ahead, I’ll wait.

Instead, try finding something relevant to the audience that only they will find funny. Inside jokes not only have a higher chance of success, but will also help you bond with your audience. A joke about ICD10 as it relates to neurology is better than the funniest Calvin and Hobbes strip. Self-deprecating humor is always appreciated. I’m not among the gifted who can come up with a great one-liner on the spot. It’s OK to plan it ahead.

Once you’ve got your talk built, it’s time to run it. This is hard, as it requires planning to have your content done in time to rehearse. Find the discipline to do it. The first time you run it, you’ll likely realize that 1/3 of the content needs to be cut. Cut it. Indeed, plan to run 10% less than the time allotted. Leave your audience wanting for more rather than wishing for less.

As I’ve learned, your talking points and slides will always be most appreciated in your own head. Keeping to time shows your respect for your audience and makes you appear polished.

The day of, get to the venue well ahead of time and check the sound, lights, and temperature. All of your preparation will be for naught if they can’t hear you, see your slides, or feel their fingers due to the frigid AC.

One of the reasons I love giving talks is because they are live. You and your audience are intimately engaged, and like any conversation, you’ll sense how it’s going. Are they looking at you or at their phones? Do they seem bored? Do they laugh easily, even when you weren’t expecting them to? Observe what is happening and adjust your performance accordingly. Are you losing them? Pause. Let them catch up. Are you putting them to sleep? Pick up the pace. Try that bit of humor now.

Your delivery is critical to your success. If you’re on the dais and behind the podium of a large audience, then be big, Greek theatre big, which means bigger facial expressions and bigger arm and hand gestures. Vary the tone and pace of your voice. Speed it up to build excitement. Slow down and lower your pitch for gravity and authority. Pause for 3-4 seconds to create suspense and drama.

Leave time for discussion when possible. Invite the audience to engage by asking, What do you think? Finally, on the plane ride home, or even as you walk back from the auditorium to your clinic, think about your presentation: What worked? What fell flat? What roused the audience? How can you deliver it better next time?

Even if it didn’t go well, remember, there’s always next week. It’s on to Cincinnati.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

 

Healthy men younger than 45 years have the lowest risk of relapse after reflux surgery compared with other demographic subgroups, according to data from a population-based study of 2,655 adults in Sweden. The findings were published online in JAMA.

“Cohort studies have shown a high risk of recurrent symptoms of GERD after surgery, which may have contributed to the decline in the use of antireflux surgery,” but long-term reflux recurrence rates and potential risk factors have not been well studied, wrote John Maret-Ouda, MD, and colleagues at the Karolinska Institutet in Stockholm, Sweden.

copyright nebari/Thinkstock

To characterize reflux recurrence after surgery, the researchers reviewed data from 2,655 adults with a median age of 51 years who underwent laparoscopic antireflux surgery between Jan. 1, 2005, and Dec. 31, 2014. Data were taken from the Swedish Patient Registry. The patients were followed for approximately 6 years, and approximately half were men (JAMA. 2017;318[10]:939-6).

Overall, 18% of the patients suffered a reflux relapse; 84% of these were prescribed long-term medication, and 16% underwent additional surgery.

The highest relapse rates occurred among women, older patients, and those with comorbid conditions. Reflux occurred in 22% of women vs. 14% of men (hazard ratio 1.57), and the hazard ratio was 1.41 for patients aged 61 years and older compared with those aged 45 years and younger. Patients with one or more comorbidities were approximately one-third more likely to have a recurrence of reflux, compared with those who had no comorbidities (hazard ratio 1.36).

Approximately 4% of patients reported complications; the most common complication was infection (1.1%), followed by bleeding (0.9%), and esophageal perforation (0.9%).

The recurrence rate of 18% is low compared with other studies, the researchers noted. Possible reasons for the difference include the population-based design of the current study, which meant that no patients were lost to follow-up, as well as the recent time period, “in which laparoscopic antireflux surgery has become more centralized to expert centers where selection of patients might be stricter and the quality of surgery might be higher,” they wrote.

The study findings were limited by several factors including clinical variations on coding, lack of data on certain confounding variables including body mass index and smoking, and a lack of control GERD patients who did not undergo antireflux surgery, the researchers said. The results suggest that the benefits of laparoscopic antireflux surgery may be diminished by the potential for recurrent GERD, they added.

The Swedish Research Council funded the study. The researchers had no financial conflicts to disclose.

 

Healthy men younger than 45 years have the lowest risk of relapse after reflux surgery compared with other demographic subgroups, according to data from a population-based study of 2,655 adults in Sweden. The findings were published online in JAMA.

“Cohort studies have shown a high risk of recurrent symptoms of GERD after surgery, which may have contributed to the decline in the use of antireflux surgery,” but long-term reflux recurrence rates and potential risk factors have not been well studied, wrote John Maret-Ouda, MD, and colleagues at the Karolinska Institutet in Stockholm, Sweden.

copyright nebari/Thinkstock

To characterize reflux recurrence after surgery, the researchers reviewed data from 2,655 adults with a median age of 51 years who underwent laparoscopic antireflux surgery between Jan. 1, 2005, and Dec. 31, 2014. Data were taken from the Swedish Patient Registry. The patients were followed for approximately 6 years, and approximately half were men (JAMA. 2017;318[10]:939-6).

Overall, 18% of the patients suffered a reflux relapse; 84% of these were prescribed long-term medication, and 16% underwent additional surgery.

The highest relapse rates occurred among women, older patients, and those with comorbid conditions. Reflux occurred in 22% of women vs. 14% of men (hazard ratio 1.57), and the hazard ratio was 1.41 for patients aged 61 years and older compared with those aged 45 years and younger. Patients with one or more comorbidities were approximately one-third more likely to have a recurrence of reflux, compared with those who had no comorbidities (hazard ratio 1.36).

Approximately 4% of patients reported complications; the most common complication was infection (1.1%), followed by bleeding (0.9%), and esophageal perforation (0.9%).

The recurrence rate of 18% is low compared with other studies, the researchers noted. Possible reasons for the difference include the population-based design of the current study, which meant that no patients were lost to follow-up, as well as the recent time period, “in which laparoscopic antireflux surgery has become more centralized to expert centers where selection of patients might be stricter and the quality of surgery might be higher,” they wrote.

The study findings were limited by several factors including clinical variations on coding, lack of data on certain confounding variables including body mass index and smoking, and a lack of control GERD patients who did not undergo antireflux surgery, the researchers said. The results suggest that the benefits of laparoscopic antireflux surgery may be diminished by the potential for recurrent GERD, they added.

The Swedish Research Council funded the study. The researchers had no financial conflicts to disclose.

 

Healthy men younger than 45 years have the lowest risk of relapse after reflux surgery compared with other demographic subgroups, according to data from a population-based study of 2,655 adults in Sweden. The findings were published online in JAMA.

“Cohort studies have shown a high risk of recurrent symptoms of GERD after surgery, which may have contributed to the decline in the use of antireflux surgery,” but long-term reflux recurrence rates and potential risk factors have not been well studied, wrote John Maret-Ouda, MD, and colleagues at the Karolinska Institutet in Stockholm, Sweden.

copyright nebari/Thinkstock

To characterize reflux recurrence after surgery, the researchers reviewed data from 2,655 adults with a median age of 51 years who underwent laparoscopic antireflux surgery between Jan. 1, 2005, and Dec. 31, 2014. Data were taken from the Swedish Patient Registry. The patients were followed for approximately 6 years, and approximately half were men (JAMA. 2017;318[10]:939-6).

Overall, 18% of the patients suffered a reflux relapse; 84% of these were prescribed long-term medication, and 16% underwent additional surgery.

The highest relapse rates occurred among women, older patients, and those with comorbid conditions. Reflux occurred in 22% of women vs. 14% of men (hazard ratio 1.57), and the hazard ratio was 1.41 for patients aged 61 years and older compared with those aged 45 years and younger. Patients with one or more comorbidities were approximately one-third more likely to have a recurrence of reflux, compared with those who had no comorbidities (hazard ratio 1.36).

Approximately 4% of patients reported complications; the most common complication was infection (1.1%), followed by bleeding (0.9%), and esophageal perforation (0.9%).

The recurrence rate of 18% is low compared with other studies, the researchers noted. Possible reasons for the difference include the population-based design of the current study, which meant that no patients were lost to follow-up, as well as the recent time period, “in which laparoscopic antireflux surgery has become more centralized to expert centers where selection of patients might be stricter and the quality of surgery might be higher,” they wrote.

The study findings were limited by several factors including clinical variations on coding, lack of data on certain confounding variables including body mass index and smoking, and a lack of control GERD patients who did not undergo antireflux surgery, the researchers said. The results suggest that the benefits of laparoscopic antireflux surgery may be diminished by the potential for recurrent GERD, they added.

The Swedish Research Council funded the study. The researchers had no financial conflicts to disclose.

This is the first in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Primary care providers deal with a multitude of challenging clinical issues (e.g., providing first contact and preventive care, diagnosis in the undifferentiated patient, care of patients with chronic illness and multiple chronic conditions, keeping up with the literature) while managing a rapidly changing and often difficult health care environment. Despite this complexity and these challenges, primary care clinicians and health care systems strive to provide high-quality health care – i.e., care that is safe, effective, patient centered, timely, efficient, and equitable.

The Agency for Healthcare Research and Quality (AHRQ), a subdivision of the U.S. Department of Health & Human Services, recognizes that revitalizing this nation’s primary care system is critical to achieving quality health care. To that end, the agency is committed to helping you improve the care you deliver by offering the latest information, providing evidence syntheses, developing tools for improving primary care practice, and generating data and measures to track and improve performance in primary care.

AHRQ established the National Center for Excellence in Primary Care Research (NCEPCR) to be its intellectual home for primary care research. It is the agency’s vehicle for communicating the evidence from AHRQ’s research – and information about how this evidence can be used to improve health and primary health care – to researchers, primary care professionals, health care decision makers, patients, and families.

Electronic resources for daily practice
 

Every day you rely on guidelines for handling issues that range from prevention to caring for those with multiple chronic conditions. Two of AHRQ’s tools make the use of these guidelines easier.

