MDedge Psychiatry

Adolescents later diagnosed with anorexia nervosa (AN) likely embark on the trajectory to AN with undisclosed dieting for weight loss at about age 14, a study of teens and parents found.

In the interview-based study, both adolescents and their parents described a similar prediagnosis sequence of behavioral changes occurring over roughly 1 year to 18 months, but parents lagged some 6 months behind in noticing their children’s disordered eating.

The findings suggest that even teens of normal weight should be asked about their eating habits and monitored more closely for contact with those who endorse these potentially harmful eating behaviors, according to Lisa M. Ranzenhofer, PhD, assistant professor of clinical psychology in psychiatry at Columbia University Medical Center in New York, and colleagues. Their report is in the Journal of Adolescent Health.

“We know that adolescents often have eating disorder behaviors long before they’re diagnosed, so we developed this interview as a tool to figure out how long a maladaptive behavior has been present,” Dr. Ranzenhofer said in an interview. “Most studies that report illness duration do so based on diagnosis, so this interview provides a more fine-grained assessment of the duration of problematic behavior, which may help improve understanding of the impact of duration on outcome, and hopefully facilitate better methods for early detection.” Since healthy adolescents are often seen once per year at an annual pediatrician visit, she added, teens engaging in significant dieting might benefit from more frequent monitoring since this behavior can evolve into an eating disorder over a relatively short time frame.

AN is associated with significant medical and psychiatric comorbidity and has a mortality rate among the highest of any psychiatric illness, the authors noted.
 

The study

The study cohort consisted of 71 girls ages 12-18 years participating in research from 2017 to 2021 at the Eating Disorders Research Unit of New York (N.Y.) State Psychiatric Institute. Patients had either the restricting or binge-eating/purging subtype of AN as diagnosed by the Eating Disorder Assessment–5 questionnaire. A semistructured 15-minute interview with the girls and their parents explored food restriction, dieting, loss of control/binge eating, purging, excessive/compulsive exercise, weight history, and amenorrhea.

Both parents and children were asked whether and when the children had been underweight or overweight, and whether and when primary amenorrhea (no menarche) or secondary amenorrhea (periods missed for 3 months) became evident. Dieting was defined as “deliberately changing eating patterns in any way to influence your shape or weight,” and restriction as “deliberately cutting down on the amount of food that you are eating, in order to change your shape or weight.” Loss-of-control eating was defined as “feeling unable to stop eating or control what or how much you are eating.”

In other characterizations, purging was defined as making yourself vomit on purpose, taking diuretics, or feeling driven to engage in these behaviors. Questions on exercise explored whether children might feel anxious when they do not exercise or inclined to exercise even if sick or injured, with excessive exercise defined as “Feeling like you must exercise, might continue exercising, sometimes in secret, if parents or doctors have told you to stop.”

Other questions focused on use of diuretics or laxatives and other strategies to compensate for calories consumed.

Responses revealed that restriction, underweight, dieting, and excessive exercise were present in most of the sample, while purging, loss-of-control eating, and overweight were reported by fewer than a third. With dieting typically emerging first around age 14, the other behaviors tended to manifest from age 14 to 14 and a half. The average age of formal diagnosis was just over 15 years. Parent-child dyads showed good agreement on the presence and timing of all behaviors except for dieting, for which children reported onset about 6 months earlier or longer duration compared with parents.

Although older age at the time of interview was associated with a lower body mass index percentile and higher eating disorder score, neither age of onset nor duration of disordered eating was associated with severity when researchers controlled for current age.
 

Telltale signs for parents

“For teens starting at a healthy weight, significant and intentional weight loss of more than 5-10 pounds can be a cause for concern,” Dr. Ranzenhofer said. Missed periods, refusing meals, skipping meals, fighting or arguing about eating, and withdrawal from normal activities and relationships are other signs of disordered eating. For overweight or obese teens, rapid weight loss and weight loss above and beyond that recommended are also concerning.

As for compulsive exercise, she said, “Altered exercise behavior might look like exercise that interferes with other activities, for example, being late to school or not doing homework in order to exercise.” Other red flags would be physical activity that varies considerably from that of peers, for instance, going running after a 2-hour sports practice and an inflexible routine that precludes being able to skip a day.