First, the Electronic Prevention Services Selector (ePSS) is a free application that allows you to search or browse U.S. Preventive Services Task Force recommendations on the Web, a PDA, or a mobile device. You can enter patient-specific information (for example, age, sex, smoking status) to get customized information for your patient. The ePSS brings information on clinical preventive services – recommendations, clinical considerations, and selected practice tools – to the point of care. You can sign up for notifications when there are updates.

The National Guideline Clearinghouse (NGC) provides health professionals with a tool for obtaining objective, detailed information on evidence-based clinical practice guidelines. After you enter a condition onto the webpage, the site offers key information on guidelines related to that condition – including relevant FDA drug safety alerts – and flags guidelines addressing multiple chronic conditions. The site lets you readily compare different guidelines on the same topic.

Like all of AHRQ’s tools and resources, the ePSS and NGC are freely available. These and other tools can be found at the NCEPCR website.
 

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the first in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Primary care providers deal with a multitude of challenging clinical issues (e.g., providing first contact and preventive care, diagnosis in the undifferentiated patient, care of patients with chronic illness and multiple chronic conditions, keeping up with the literature) while managing a rapidly changing and often difficult health care environment. Despite this complexity and these challenges, primary care clinicians and health care systems strive to provide high-quality health care – i.e., care that is safe, effective, patient centered, timely, efficient, and equitable.

The Agency for Healthcare Research and Quality (AHRQ), a subdivision of the U.S. Department of Health & Human Services, recognizes that revitalizing this nation’s primary care system is critical to achieving quality health care. To that end, the agency is committed to helping you improve the care you deliver by offering the latest information, providing evidence syntheses, developing tools for improving primary care practice, and generating data and measures to track and improve performance in primary care.

AHRQ established the National Center for Excellence in Primary Care Research (NCEPCR) to be its intellectual home for primary care research. It is the agency’s vehicle for communicating the evidence from AHRQ’s research – and information about how this evidence can be used to improve health and primary health care – to researchers, primary care professionals, health care decision makers, patients, and families.

Electronic resources for daily practice
 

Every day you rely on guidelines for handling issues that range from prevention to caring for those with multiple chronic conditions. Two of AHRQ’s tools make the use of these guidelines easier.

First, the Electronic Prevention Services Selector (ePSS) is a free application that allows you to search or browse U.S. Preventive Services Task Force recommendations on the Web, a PDA, or a mobile device. You can enter patient-specific information (for example, age, sex, smoking status) to get customized information for your patient. The ePSS brings information on clinical preventive services – recommendations, clinical considerations, and selected practice tools – to the point of care. You can sign up for notifications when there are updates.

The National Guideline Clearinghouse (NGC) provides health professionals with a tool for obtaining objective, detailed information on evidence-based clinical practice guidelines. After you enter a condition onto the webpage, the site offers key information on guidelines related to that condition – including relevant FDA drug safety alerts – and flags guidelines addressing multiple chronic conditions. The site lets you readily compare different guidelines on the same topic.

Like all of AHRQ’s tools and resources, the ePSS and NGC are freely available. These and other tools can be found at the NCEPCR website.
 

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

This is the first in a series of articles from the National Center for Excellence in Primary Care Research (NCEPCR) in the Agency for Healthcare Research and Quality (AHRQ). This series introduces sets of tools and resources designed to help your practice.

Primary care providers deal with a multitude of challenging clinical issues (e.g., providing first contact and preventive care, diagnosis in the undifferentiated patient, care of patients with chronic illness and multiple chronic conditions, keeping up with the literature) while managing a rapidly changing and often difficult health care environment. Despite this complexity and these challenges, primary care clinicians and health care systems strive to provide high-quality health care – i.e., care that is safe, effective, patient centered, timely, efficient, and equitable.

The Agency for Healthcare Research and Quality (AHRQ), a subdivision of the U.S. Department of Health & Human Services, recognizes that revitalizing this nation’s primary care system is critical to achieving quality health care. To that end, the agency is committed to helping you improve the care you deliver by offering the latest information, providing evidence syntheses, developing tools for improving primary care practice, and generating data and measures to track and improve performance in primary care.

AHRQ established the National Center for Excellence in Primary Care Research (NCEPCR) to be its intellectual home for primary care research. It is the agency’s vehicle for communicating the evidence from AHRQ’s research – and information about how this evidence can be used to improve health and primary health care – to researchers, primary care professionals, health care decision makers, patients, and families.

Electronic resources for daily practice
 

Every day you rely on guidelines for handling issues that range from prevention to caring for those with multiple chronic conditions. Two of AHRQ’s tools make the use of these guidelines easier.

First, the Electronic Prevention Services Selector (ePSS) is a free application that allows you to search or browse U.S. Preventive Services Task Force recommendations on the Web, a PDA, or a mobile device. You can enter patient-specific information (for example, age, sex, smoking status) to get customized information for your patient. The ePSS brings information on clinical preventive services – recommendations, clinical considerations, and selected practice tools – to the point of care. You can sign up for notifications when there are updates.

The National Guideline Clearinghouse (NGC) provides health professionals with a tool for obtaining objective, detailed information on evidence-based clinical practice guidelines. After you enter a condition onto the webpage, the site offers key information on guidelines related to that condition – including relevant FDA drug safety alerts – and flags guidelines addressing multiple chronic conditions. The site lets you readily compare different guidelines on the same topic.

Like all of AHRQ’s tools and resources, the ePSS and NGC are freely available. These and other tools can be found at the NCEPCR website.
 

Dr. Bierman is the director of the Center for Evidence and Practice Improvement at AHRQ. Dr. Ganiats is the director for the National Center for Excellence in Primary Care Research at AHRQ.

 

Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.

The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).

copyright designer491/Thinkstock

COPD affects about 12% of adults aged 30 years and older worldwide and is associated with increased risk of progressive cardiovascular disease and cardiovascular mortality. “Localized chronic inflammation of the airways has long been observed in COPD patients, but there is a growing understanding of systemic inflammation in a subset of patients,” the researchers noted. For example, studies have linked chronic low-level systemic inflammation or elevated C-reactive protein levels with increased risks of severe airway obstruction, other pulmonary outcomes, and adverse cardiovascular events. Such findings prompted experts to suggest that COPD progression results from systemic inflammation, not a “spill over” of pulmonary inflammation, and that statins might help slow or block this process. Although STATCOPE did not support this idea, several prior observational studies did.

To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.

A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.

The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).

The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.

Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.

 

Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.

The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).

copyright designer491/Thinkstock

COPD affects about 12% of adults aged 30 years and older worldwide and is associated with increased risk of progressive cardiovascular disease and cardiovascular mortality. “Localized chronic inflammation of the airways has long been observed in COPD patients, but there is a growing understanding of systemic inflammation in a subset of patients,” the researchers noted. For example, studies have linked chronic low-level systemic inflammation or elevated C-reactive protein levels with increased risks of severe airway obstruction, other pulmonary outcomes, and adverse cardiovascular events. Such findings prompted experts to suggest that COPD progression results from systemic inflammation, not a “spill over” of pulmonary inflammation, and that statins might help slow or block this process. Although STATCOPE did not support this idea, several prior observational studies did.

To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.

A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.

The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).

The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.

Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.

 

Receiving a statin prescription within a year after diagnosis of chronic obstructive pulmonary disease was associated with a 21% decrease in the subsequent risk of all-cause mortality and a 45% drop in risk of pulmonary mortality, according to the results of a large retrospective administrative database study.

The findings belie those of the recent Simvastatin in the Prevention of COPD Exacerbation (STATCOPE) trial, in which daily simvastatin (40 mg) did not affect exacerbation rates or time to first exacerbation in high-risk COPD patients, wrote Adam Raymakers, MSc, a doctoral candidate at the University of British Columbia, Vancouver, and his associates. Their study was observational, but the association between statin use and decreased mortality “persisted across several measures of statin exposure,” they wrote. “Our findings, in conjunction with previously reported evidence, suggests that there may be a specific subtype of COPD patients that may benefit from statin use.” The study appears in the September issue of Chest (2017;152;486-93).

copyright designer491/Thinkstock

COPD affects about 12% of adults aged 30 years and older worldwide and is associated with increased risk of progressive cardiovascular disease and cardiovascular mortality. “Localized chronic inflammation of the airways has long been observed in COPD patients, but there is a growing understanding of systemic inflammation in a subset of patients,” the researchers noted. For example, studies have linked chronic low-level systemic inflammation or elevated C-reactive protein levels with increased risks of severe airway obstruction, other pulmonary outcomes, and adverse cardiovascular events. Such findings prompted experts to suggest that COPD progression results from systemic inflammation, not a “spill over” of pulmonary inflammation, and that statins might help slow or block this process. Although STATCOPE did not support this idea, several prior observational studies did.

To further explore the question, the researchers analyzed linked health databases from nearly 40,000 patients aged 50 years and older who had received at least three prescriptions for an anticholinergic or a short-acting beta agonist in 12 months some time between 1998 and 2007. The first prescription was considered the date of COPD “diagnosis.” The average age of the patients was 71 years; 55% were female.

A total of 7,775 patients (19.6%) who met this definition of incident COPD were prescribed a statin at least once during the subsequent year. These patients had a significantly reduced risk of subsequent all-cause mortality in univariate and multivariate analyses, with hazard ratios of 0.79 (95% confidence intervals, 0.68 to 0.91; P less than .002). Statins also showed a protective effect against pulmonary mortality, with univariate and multivariate hazard ratios of 0.52 (P = .01) and 0.55 (P = .03), respectively.

The protective effect of statins held up when the investigators narrowed the exposure period to 6 months after COPD diagnosis and when they expanded it to 18 months. Exposure to statins for 80% of the 1-year window after COPD diagnosis – a proxy for statin adherence – also led to a reduced risk of all-cause mortality, but the 95% confidence interval for the hazard ratio did not reach statistical significance (0.71 to 1.01; P = .06).

The most common prescription was for atorvastatin (49%), usually for 90 days (23%), 100 days (20%), or 30 days (15%), the researchers said. While the “possibility of the ‘healthy user’ or the ‘healthy adherer’ cannot be ignored,” they adjusted for other prescriptions, comorbidities, and income level, which should have helped eliminate this effect, they added. However, they lacked data on smoking and lung function assessments, both of which are “important confounders and contributors to mortality,” they acknowledged.

Canadian Institutes of Health Research supported the study. One coinvestigator disclosed consulting relationships with Teva, Pfizer, and Novartis. The others had no conflicts of interest.

While palliative care grows as an interdisciplinary specialty, more clinicians are asking how it can benefit certain patients with severe mental illness.

Palliative care, which developed with the founding of hospices in the 1960s, initially focused on patients who were dying from cancer. The specialty – which emphasizes improving patients’ quality of life rather than finding a cure, and which is different from hospice – can now be used for patients with noncancer diagnoses such as dementia and HIV/AIDS (Psychiatry. 2009 Jun;8[6]:212-15).

Some psychiatrists think that certain patients with another diagnosis would benefit from palliative care: those with severe persistent mental illness.

In fact, this approach might apply to psychiatric patients who are in long-term residential care with “severe/chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa,” wrote Manuel Trachsel, MD, PhD, and his colleagues (BMC Psychiatry (2016 Jul 14:1-9).

Scott A. Irwin, MD, PhD, who coauthored that article and a letter examining these issues, said Dr. Trachsel’s theories lie on the frontiers of current thinking about incorporating palliative care and psychiatric medicine.

Meanwhile, both Dr. Irwin and Maria I. Lapid, MD, another psychiatrist with expertise in palliative care, said that in many ways, the field of psychiatry is inherently palliative in nature.
 

Palliative ‘approach’ in SPMI

Dr. Trachsel presented unpublished results from a survey of U.S. psychiatrists at the annual meeting of the American Psychiatric Association in May that sought to discern whether they favored supporting short-term quality of life rather than long-term disease modification in certain patients with severe and persistent mental illness (SPMI) – defined as mental illness that is chronic or recurring, requires ongoing intensive psychiatric treatment, and seriously impairs functioning.

Courtesy Dr. Trachsel

The response to Dr. Trachsel’s survey was poor – 60 U.S. psychiatrists responded out of nearly 1,000 randomly queried. This means the results are likely to be biased and difficult to generalize. However, all of the psychiatrists who responded agreed that improving function in daily life was important for patients with SPMI, and 90% agreed that reducing suffering was important. Nearly two-thirds ranked as important patient autonomy. The results argued for psychiatrists to focus the goals for their most treatment-refractory patients toward patient desires and quality of life. This approach, which emphasizes preventing and relieving suffering, aligns with the World Health Organization’s definition of palliative care, said Dr. Trachsel, who is affiliated with the University of Zürich.

Specifically, a palliative care approach to SPMI could include a more relaxed use of agents considered potentially addictive or problematic long term, such as benzodiazepines, Dr. Trachsel said. For patients with medical decision-making capacity, it could 1) include withdrawal of care at a patient’s insistence or periods of intermittent sedation – which is used in palliative medicine for patients with intractable pain; or 2) mean switching a patient with end-stage anorexia and multiple failed treatment attempts to hospice care rather than force feeding, Dr. Trachsel said.

Neither Dr. Trachsel’s survey respondents nor those who attended his presentation seemed comfortable with the idea of extending the term “palliative care” – which is often and incorrectly associated with well-defined end-of-life scenarios – to serious, treatment-refractory mental illness. In those illnesses, disease trajectories may be less certain and futility is harder to define. They and other clinicians, however, did voice general support for the underlying concepts of promoting quality of life and decision-making autonomy for patients with SPMI, as well as palliative care targeted at the medical illnesses often acquired by those with SPMI.

According to Dr. Irwin and Dr. Lapid, reducing symptoms, acknowledging that there is no cure for SPMI, and focusing on optimizing patients’ quality of life would be core components of palliative care.

Futility difficult to define

Dr. Irwin said in an interview that the ideas in the letter (Lancet Psychiatry. 2016 Mar;3[3]:200) in which he and a few other colleagues collaborated with Dr. Trachsel were essentially “a thought experiment and very philosophical.” In addition, the letter, which proposed palliative psychiatry “as a means to improve quality of care, person-centeredness, and autonomy” for patients with SPMI, was supported by a handful of case studies, most of them in patients with end-stage anorexia, he said. Furthermore, end-of-life interventions are only a subset of what palliative care brings to the table, said Dr. Irwin, palliative care psychiatrist at Cedars-Sinai Health System’s Samuel Oschin Comprehensive Cancer Center in Los Angeles.

 

With a psychiatric illness, the goals are usually around symptom management and quality of life, and for certain palliative care interventions reserved for end-of-life situations, “there’s usually not something knocking at the door that’s putting that end-of-life question into focus,” Dr. Irwin said. To create end-of-life protocols for SPMI, “you would need to know what the prognosis and trajectory are of each stage of these illnesses. And we don’t have good evidence guiding us.

“If we have a patient who is depressed and wants to commit suicide, who knows how many years they could have left if we intervene?” said Dr. Irwin, who has mentored Dr. Trachsel. “If we had the data that this person’s 90% likely to complete a suicide within the next year, it might change the conversation and treatment decisions.”

Dr. Lapid, a board-certified practitioner of palliative and hospice medicine and geriatric psychiatry at the Mayo Clinic in Rochester, Minn., agreed in an interview that for patients with an SPMI and no life-limiting comorbidity, it becomes complicated to attempt to define futility.

In palliative and hospice care, for the end-of-life piece, “we rely on a classic literature of functional trajectories at the end of life,” she said. “We know what the curve is for cancer, chronic medical conditions such as chronic obstructive pulmonary disease or chronic kidney disease, or even for dementia – but what about major depression, schizophrenia, or schizoaffective disorder? What does the end of life trajectory look like for them? That would be really important to know, because this knowledge will help us determine at what point they are in their life/disorder trajectory, which will help guide advanced care planning.”

Moreover, while Medicare and insurance have precisely detailed guidelines for hospice, which provides palliative care for those with a prognosis of 6 months or less, “there’s no psychiatric illness currently considered a terminal disease eligible for hospice care,” Dr. Lapid said.

Obstacles to access

Patients with SPMI die 25 years earlier than do their peers without SPMI. Most of the premature mortality associated with SPMI, which cuts across age groups, is attributable to chronic diseases rather than to violence or suicide. Less overall engagement with the health care system, leading to late treatment or undertreatment of disease, is one explanation for the premature mortality found among some people in this demographic.

In addition, studies have shown that individuals with SPMI have less access to palliative and hospice care. One study, for example, found that people with schizophrenia and a terminal illness went into hospice half as often as did people without SPMI (Schizophr Res. 2012 Nov;141:241-6). In a recent editorial, a team of psychiatrists and pain specialists called such disparities “unacceptable” and demanded cross-collaboration to resolve them (Gen Hospital Psych. 2017 Jan-Feb;44:1-3).

Dr. Lapid said one reason people with SPMI – with or without a life-limiting comorbidity – end up with less access to palliative and hospice care is that “the art of what we do in hospice and palliative care, advanced planning – is not something we do well or routinely in psychiatry.”

And palliative care specialists may find that for some people with severe mental illness, “it can be hard to really palliate their symptoms,” Dr. Lapid said.

Dr. Irwin noted that patients with SPMI and a terminal illness generally are not extended the same level of agency over their treatment choices as are people without it. Cancer patients, for example, can elect not to receive a treatment even when their prognosis is good. People with serious mental illness – even when they have life-limiting medical comorbidities – may not be given the option of deciding whether to opt for treatment.

Rebecca L. Bauer, MD, a psychosomatic medicine fellow at the Medical College of Wisconsin in Milwaukee, said that psychiatrists, including those with outpatient practices, are well positioned to help patients gain greater access to palliative care and end-of-life planning.

Dr. Bauer, the author of a paper exploring ethical considerations involved in end-of-life and palliative care in patients with SPMI, said people with chronic mental illness “don’t always have a strong support network, and we can’t always figure out what their wishes or desires are. They may have treatment-resistant aspects to their mental illness, and when you add on top a medical condition, it can be hard to figure out which to address first” (Am J Psychiatry. Residents’ Journal 2016;11[5]:4-6).

These patients’ medical needs become so pressing at the end of life that psychiatric disease and the distress it inflicts end up a secondary concern, she said, resulting in the patient suffering.

Psychiatrists “can play an important role in removing some of these barriers,” Dr. Bauer said, especially on multidisciplinary teams. For one thing, psychiatrists are adept at prescribing medications aimed at treating concurrent psychiatric symptoms. In addition, they are more likely than are other clinicians to have experience in communicating with patients with psychosis or other thought disorders.

Another important way psychiatrists can help secure access to palliative care for their patients who need it, she said, is to engage patients during times of relative wellness by encouraging them to discuss end-of-life desires and plans, and help them create formal health care directives.

“We know that sometimes patients [with SPMI] are not as engaged in their primary and medical care, and sometimes the psychiatrist is the only provider they consistently follow up with,” Dr. Bauer said.

All the clinicians interviewed acknowledged that, regardless of the feasibility or ethical viability of any single approach, the idea of incorporating some of the pillars of palliative care for patients with SPMI merits more consideration.

The approach used by psychiatrists treating patients with SPMI is very palliative in approach, Dr. Irwin and Dr. Lapid said. Psychiatrists reduce symptoms and acknowledge that SPMIs are chronic diseases for which there is no cure. To palliate is to make comfortable, to reduce symptoms, to reduce distress and pain, and to relieve suffering and optimize quality of life.

“In cancer, we’ve been telling people for 30 years, ‘keep fighting, because tomorrow there could be a new cure.’ But there’ve been very few new cures,” Dr. Irwin said. “And while some people want to fight to the end in case that cure comes, there are many who would have rather known that there really was little chance and might have made different choices.” In psychiatry, for psychiatric illnesses, he continued, “we need to really start thinking about the course of a person’s life, their quality of life, and the likelihood that they will get better or meet their goals, and what is a tolerable symptom burden for them. Because in the end, these questions apply to all patients.”

While palliative care grows as an interdisciplinary specialty, more clinicians are asking how it can benefit certain patients with severe mental illness.

Palliative care, which developed with the founding of hospices in the 1960s, initially focused on patients who were dying from cancer. The specialty – which emphasizes improving patients’ quality of life rather than finding a cure, and which is different from hospice – can now be used for patients with noncancer diagnoses such as dementia and HIV/AIDS (Psychiatry. 2009 Jun;8[6]:212-15).