“All adolescents, male and female, should be screened regardless of weight trends – underweight, overweight, obese, or normal weight – regarding their body image and thoughts of dieting,” said Margaret E. Thew, DNP, FNP-BC, of the Medical College of Wisconsin, and medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, commenting on the study but not involved in it. “Most adolescents make decisions to lose weight after trying to ‘eat healthy’ but may take an aggressive approach when they don’t see the weight loss they hope to see.”

According to Ms. Thew, the study findings support the benefit of giving medical caregivers and parents training on the red flags regarding eating disorders to foster early detection. “These include starting a new fad diet, eliminating foods, ‘healthy eating,’ over-exercising, skipping meals, or no longer eating foods they previously loved.”

She added that times of transition are key junctures to watch: The transition from grade school to middle school, middle to high school, and high school to college. “These tend to provoke eating disorder onset or relapse of eating disorder thoughts and behaviors after diagnosis,” Ms. Thew said. “It would benefit the patient to screen for concerns about disordered eating and provide resources, including consultation with a dietitian, as appropriate.”

This study was supported by grants from the National Institute of Mental Health and the Hilda and Preston Davis Foundation. Coauthor Joanna E. Steinglass, MD, disclosed receiving royalties from UpToDate. Ms. Thew disclosed no competing interests with regard to her comments.

Adolescents later diagnosed with anorexia nervosa (AN) likely embark on the trajectory to AN with undisclosed dieting for weight loss at about age 14, a study of teens and parents found.

In the interview-based study, both adolescents and their parents described a similar prediagnosis sequence of behavioral changes occurring over roughly 1 year to 18 months, but parents lagged some 6 months behind in noticing their children’s disordered eating.

The findings suggest that even teens of normal weight should be asked about their eating habits and monitored more closely for contact with those who endorse these potentially harmful eating behaviors, according to Lisa M. Ranzenhofer, PhD, assistant professor of clinical psychology in psychiatry at Columbia University Medical Center in New York, and colleagues. Their report is in the Journal of Adolescent Health.

“We know that adolescents often have eating disorder behaviors long before they’re diagnosed, so we developed this interview as a tool to figure out how long a maladaptive behavior has been present,” Dr. Ranzenhofer said in an interview. “Most studies that report illness duration do so based on diagnosis, so this interview provides a more fine-grained assessment of the duration of problematic behavior, which may help improve understanding of the impact of duration on outcome, and hopefully facilitate better methods for early detection.” Since healthy adolescents are often seen once per year at an annual pediatrician visit, she added, teens engaging in significant dieting might benefit from more frequent monitoring since this behavior can evolve into an eating disorder over a relatively short time frame.

AN is associated with significant medical and psychiatric comorbidity and has a mortality rate among the highest of any psychiatric illness, the authors noted.
 

The study

The study cohort consisted of 71 girls ages 12-18 years participating in research from 2017 to 2021 at the Eating Disorders Research Unit of New York (N.Y.) State Psychiatric Institute. Patients had either the restricting or binge-eating/purging subtype of AN as diagnosed by the Eating Disorder Assessment–5 questionnaire. A semistructured 15-minute interview with the girls and their parents explored food restriction, dieting, loss of control/binge eating, purging, excessive/compulsive exercise, weight history, and amenorrhea.

Both parents and children were asked whether and when the children had been underweight or overweight, and whether and when primary amenorrhea (no menarche) or secondary amenorrhea (periods missed for 3 months) became evident. Dieting was defined as “deliberately changing eating patterns in any way to influence your shape or weight,” and restriction as “deliberately cutting down on the amount of food that you are eating, in order to change your shape or weight.” Loss-of-control eating was defined as “feeling unable to stop eating or control what or how much you are eating.”

In other characterizations, purging was defined as making yourself vomit on purpose, taking diuretics, or feeling driven to engage in these behaviors. Questions on exercise explored whether children might feel anxious when they do not exercise or inclined to exercise even if sick or injured, with excessive exercise defined as “Feeling like you must exercise, might continue exercising, sometimes in secret, if parents or doctors have told you to stop.”

Other questions focused on use of diuretics or laxatives and other strategies to compensate for calories consumed.