Some psychiatrists think that certain patients with another diagnosis would benefit from palliative care: those with severe persistent mental illness.

In fact, this approach might apply to psychiatric patients who are in long-term residential care with “severe/chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa,” wrote Manuel Trachsel, MD, PhD, and his colleagues (BMC Psychiatry (2016 Jul 14:1-9).

Scott A. Irwin, MD, PhD, who coauthored that article and a letter examining these issues, said Dr. Trachsel’s theories lie on the frontiers of current thinking about incorporating palliative care and psychiatric medicine.

Meanwhile, both Dr. Irwin and Maria I. Lapid, MD, another psychiatrist with expertise in palliative care, said that in many ways, the field of psychiatry is inherently palliative in nature.
 

Palliative ‘approach’ in SPMI

Dr. Trachsel presented unpublished results from a survey of U.S. psychiatrists at the annual meeting of the American Psychiatric Association in May that sought to discern whether they favored supporting short-term quality of life rather than long-term disease modification in certain patients with severe and persistent mental illness (SPMI) – defined as mental illness that is chronic or recurring, requires ongoing intensive psychiatric treatment, and seriously impairs functioning.

Courtesy Dr. Trachsel

The response to Dr. Trachsel’s survey was poor – 60 U.S. psychiatrists responded out of nearly 1,000 randomly queried. This means the results are likely to be biased and difficult to generalize. However, all of the psychiatrists who responded agreed that improving function in daily life was important for patients with SPMI, and 90% agreed that reducing suffering was important. Nearly two-thirds ranked as important patient autonomy. The results argued for psychiatrists to focus the goals for their most treatment-refractory patients toward patient desires and quality of life. This approach, which emphasizes preventing and relieving suffering, aligns with the World Health Organization’s definition of palliative care, said Dr. Trachsel, who is affiliated with the University of Zürich.

Specifically, a palliative care approach to SPMI could include a more relaxed use of agents considered potentially addictive or problematic long term, such as benzodiazepines, Dr. Trachsel said. For patients with medical decision-making capacity, it could 1) include withdrawal of care at a patient’s insistence or periods of intermittent sedation – which is used in palliative medicine for patients with intractable pain; or 2) mean switching a patient with end-stage anorexia and multiple failed treatment attempts to hospice care rather than force feeding, Dr. Trachsel said.

Neither Dr. Trachsel’s survey respondents nor those who attended his presentation seemed comfortable with the idea of extending the term “palliative care” – which is often and incorrectly associated with well-defined end-of-life scenarios – to serious, treatment-refractory mental illness. In those illnesses, disease trajectories may be less certain and futility is harder to define. They and other clinicians, however, did voice general support for the underlying concepts of promoting quality of life and decision-making autonomy for patients with SPMI, as well as palliative care targeted at the medical illnesses often acquired by those with SPMI.

According to Dr. Irwin and Dr. Lapid, reducing symptoms, acknowledging that there is no cure for SPMI, and focusing on optimizing patients’ quality of life would be core components of palliative care.

Futility difficult to define

Dr. Irwin said in an interview that the ideas in the letter (Lancet Psychiatry. 2016 Mar;3[3]:200) in which he and a few other colleagues collaborated with Dr. Trachsel were essentially “a thought experiment and very philosophical.” In addition, the letter, which proposed palliative psychiatry “as a means to improve quality of care, person-centeredness, and autonomy” for patients with SPMI, was supported by a handful of case studies, most of them in patients with end-stage anorexia, he said. Furthermore, end-of-life interventions are only a subset of what palliative care brings to the table, said Dr. Irwin, palliative care psychiatrist at Cedars-Sinai Health System’s Samuel Oschin Comprehensive Cancer Center in Los Angeles.

 

With a psychiatric illness, the goals are usually around symptom management and quality of life, and for certain palliative care interventions reserved for end-of-life situations, “there’s usually not something knocking at the door that’s putting that end-of-life question into focus,” Dr. Irwin said. To create end-of-life protocols for SPMI, “you would need to know what the prognosis and trajectory are of each stage of these illnesses. And we don’t have good evidence guiding us.

“If we have a patient who is depressed and wants to commit suicide, who knows how many years they could have left if we intervene?” said Dr. Irwin, who has mentored Dr. Trachsel. “If we had the data that this person’s 90% likely to complete a suicide within the next year, it might change the conversation and treatment decisions.”

Dr. Lapid, a board-certified practitioner of palliative and hospice medicine and geriatric psychiatry at the Mayo Clinic in Rochester, Minn., agreed in an interview that for patients with an SPMI and no life-limiting comorbidity, it becomes complicated to attempt to define futility.

In palliative and hospice care, for the end-of-life piece, “we rely on a classic literature of functional trajectories at the end of life,” she said. “We know what the curve is for cancer, chronic medical conditions such as chronic obstructive pulmonary disease or chronic kidney disease, or even for dementia – but what about major depression, schizophrenia, or schizoaffective disorder? What does the end of life trajectory look like for them? That would be really important to know, because this knowledge will help us determine at what point they are in their life/disorder trajectory, which will help guide advanced care planning.”

Moreover, while Medicare and insurance have precisely detailed guidelines for hospice, which provides palliative care for those with a prognosis of 6 months or less, “there’s no psychiatric illness currently considered a terminal disease eligible for hospice care,” Dr. Lapid said.

Obstacles to access

Patients with SPMI die 25 years earlier than do their peers without SPMI. Most of the premature mortality associated with SPMI, which cuts across age groups, is attributable to chronic diseases rather than to violence or suicide. Less overall engagement with the health care system, leading to late treatment or undertreatment of disease, is one explanation for the premature mortality found among some people in this demographic.

In addition, studies have shown that individuals with SPMI have less access to palliative and hospice care. One study, for example, found that people with schizophrenia and a terminal illness went into hospice half as often as did people without SPMI (Schizophr Res. 2012 Nov;141:241-6). In a recent editorial, a team of psychiatrists and pain specialists called such disparities “unacceptable” and demanded cross-collaboration to resolve them (Gen Hospital Psych. 2017 Jan-Feb;44:1-3).

Dr. Lapid said one reason people with SPMI – with or without a life-limiting comorbidity – end up with less access to palliative and hospice care is that “the art of what we do in hospice and palliative care, advanced planning – is not something we do well or routinely in psychiatry.”

And palliative care specialists may find that for some people with severe mental illness, “it can be hard to really palliate their symptoms,” Dr. Lapid said.

Dr. Irwin noted that patients with SPMI and a terminal illness generally are not extended the same level of agency over their treatment choices as are people without it. Cancer patients, for example, can elect not to receive a treatment even when their prognosis is good. People with serious mental illness – even when they have life-limiting medical comorbidities – may not be given the option of deciding whether to opt for treatment.

Rebecca L. Bauer, MD, a psychosomatic medicine fellow at the Medical College of Wisconsin in Milwaukee, said that psychiatrists, including those with outpatient practices, are well positioned to help patients gain greater access to palliative care and end-of-life planning.

Dr. Bauer, the author of a paper exploring ethical considerations involved in end-of-life and palliative care in patients with SPMI, said people with chronic mental illness “don’t always have a strong support network, and we can’t always figure out what their wishes or desires are. They may have treatment-resistant aspects to their mental illness, and when you add on top a medical condition, it can be hard to figure out which to address first” (Am J Psychiatry. Residents’ Journal 2016;11[5]:4-6).

These patients’ medical needs become so pressing at the end of life that psychiatric disease and the distress it inflicts end up a secondary concern, she said, resulting in the patient suffering.

Psychiatrists “can play an important role in removing some of these barriers,” Dr. Bauer said, especially on multidisciplinary teams. For one thing, psychiatrists are adept at prescribing medications aimed at treating concurrent psychiatric symptoms. In addition, they are more likely than are other clinicians to have experience in communicating with patients with psychosis or other thought disorders.

Another important way psychiatrists can help secure access to palliative care for their patients who need it, she said, is to engage patients during times of relative wellness by encouraging them to discuss end-of-life desires and plans, and help them create formal health care directives.

“We know that sometimes patients [with SPMI] are not as engaged in their primary and medical care, and sometimes the psychiatrist is the only provider they consistently follow up with,” Dr. Bauer said.

All the clinicians interviewed acknowledged that, regardless of the feasibility or ethical viability of any single approach, the idea of incorporating some of the pillars of palliative care for patients with SPMI merits more consideration.

The approach used by psychiatrists treating patients with SPMI is very palliative in approach, Dr. Irwin and Dr. Lapid said. Psychiatrists reduce symptoms and acknowledge that SPMIs are chronic diseases for which there is no cure. To palliate is to make comfortable, to reduce symptoms, to reduce distress and pain, and to relieve suffering and optimize quality of life.

“In cancer, we’ve been telling people for 30 years, ‘keep fighting, because tomorrow there could be a new cure.’ But there’ve been very few new cures,” Dr. Irwin said. “And while some people want to fight to the end in case that cure comes, there are many who would have rather known that there really was little chance and might have made different choices.” In psychiatry, for psychiatric illnesses, he continued, “we need to really start thinking about the course of a person’s life, their quality of life, and the likelihood that they will get better or meet their goals, and what is a tolerable symptom burden for them. Because in the end, these questions apply to all patients.”

While palliative care grows as an interdisciplinary specialty, more clinicians are asking how it can benefit certain patients with severe mental illness.

Palliative care, which developed with the founding of hospices in the 1960s, initially focused on patients who were dying from cancer. The specialty – which emphasizes improving patients’ quality of life rather than finding a cure, and which is different from hospice – can now be used for patients with noncancer diagnoses such as dementia and HIV/AIDS (Psychiatry. 2009 Jun;8[6]:212-15).

Some psychiatrists think that certain patients with another diagnosis would benefit from palliative care: those with severe persistent mental illness.

In fact, this approach might apply to psychiatric patients who are in long-term residential care with “severe/chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa,” wrote Manuel Trachsel, MD, PhD, and his colleagues (BMC Psychiatry (2016 Jul 14:1-9).

Scott A. Irwin, MD, PhD, who coauthored that article and a letter examining these issues, said Dr. Trachsel’s theories lie on the frontiers of current thinking about incorporating palliative care and psychiatric medicine.

Meanwhile, both Dr. Irwin and Maria I. Lapid, MD, another psychiatrist with expertise in palliative care, said that in many ways, the field of psychiatry is inherently palliative in nature.
 

Palliative ‘approach’ in SPMI

Dr. Trachsel presented unpublished results from a survey of U.S. psychiatrists at the annual meeting of the American Psychiatric Association in May that sought to discern whether they favored supporting short-term quality of life rather than long-term disease modification in certain patients with severe and persistent mental illness (SPMI) – defined as mental illness that is chronic or recurring, requires ongoing intensive psychiatric treatment, and seriously impairs functioning.

Courtesy Dr. Trachsel

The response to Dr. Trachsel’s survey was poor – 60 U.S. psychiatrists responded out of nearly 1,000 randomly queried. This means the results are likely to be biased and difficult to generalize. However, all of the psychiatrists who responded agreed that improving function in daily life was important for patients with SPMI, and 90% agreed that reducing suffering was important. Nearly two-thirds ranked as important patient autonomy. The results argued for psychiatrists to focus the goals for their most treatment-refractory patients toward patient desires and quality of life. This approach, which emphasizes preventing and relieving suffering, aligns with the World Health Organization’s definition of palliative care, said Dr. Trachsel, who is affiliated with the University of Zürich.

Specifically, a palliative care approach to SPMI could include a more relaxed use of agents considered potentially addictive or problematic long term, such as benzodiazepines, Dr. Trachsel said. For patients with medical decision-making capacity, it could 1) include withdrawal of care at a patient’s insistence or periods of intermittent sedation – which is used in palliative medicine for patients with intractable pain; or 2) mean switching a patient with end-stage anorexia and multiple failed treatment attempts to hospice care rather than force feeding, Dr. Trachsel said.

Neither Dr. Trachsel’s survey respondents nor those who attended his presentation seemed comfortable with the idea of extending the term “palliative care” – which is often and incorrectly associated with well-defined end-of-life scenarios – to serious, treatment-refractory mental illness. In those illnesses, disease trajectories may be less certain and futility is harder to define. They and other clinicians, however, did voice general support for the underlying concepts of promoting quality of life and decision-making autonomy for patients with SPMI, as well as palliative care targeted at the medical illnesses often acquired by those with SPMI.

According to Dr. Irwin and Dr. Lapid, reducing symptoms, acknowledging that there is no cure for SPMI, and focusing on optimizing patients’ quality of life would be core components of palliative care.

Futility difficult to define

Dr. Irwin said in an interview that the ideas in the letter (Lancet Psychiatry. 2016 Mar;3[3]:200) in which he and a few other colleagues collaborated with Dr. Trachsel were essentially “a thought experiment and very philosophical.” In addition, the letter, which proposed palliative psychiatry “as a means to improve quality of care, person-centeredness, and autonomy” for patients with SPMI, was supported by a handful of case studies, most of them in patients with end-stage anorexia, he said. Furthermore, end-of-life interventions are only a subset of what palliative care brings to the table, said Dr. Irwin, palliative care psychiatrist at Cedars-Sinai Health System’s Samuel Oschin Comprehensive Cancer Center in Los Angeles.

 

With a psychiatric illness, the goals are usually around symptom management and quality of life, and for certain palliative care interventions reserved for end-of-life situations, “there’s usually not something knocking at the door that’s putting that end-of-life question into focus,” Dr. Irwin said. To create end-of-life protocols for SPMI, “you would need to know what the prognosis and trajectory are of each stage of these illnesses. And we don’t have good evidence guiding us.

“If we have a patient who is depressed and wants to commit suicide, who knows how many years they could have left if we intervene?” said Dr. Irwin, who has mentored Dr. Trachsel. “If we had the data that this person’s 90% likely to complete a suicide within the next year, it might change the conversation and treatment decisions.”

Dr. Lapid, a board-certified practitioner of palliative and hospice medicine and geriatric psychiatry at the Mayo Clinic in Rochester, Minn., agreed in an interview that for patients with an SPMI and no life-limiting comorbidity, it becomes complicated to attempt to define futility.

In palliative and hospice care, for the end-of-life piece, “we rely on a classic literature of functional trajectories at the end of life,” she said. “We know what the curve is for cancer, chronic medical conditions such as chronic obstructive pulmonary disease or chronic kidney disease, or even for dementia – but what about major depression, schizophrenia, or schizoaffective disorder? What does the end of life trajectory look like for them? That would be really important to know, because this knowledge will help us determine at what point they are in their life/disorder trajectory, which will help guide advanced care planning.”

Moreover, while Medicare and insurance have precisely detailed guidelines for hospice, which provides palliative care for those with a prognosis of 6 months or less, “there’s no psychiatric illness currently considered a terminal disease eligible for hospice care,” Dr. Lapid said.

Obstacles to access

Patients with SPMI die 25 years earlier than do their peers without SPMI. Most of the premature mortality associated with SPMI, which cuts across age groups, is attributable to chronic diseases rather than to violence or suicide. Less overall engagement with the health care system, leading to late treatment or undertreatment of disease, is one explanation for the premature mortality found among some people in this demographic.

In addition, studies have shown that individuals with SPMI have less access to palliative and hospice care. One study, for example, found that people with schizophrenia and a terminal illness went into hospice half as often as did people without SPMI (Schizophr Res. 2012 Nov;141:241-6). In a recent editorial, a team of psychiatrists and pain specialists called such disparities “unacceptable” and demanded cross-collaboration to resolve them (Gen Hospital Psych. 2017 Jan-Feb;44:1-3).

Dr. Lapid said one reason people with SPMI – with or without a life-limiting comorbidity – end up with less access to palliative and hospice care is that “the art of what we do in hospice and palliative care, advanced planning – is not something we do well or routinely in psychiatry.”

And palliative care specialists may find that for some people with severe mental illness, “it can be hard to really palliate their symptoms,” Dr. Lapid said.

Dr. Irwin noted that patients with SPMI and a terminal illness generally are not extended the same level of agency over their treatment choices as are people without it. Cancer patients, for example, can elect not to receive a treatment even when their prognosis is good. People with serious mental illness – even when they have life-limiting medical comorbidities – may not be given the option of deciding whether to opt for treatment.

Rebecca L. Bauer, MD, a psychosomatic medicine fellow at the Medical College of Wisconsin in Milwaukee, said that psychiatrists, including those with outpatient practices, are well positioned to help patients gain greater access to palliative care and end-of-life planning.

Dr. Bauer, the author of a paper exploring ethical considerations involved in end-of-life and palliative care in patients with SPMI, said people with chronic mental illness “don’t always have a strong support network, and we can’t always figure out what their wishes or desires are. They may have treatment-resistant aspects to their mental illness, and when you add on top a medical condition, it can be hard to figure out which to address first” (Am J Psychiatry. Residents’ Journal 2016;11[5]:4-6).

These patients’ medical needs become so pressing at the end of life that psychiatric disease and the distress it inflicts end up a secondary concern, she said, resulting in the patient suffering.

Psychiatrists “can play an important role in removing some of these barriers,” Dr. Bauer said, especially on multidisciplinary teams. For one thing, psychiatrists are adept at prescribing medications aimed at treating concurrent psychiatric symptoms. In addition, they are more likely than are other clinicians to have experience in communicating with patients with psychosis or other thought disorders.

Another important way psychiatrists can help secure access to palliative care for their patients who need it, she said, is to engage patients during times of relative wellness by encouraging them to discuss end-of-life desires and plans, and help them create formal health care directives.

“We know that sometimes patients [with SPMI] are not as engaged in their primary and medical care, and sometimes the psychiatrist is the only provider they consistently follow up with,” Dr. Bauer said.

All the clinicians interviewed acknowledged that, regardless of the feasibility or ethical viability of any single approach, the idea of incorporating some of the pillars of palliative care for patients with SPMI merits more consideration.

The approach used by psychiatrists treating patients with SPMI is very palliative in approach, Dr. Irwin and Dr. Lapid said. Psychiatrists reduce symptoms and acknowledge that SPMIs are chronic diseases for which there is no cure. To palliate is to make comfortable, to reduce symptoms, to reduce distress and pain, and to relieve suffering and optimize quality of life.

“In cancer, we’ve been telling people for 30 years, ‘keep fighting, because tomorrow there could be a new cure.’ But there’ve been very few new cures,” Dr. Irwin said. “And while some people want to fight to the end in case that cure comes, there are many who would have rather known that there really was little chance and might have made different choices.” In psychiatry, for psychiatric illnesses, he continued, “we need to really start thinking about the course of a person’s life, their quality of life, and the likelihood that they will get better or meet their goals, and what is a tolerable symptom burden for them. Because in the end, these questions apply to all patients.”

I supervise the family clinic in the outpatient psychiatry resident-run clinic. The Suttons are a typical couple, encountered by the new resident, whom I will call Dr. Suraj. Initially, Dr. Suraj is enthusiastic in his meeting with the Suttons, but soon enters into a conundrum and brings the case to supervision. The couple has an intricate inexplicable dance, leaving the resident baffled. Let’s review the case. (I have changed several key details to protect the couple’s confidentiality.)

Ms. Sutton presents with complaints of “depression,” and slowly, it becomes clear that her complaints center on her spouse’s deficiencies. “He doesn’t understand me; he doesn’t know what it is like being depressed.”

Other complaints follow; some are practical, such as: “He doesn’t help around the house.” Ms. Sutton’s complaints mostly reflect her perception that either her spouse does not care for her adequately, he has lost interest in her, or he is fundamentally unable to respond adequately to her needs. “He says bad things to me, like ‘Just get over it,’ or ‘Don’t make such a fuss about things.’ ”

After three further sessions of listening to her complaints, and a general lack of response to prior and current medications, Dr. Suraj decides that Mr. Sutton needs to come in. Dr. Suraj follows what he has been taught so far: Get a history from the partner to validate symptoms, functioning, and quality of life. Mostly, the session goes as predicted, ending with Dr. Suraj’s attempt to educate Mr. Sutton about the signs and symptoms of depression. It doesn’t come out right, because the impression that Mr. Sutton gets is that Dr. Suraj is siding with his wife. This seems to make things worse, as Mr. Sutton then complains to his wife that “The doctor doesn’t know what he’s talking about,” “is too young to understand,” or a myriad of other put-downs. Ms. Sutton, of course, tells Dr. Suraj about all of this, following it up with “Don’t worry Doc; you are doing a great job.” Other comments are more in the way of commentary: “I told my husband what you said last week, and he disagrees with you.”

Dr. Suraj realizes that “something is amiss;” the case is stuck, and worse, he is stuck in the middle. The general impression, says Dr. Suraj, “is of a woman who feels victimized, neglected, or overlooked, but somehow, she has the power. She presents as the victim but also is the victimizer. He seems to be the victimizer and tormenter, but all in all, just as much the victim of her torments! I do not know how to think about this couple: They seem stuck, unhappily but inexorably stuck together in perpetuity.” Can anything be done to change this relationship?

Dr. Suraj’s uncensored thoughts: Perhaps they should break up or at least stop complaining. What is it that makes people keep complaining about their relationships? Either they accept it or they leave.
 

Initial areas of focus

Interpersonal violence. The archetypal extreme is that of an abusive relationship, where the victim is subjected to domestic violence. As I wrote in Advances in Psychiatric Treatment, many relationships where violence is present are bidirectional (2007;13[5]:376-83). Couples may not voice this concern for fear of the spouse being turned over to the police. I usually include a question such as: “How many times do your arguments include pushing or shoving or things like that?”

Asking about income, specifically, who controls the finances and how money is spent, clarifies whether one person feels that he or she has no option but to stay in the relationship.

If intimate partner violence (IPV) exists, there are typical protocols for helping the victim leave. When IPV is not a consideration, the resident wonders about the Suttons, when the victim and abuser change or share roles. Why do they keep up this struggle if they are unhappy?

Life expectations. Many couples do not discuss their expectations or what they imagine will happen when they get married. There may be unspoken fantasies such as “I always assumed that you would retire at 65, and we would go traveling together.” People may change their minds, or life circumstances change so that expectations and fantasies about their life together can no longer be sustained. Are there goals that have changed? Are there dependent relatives that prevent marital goals from being achieved? Is there a lack of agreement about what are important life goals?

Change! One spouse may try to make the other person change, according to his or her preferences. In the psychiatrist’s office, this can take the form of pathologizing: He just wasn’t brought up to talk about feelings, meaning he needs to talk about feelings. We hear questions such as: “Can you take him on in therapy?”; “He doesn’t listen ... can you check him for hearing loss?”; “She doesn’t remember what I said: Can you check her for dementia?” These complaints may come up at the beginning of a relationship or later in life, for example, after retirement when the couple is home together for extended periods of time. Is the expectation that each person should be able to fulfill the partner’s every wish and desire? Be all things? That is a tough order.

The Suttons report that change is the main thing they want from each other. After a full family assessment, it is clear that roles are evenly and acceptably shared; they have no differences in family rules; they both enjoy the same hobbies, care for each other, and work together to solve family crises. However, they cannot accept each other the way they are. When the children were young, she said: “I was too busy to get depressed.” Mr. Sutton states that she now wants him to be attentive to her but he is too tired after a lifetime of work, and anyway, she is so whiny he does not want to be around her. So they bicker back and forth, neither giving an inch.
 

 

Useful theories

A. Dr. Gottman’s typology. John Gottman, PhD, categorizes couples into five types: Conflict-Avoiding, Validating, Volatile, Hostile, and Hostile-Detached. The three happy couple types (Conflict-Avoiding, Validating, and Volatile) are very different from one another, and each type has its own benefits and risks. Of the two unhappy couple types, hostile couples stayed unhappily married. He derived this categorization from observations of couples in his lab (https://www.gottman.com).

Conflict-Avoiding: Conflict avoiders minimize persuasion attempts and instead emphasize their areas of common ground. They avoid conflict, avoid expressing what they need from one another, and congratulate their relationship for being generally happy. Conflict-avoiding couples balance independence and interdependence. They have clear boundaries, and are separate people with separate interests. They can be connected and caring in areas of overlap where they are interdependent. While they are minimally emotionally expressive, they maintain a ratio of positive-to-negative affect around 5 to 1. Their interaction is good enough for them.

Validating: The interaction of these couples is characterized by ease and calm. They are somewhat expressive but mostly neutral. They are intermediate between avoiders and the volatile couples. They put a lot of emphasis on supporting and understanding their partner’s point of view, and are often empathetic about their partner’s feelings. They will confront their differences, but only on some topics and not on others. They can become highly competitive on some issues, which can turn into a power struggle, but they usually calm down and compromise. The ratio of positive-to-negative comments is 5 to 1.

Volatile: Volatile couples are intensely emotional. During a conflict discussion, they begin persuasion immediately, and they debate with laughter and humor. They are not disrespectful or insulting. Their positive-to-negative comments ratio is 5 to 1. Anger and feelings of insecurity are expressed, but not contempt. They have no clear boundaries around their individual worlds. While they argue about their roles, they emphasize connection and honesty in their communication.

Hostile: Hostile couples are like validators, except there are high levels of defensiveness on the part of both partners. In Dr. Gottman’s lab, the husband was usually the validator and the wife was the avoider.

Hostile-Detached: These couples are like two armies engaged in a standoff. They snipe at one another during conflict, although the air is one of emotional detachment and resignation. In Dr. Gottman’s lab, usually there was a validator husband with a volatile wife. Escalating conflict will occur between two validators, but then one of them will back down. But the volatile will not let the validator withdraw. Dr. Gottman notes that there is a superiority involved in the woman: that the man needs to be taught the right way to be. The woman does not see the need to change.
 

B. The approach/avoidance dance

The approach/avoidance dance is based on the motivation of each person (Psychol Sci. 2008 Oct 19;[10]:1030-6). A partner with approach goals focuses on attaining positive outcomes, such as intimacy and growth. A partner with avoidance goals focuses away from negative outcomes, such as conflict and rejection (Educational Psychologist. 1999;34:169-89). For example, in a discussion about child care, a husband who has strong approach goals may be concerned with wanting the discussion to go smoothly and wanting both partners to be happy with the outcome. In contrast, a husband with strong avoidance goals may be more concerned with avoiding conflict about child care and preventing both partners from being unhappy with the outcome. People who are not motivated by approach goals are not particularly interested in pursuing positive experiences in their relationships, such as bonding, intimacy, or fun activities. In contrast, people who are motivated by avoidance goals are interested in avoiding negative experiences, such as conflict, betrayal, or rejection by a romantic partner.

C. Attachment

Both of the previously discussed theories have attachment theory at their core, and are organized around anxiety and avoidance. The anxiety would be tied to concern that the partner may not be available or supportive in times of need, and the avoidance piece would be tied to worry that the partner cannot be fully trusted (Fam Process. 2002 Fall;41[3]:546-50). A low score on both of these indices means a secure attachment style. For unhappy couples with cemented attachments, there is no thought that one would leave. They are bound together in unhappiness (Current Opin Psychol. 2017 Feb;13:60-4).

Nice guy husband/borderline wife relationship or hysterical wife/obsessive-compulsive husband: These relationship can be explained using an attachment framework. This male personality type truly enjoys giving and often finds that he needs nothing more in return than a feeling of being appreciated.
 

 

D. Emotionally focused therapy

Sue Johnson, EdD, has an evidence-based couples therapy called emotionally focused couples and family therapy. She would interpret the Suttons as a couple caught in a dance of negativity. The goal of therapy is to help couples let down defenses enough to be vulnerable and then to help them express emotional needs to each other. Dr. Johnson helps each person meet the emotional needs of the other. (See http://drsuejohnson.com/)

E. The game of struggle for power and control

In most relationships, there is a minimizer and a maximizer. The minimizer is more subdued within the relationship, while the maximizer is more evocative. When this turns into a game of “Who has the power,” then minimizing and maximizing turns into submission and dominance. Typically, the minimizer becomes dominant, and the maximizer becomes submissive. One partner can become parentalized and the other infantilized. Most often, the maximizer, being more emotional, tends to become infantilized and submissive for fear of angering or disappointing his or her partner. The minimizer, being more contained, tends to gather the power in the relationship, whether by intention or default, and, in this way, becomes parentalized.

The balance of power shifts within the relationship based on the actions of the partners. As the submissive/infantilized partner withdraws emotionally and physically to try to keep the peace, the dominant/parentalized partner becomes anxious and becomes more attentive, needy, and infantile. The submissive/infantilized partner responds by reinvesting, the dominant/parentalized partner is satisfied that all is well, and the balance of power shifts back again.

Is this power struggle similar to the developmental challenges faced by toddlers? Being in a growth-supporting relationship means that the relationship helps people develop a more mature interpersonal relationship. It is this notion that supports the theory that people at the same developmental level find each other compatible, as they both face the same challenges in life.

So what happened to the Suttons? The resident referred the patient to the outpatient couples therapist, who treated them for six sessions. The assessment revealed that they had played this dance for decades, but it had intensified after Mr. Sutton retired and was available as a daily target for Ms. Sutton’s unhappiness with the way that life had treated her. The mutual negative impact of their interactions was ameliorated to some extent, by helping the couple develop individual interests. They moved from being hostile-detached to conflict-avoiding. The Suttons moved from waltzing to circle dancing.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.

I supervise the family clinic in the outpatient psychiatry resident-run clinic. The Suttons are a typical couple, encountered by the new resident, whom I will call Dr. Suraj. Initially, Dr. Suraj is enthusiastic in his meeting with the Suttons, but soon enters into a conundrum and brings the case to supervision. The couple has an intricate inexplicable dance, leaving the resident baffled. Let’s review the case. (I have changed several key details to protect the couple’s confidentiality.)

Ms. Sutton presents with complaints of “depression,” and slowly, it becomes clear that her complaints center on her spouse’s deficiencies. “He doesn’t understand me; he doesn’t know what it is like being depressed.”

Other complaints follow; some are practical, such as: “He doesn’t help around the house.” Ms. Sutton’s complaints mostly reflect her perception that either her spouse does not care for her adequately, he has lost interest in her, or he is fundamentally unable to respond adequately to her needs. “He says bad things to me, like ‘Just get over it,’ or ‘Don’t make such a fuss about things.’ ”

After three further sessions of listening to her complaints, and a general lack of response to prior and current medications, Dr. Suraj decides that Mr. Sutton needs to come in. Dr. Suraj follows what he has been taught so far: Get a history from the partner to validate symptoms, functioning, and quality of life. Mostly, the session goes as predicted, ending with Dr. Suraj’s attempt to educate Mr. Sutton about the signs and symptoms of depression. It doesn’t come out right, because the impression that Mr. Sutton gets is that Dr. Suraj is siding with his wife. This seems to make things worse, as Mr. Sutton then complains to his wife that “The doctor doesn’t know what he’s talking about,” “is too young to understand,” or a myriad of other put-downs. Ms. Sutton, of course, tells Dr. Suraj about all of this, following it up with “Don’t worry Doc; you are doing a great job.” Other comments are more in the way of commentary: “I told my husband what you said last week, and he disagrees with you.”

Dr. Suraj realizes that “something is amiss;” the case is stuck, and worse, he is stuck in the middle. The general impression, says Dr. Suraj, “is of a woman who feels victimized, neglected, or overlooked, but somehow, she has the power. She presents as the victim but also is the victimizer. He seems to be the victimizer and tormenter, but all in all, just as much the victim of her torments! I do not know how to think about this couple: They seem stuck, unhappily but inexorably stuck together in perpetuity.” Can anything be done to change this relationship?

Dr. Suraj’s uncensored thoughts: Perhaps they should break up or at least stop complaining. What is it that makes people keep complaining about their relationships? Either they accept it or they leave.
 

Initial areas of focus

Interpersonal violence. The archetypal extreme is that of an abusive relationship, where the victim is subjected to domestic violence. As I wrote in Advances in Psychiatric Treatment, many relationships where violence is present are bidirectional (2007;13[5]:376-83). Couples may not voice this concern for fear of the spouse being turned over to the police. I usually include a question such as: “How many times do your arguments include pushing or shoving or things like that?”

Asking about income, specifically, who controls the finances and how money is spent, clarifies whether one person feels that he or she has no option but to stay in the relationship.

If intimate partner violence (IPV) exists, there are typical protocols for helping the victim leave. When IPV is not a consideration, the resident wonders about the Suttons, when the victim and abuser change or share roles. Why do they keep up this struggle if they are unhappy?

Life expectations. Many couples do not discuss their expectations or what they imagine will happen when they get married. There may be unspoken fantasies such as “I always assumed that you would retire at 65, and we would go traveling together.” People may change their minds, or life circumstances change so that expectations and fantasies about their life together can no longer be sustained. Are there goals that have changed? Are there dependent relatives that prevent marital goals from being achieved? Is there a lack of agreement about what are important life goals?

Change! One spouse may try to make the other person change, according to his or her preferences. In the psychiatrist’s office, this can take the form of pathologizing: He just wasn’t brought up to talk about feelings, meaning he needs to talk about feelings. We hear questions such as: “Can you take him on in therapy?”; “He doesn’t listen ... can you check him for hearing loss?”; “She doesn’t remember what I said: Can you check her for dementia?” These complaints may come up at the beginning of a relationship or later in life, for example, after retirement when the couple is home together for extended periods of time. Is the expectation that each person should be able to fulfill the partner’s every wish and desire? Be all things? That is a tough order.

The Suttons report that change is the main thing they want from each other. After a full family assessment, it is clear that roles are evenly and acceptably shared; they have no differences in family rules; they both enjoy the same hobbies, care for each other, and work together to solve family crises. However, they cannot accept each other the way they are. When the children were young, she said: “I was too busy to get depressed.” Mr. Sutton states that she now wants him to be attentive to her but he is too tired after a lifetime of work, and anyway, she is so whiny he does not want to be around her. So they bicker back and forth, neither giving an inch.
 

 

Useful theories

A. Dr. Gottman’s typology. John Gottman, PhD, categorizes couples into five types: Conflict-Avoiding, Validating, Volatile, Hostile, and Hostile-Detached. The three happy couple types (Conflict-Avoiding, Validating, and Volatile) are very different from one another, and each type has its own benefits and risks. Of the two unhappy couple types, hostile couples stayed unhappily married. He derived this categorization from observations of couples in his lab (https://www.gottman.com).

Conflict-Avoiding: Conflict avoiders minimize persuasion attempts and instead emphasize their areas of common ground. They avoid conflict, avoid expressing what they need from one another, and congratulate their relationship for being generally happy. Conflict-avoiding couples balance independence and interdependence. They have clear boundaries, and are separate people with separate interests. They can be connected and caring in areas of overlap where they are interdependent. While they are minimally emotionally expressive, they maintain a ratio of positive-to-negative affect around 5 to 1. Their interaction is good enough for them.

Validating: The interaction of these couples is characterized by ease and calm. They are somewhat expressive but mostly neutral. They are intermediate between avoiders and the volatile couples. They put a lot of emphasis on supporting and understanding their partner’s point of view, and are often empathetic about their partner’s feelings. They will confront their differences, but only on some topics and not on others. They can become highly competitive on some issues, which can turn into a power struggle, but they usually calm down and compromise. The ratio of positive-to-negative comments is 5 to 1.

Volatile: Volatile couples are intensely emotional. During a conflict discussion, they begin persuasion immediately, and they debate with laughter and humor. They are not disrespectful or insulting. Their positive-to-negative comments ratio is 5 to 1. Anger and feelings of insecurity are expressed, but not contempt. They have no clear boundaries around their individual worlds. While they argue about their roles, they emphasize connection and honesty in their communication.

Hostile: Hostile couples are like validators, except there are high levels of defensiveness on the part of both partners. In Dr. Gottman’s lab, the husband was usually the validator and the wife was the avoider.

Hostile-Detached: These couples are like two armies engaged in a standoff. They snipe at one another during conflict, although the air is one of emotional detachment and resignation. In Dr. Gottman’s lab, usually there was a validator husband with a volatile wife. Escalating conflict will occur between two validators, but then one of them will back down. But the volatile will not let the validator withdraw. Dr. Gottman notes that there is a superiority involved in the woman: that the man needs to be taught the right way to be. The woman does not see the need to change.
 

B. The approach/avoidance dance

The approach/avoidance dance is based on the motivation of each person (Psychol Sci. 2008 Oct 19;[10]:1030-6). A partner with approach goals focuses on attaining positive outcomes, such as intimacy and growth. A partner with avoidance goals focuses away from negative outcomes, such as conflict and rejection (Educational Psychologist. 1999;34:169-89). For example, in a discussion about child care, a husband who has strong approach goals may be concerned with wanting the discussion to go smoothly and wanting both partners to be happy with the outcome. In contrast, a husband with strong avoidance goals may be more concerned with avoiding conflict about child care and preventing both partners from being unhappy with the outcome. People who are not motivated by approach goals are not particularly interested in pursuing positive experiences in their relationships, such as bonding, intimacy, or fun activities. In contrast, people who are motivated by avoidance goals are interested in avoiding negative experiences, such as conflict, betrayal, or rejection by a romantic partner.

C. Attachment

Both of the previously discussed theories have attachment theory at their core, and are organized around anxiety and avoidance. The anxiety would be tied to concern that the partner may not be available or supportive in times of need, and the avoidance piece would be tied to worry that the partner cannot be fully trusted (Fam Process. 2002 Fall;41[3]:546-50). A low score on both of these indices means a secure attachment style. For unhappy couples with cemented attachments, there is no thought that one would leave. They are bound together in unhappiness (Current Opin Psychol. 2017 Feb;13:60-4).

Nice guy husband/borderline wife relationship or hysterical wife/obsessive-compulsive husband: These relationship can be explained using an attachment framework. This male personality type truly enjoys giving and often finds that he needs nothing more in return than a feeling of being appreciated.
 

 

D. Emotionally focused therapy

Sue Johnson, EdD, has an evidence-based couples therapy called emotionally focused couples and family therapy. She would interpret the Suttons as a couple caught in a dance of negativity. The goal of therapy is to help couples let down defenses enough to be vulnerable and then to help them express emotional needs to each other. Dr. Johnson helps each person meet the emotional needs of the other. (See http://drsuejohnson.com/)

E. The game of struggle for power and control

In most relationships, there is a minimizer and a maximizer. The minimizer is more subdued within the relationship, while the maximizer is more evocative. When this turns into a game of “Who has the power,” then minimizing and maximizing turns into submission and dominance. Typically, the minimizer becomes dominant, and the maximizer becomes submissive. One partner can become parentalized and the other infantilized. Most often, the maximizer, being more emotional, tends to become infantilized and submissive for fear of angering or disappointing his or her partner. The minimizer, being more contained, tends to gather the power in the relationship, whether by intention or default, and, in this way, becomes parentalized.

The balance of power shifts within the relationship based on the actions of the partners. As the submissive/infantilized partner withdraws emotionally and physically to try to keep the peace, the dominant/parentalized partner becomes anxious and becomes more attentive, needy, and infantile. The submissive/infantilized partner responds by reinvesting, the dominant/parentalized partner is satisfied that all is well, and the balance of power shifts back again.

Is this power struggle similar to the developmental challenges faced by toddlers? Being in a growth-supporting relationship means that the relationship helps people develop a more mature interpersonal relationship. It is this notion that supports the theory that people at the same developmental level find each other compatible, as they both face the same challenges in life.

So what happened to the Suttons? The resident referred the patient to the outpatient couples therapist, who treated them for six sessions. The assessment revealed that they had played this dance for decades, but it had intensified after Mr. Sutton retired and was available as a daily target for Ms. Sutton’s unhappiness with the way that life had treated her. The mutual negative impact of their interactions was ameliorated to some extent, by helping the couple develop individual interests. They moved from being hostile-detached to conflict-avoiding. The Suttons moved from waltzing to circle dancing.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.

I supervise the family clinic in the outpatient psychiatry resident-run clinic. The Suttons are a typical couple, encountered by the new resident, whom I will call Dr. Suraj. Initially, Dr. Suraj is enthusiastic in his meeting with the Suttons, but soon enters into a conundrum and brings the case to supervision. The couple has an intricate inexplicable dance, leaving the resident baffled. Let’s review the case. (I have changed several key details to protect the couple’s confidentiality.)

Ms. Sutton presents with complaints of “depression,” and slowly, it becomes clear that her complaints center on her spouse’s deficiencies. “He doesn’t understand me; he doesn’t know what it is like being depressed.”

Other complaints follow; some are practical, such as: “He doesn’t help around the house.” Ms. Sutton’s complaints mostly reflect her perception that either her spouse does not care for her adequately, he has lost interest in her, or he is fundamentally unable to respond adequately to her needs. “He says bad things to me, like ‘Just get over it,’ or ‘Don’t make such a fuss about things.’ ”

After three further sessions of listening to her complaints, and a general lack of response to prior and current medications, Dr. Suraj decides that Mr. Sutton needs to come in. Dr. Suraj follows what he has been taught so far: Get a history from the partner to validate symptoms, functioning, and quality of life. Mostly, the session goes as predicted, ending with Dr. Suraj’s attempt to educate Mr. Sutton about the signs and symptoms of depression. It doesn’t come out right, because the impression that Mr. Sutton gets is that Dr. Suraj is siding with his wife. This seems to make things worse, as Mr. Sutton then complains to his wife that “The doctor doesn’t know what he’s talking about,” “is too young to understand,” or a myriad of other put-downs. Ms. Sutton, of course, tells Dr. Suraj about all of this, following it up with “Don’t worry Doc; you are doing a great job.” Other comments are more in the way of commentary: “I told my husband what you said last week, and he disagrees with you.”

Dr. Suraj realizes that “something is amiss;” the case is stuck, and worse, he is stuck in the middle. The general impression, says Dr. Suraj, “is of a woman who feels victimized, neglected, or overlooked, but somehow, she has the power. She presents as the victim but also is the victimizer. He seems to be the victimizer and tormenter, but all in all, just as much the victim of her torments! I do not know how to think about this couple: They seem stuck, unhappily but inexorably stuck together in perpetuity.” Can anything be done to change this relationship?

Dr. Suraj’s uncensored thoughts: Perhaps they should break up or at least stop complaining. What is it that makes people keep complaining about their relationships? Either they accept it or they leave.
 

Initial areas of focus

Interpersonal violence. The archetypal extreme is that of an abusive relationship, where the victim is subjected to domestic violence. As I wrote in Advances in Psychiatric Treatment, many relationships where violence is present are bidirectional (2007;13[5]:376-83). Couples may not voice this concern for fear of the spouse being turned over to the police. I usually include a question such as: “How many times do your arguments include pushing or shoving or things like that?”

Asking about income, specifically, who controls the finances and how money is spent, clarifies whether one person feels that he or she has no option but to stay in the relationship.

If intimate partner violence (IPV) exists, there are typical protocols for helping the victim leave. When IPV is not a consideration, the resident wonders about the Suttons, when the victim and abuser change or share roles. Why do they keep up this struggle if they are unhappy?

Life expectations. Many couples do not discuss their expectations or what they imagine will happen when they get married. There may be unspoken fantasies such as “I always assumed that you would retire at 65, and we would go traveling together.” People may change their minds, or life circumstances change so that expectations and fantasies about their life together can no longer be sustained. Are there goals that have changed? Are there dependent relatives that prevent marital goals from being achieved? Is there a lack of agreement about what are important life goals?

Change! One spouse may try to make the other person change, according to his or her preferences. In the psychiatrist’s office, this can take the form of pathologizing: He just wasn’t brought up to talk about feelings, meaning he needs to talk about feelings. We hear questions such as: “Can you take him on in therapy?”; “He doesn’t listen ... can you check him for hearing loss?”; “She doesn’t remember what I said: Can you check her for dementia?” These complaints may come up at the beginning of a relationship or later in life, for example, after retirement when the couple is home together for extended periods of time. Is the expectation that each person should be able to fulfill the partner’s every wish and desire? Be all things? That is a tough order.

The Suttons report that change is the main thing they want from each other. After a full family assessment, it is clear that roles are evenly and acceptably shared; they have no differences in family rules; they both enjoy the same hobbies, care for each other, and work together to solve family crises. However, they cannot accept each other the way they are. When the children were young, she said: “I was too busy to get depressed.” Mr. Sutton states that she now wants him to be attentive to her but he is too tired after a lifetime of work, and anyway, she is so whiny he does not want to be around her. So they bicker back and forth, neither giving an inch.
 

 

Useful theories

A. Dr. Gottman’s typology. John Gottman, PhD, categorizes couples into five types: Conflict-Avoiding, Validating, Volatile, Hostile, and Hostile-Detached. The three happy couple types (Conflict-Avoiding, Validating, and Volatile) are very different from one another, and each type has its own benefits and risks. Of the two unhappy couple types, hostile couples stayed unhappily married. He derived this categorization from observations of couples in his lab (https://www.gottman.com).

Conflict-Avoiding: Conflict avoiders minimize persuasion attempts and instead emphasize their areas of common ground. They avoid conflict, avoid expressing what they need from one another, and congratulate their relationship for being generally happy. Conflict-avoiding couples balance independence and interdependence. They have clear boundaries, and are separate people with separate interests. They can be connected and caring in areas of overlap where they are interdependent. While they are minimally emotionally expressive, they maintain a ratio of positive-to-negative affect around 5 to 1. Their interaction is good enough for them.

Validating: The interaction of these couples is characterized by ease and calm. They are somewhat expressive but mostly neutral. They are intermediate between avoiders and the volatile couples. They put a lot of emphasis on supporting and understanding their partner’s point of view, and are often empathetic about their partner’s feelings. They will confront their differences, but only on some topics and not on others. They can become highly competitive on some issues, which can turn into a power struggle, but they usually calm down and compromise. The ratio of positive-to-negative comments is 5 to 1.

Volatile: Volatile couples are intensely emotional. During a conflict discussion, they begin persuasion immediately, and they debate with laughter and humor. They are not disrespectful or insulting. Their positive-to-negative comments ratio is 5 to 1. Anger and feelings of insecurity are expressed, but not contempt. They have no clear boundaries around their individual worlds. While they argue about their roles, they emphasize connection and honesty in their communication.

Hostile: Hostile couples are like validators, except there are high levels of defensiveness on the part of both partners. In Dr. Gottman’s lab, the husband was usually the validator and the wife was the avoider.

Hostile-Detached: These couples are like two armies engaged in a standoff. They snipe at one another during conflict, although the air is one of emotional detachment and resignation. In Dr. Gottman’s lab, usually there was a validator husband with a volatile wife. Escalating conflict will occur between two validators, but then one of them will back down. But the volatile will not let the validator withdraw. Dr. Gottman notes that there is a superiority involved in the woman: that the man needs to be taught the right way to be. The woman does not see the need to change.
 

B. The approach/avoidance dance

The approach/avoidance dance is based on the motivation of each person (Psychol Sci. 2008 Oct 19;[10]:1030-6). A partner with approach goals focuses on attaining positive outcomes, such as intimacy and growth. A partner with avoidance goals focuses away from negative outcomes, such as conflict and rejection (Educational Psychologist. 1999;34:169-89). For example, in a discussion about child care, a husband who has strong approach goals may be concerned with wanting the discussion to go smoothly and wanting both partners to be happy with the outcome. In contrast, a husband with strong avoidance goals may be more concerned with avoiding conflict about child care and preventing both partners from being unhappy with the outcome. People who are not motivated by approach goals are not particularly interested in pursuing positive experiences in their relationships, such as bonding, intimacy, or fun activities. In contrast, people who are motivated by avoidance goals are interested in avoiding negative experiences, such as conflict, betrayal, or rejection by a romantic partner.

C. Attachment

Both of the previously discussed theories have attachment theory at their core, and are organized around anxiety and avoidance. The anxiety would be tied to concern that the partner may not be available or supportive in times of need, and the avoidance piece would be tied to worry that the partner cannot be fully trusted (Fam Process. 2002 Fall;41[3]:546-50). A low score on both of these indices means a secure attachment style. For unhappy couples with cemented attachments, there is no thought that one would leave. They are bound together in unhappiness (Current Opin Psychol. 2017 Feb;13:60-4).

Nice guy husband/borderline wife relationship or hysterical wife/obsessive-compulsive husband: These relationship can be explained using an attachment framework. This male personality type truly enjoys giving and often finds that he needs nothing more in return than a feeling of being appreciated.
 

 

D. Emotionally focused therapy

Sue Johnson, EdD, has an evidence-based couples therapy called emotionally focused couples and family therapy. She would interpret the Suttons as a couple caught in a dance of negativity. The goal of therapy is to help couples let down defenses enough to be vulnerable and then to help them express emotional needs to each other. Dr. Johnson helps each person meet the emotional needs of the other. (See http://drsuejohnson.com/)

E. The game of struggle for power and control

In most relationships, there is a minimizer and a maximizer. The minimizer is more subdued within the relationship, while the maximizer is more evocative. When this turns into a game of “Who has the power,” then minimizing and maximizing turns into submission and dominance. Typically, the minimizer becomes dominant, and the maximizer becomes submissive. One partner can become parentalized and the other infantilized. Most often, the maximizer, being more emotional, tends to become infantilized and submissive for fear of angering or disappointing his or her partner. The minimizer, being more contained, tends to gather the power in the relationship, whether by intention or default, and, in this way, becomes parentalized.

The balance of power shifts within the relationship based on the actions of the partners. As the submissive/infantilized partner withdraws emotionally and physically to try to keep the peace, the dominant/parentalized partner becomes anxious and becomes more attentive, needy, and infantile. The submissive/infantilized partner responds by reinvesting, the dominant/parentalized partner is satisfied that all is well, and the balance of power shifts back again.

Is this power struggle similar to the developmental challenges faced by toddlers? Being in a growth-supporting relationship means that the relationship helps people develop a more mature interpersonal relationship. It is this notion that supports the theory that people at the same developmental level find each other compatible, as they both face the same challenges in life.

So what happened to the Suttons? The resident referred the patient to the outpatient couples therapist, who treated them for six sessions. The assessment revealed that they had played this dance for decades, but it had intensified after Mr. Sutton retired and was available as a daily target for Ms. Sutton’s unhappiness with the way that life had treated her. The mutual negative impact of their interactions was ameliorated to some extent, by helping the couple develop individual interests. They moved from being hostile-detached to conflict-avoiding. The Suttons moved from waltzing to circle dancing.
 

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.