Responses revealed that restriction, underweight, dieting, and excessive exercise were present in most of the sample, while purging, loss-of-control eating, and overweight were reported by fewer than a third. With dieting typically emerging first around age 14, the other behaviors tended to manifest from age 14 to 14 and a half. The average age of formal diagnosis was just over 15 years. Parent-child dyads showed good agreement on the presence and timing of all behaviors except for dieting, for which children reported onset about 6 months earlier or longer duration compared with parents.

Although older age at the time of interview was associated with a lower body mass index percentile and higher eating disorder score, neither age of onset nor duration of disordered eating was associated with severity when researchers controlled for current age.
 

Telltale signs for parents

“For teens starting at a healthy weight, significant and intentional weight loss of more than 5-10 pounds can be a cause for concern,” Dr. Ranzenhofer said. Missed periods, refusing meals, skipping meals, fighting or arguing about eating, and withdrawal from normal activities and relationships are other signs of disordered eating. For overweight or obese teens, rapid weight loss and weight loss above and beyond that recommended are also concerning.

As for compulsive exercise, she said, “Altered exercise behavior might look like exercise that interferes with other activities, for example, being late to school or not doing homework in order to exercise.” Other red flags would be physical activity that varies considerably from that of peers, for instance, going running after a 2-hour sports practice and an inflexible routine that precludes being able to skip a day.

“All adolescents, male and female, should be screened regardless of weight trends – underweight, overweight, obese, or normal weight – regarding their body image and thoughts of dieting,” said Margaret E. Thew, DNP, FNP-BC, of the Medical College of Wisconsin, and medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, commenting on the study but not involved in it. “Most adolescents make decisions to lose weight after trying to ‘eat healthy’ but may take an aggressive approach when they don’t see the weight loss they hope to see.”

According to Ms. Thew, the study findings support the benefit of giving medical caregivers and parents training on the red flags regarding eating disorders to foster early detection. “These include starting a new fad diet, eliminating foods, ‘healthy eating,’ over-exercising, skipping meals, or no longer eating foods they previously loved.”

She added that times of transition are key junctures to watch: The transition from grade school to middle school, middle to high school, and high school to college. “These tend to provoke eating disorder onset or relapse of eating disorder thoughts and behaviors after diagnosis,” Ms. Thew said. “It would benefit the patient to screen for concerns about disordered eating and provide resources, including consultation with a dietitian, as appropriate.”

This study was supported by grants from the National Institute of Mental Health and the Hilda and Preston Davis Foundation. Coauthor Joanna E. Steinglass, MD, disclosed receiving royalties from UpToDate. Ms. Thew disclosed no competing interests with regard to her comments.

Adolescents later diagnosed with anorexia nervosa (AN) likely embark on the trajectory to AN with undisclosed dieting for weight loss at about age 14, a study of teens and parents found.

In the interview-based study, both adolescents and their parents described a similar prediagnosis sequence of behavioral changes occurring over roughly 1 year to 18 months, but parents lagged some 6 months behind in noticing their children’s disordered eating.

The findings suggest that even teens of normal weight should be asked about their eating habits and monitored more closely for contact with those who endorse these potentially harmful eating behaviors, according to Lisa M. Ranzenhofer, PhD, assistant professor of clinical psychology in psychiatry at Columbia University Medical Center in New York, and colleagues. Their report is in the Journal of Adolescent Health.

“We know that adolescents often have eating disorder behaviors long before they’re diagnosed, so we developed this interview as a tool to figure out how long a maladaptive behavior has been present,” Dr. Ranzenhofer said in an interview. “Most studies that report illness duration do so based on diagnosis, so this interview provides a more fine-grained assessment of the duration of problematic behavior, which may help improve understanding of the impact of duration on outcome, and hopefully facilitate better methods for early detection.” Since healthy adolescents are often seen once per year at an annual pediatrician visit, she added, teens engaging in significant dieting might benefit from more frequent monitoring since this behavior can evolve into an eating disorder over a relatively short time frame.

AN is associated with significant medical and psychiatric comorbidity and has a mortality rate among the highest of any psychiatric illness, the authors noted.
 

The study

The study cohort consisted of 71 girls ages 12-18 years participating in research from 2017 to 2021 at the Eating Disorders Research Unit of New York (N.Y.) State Psychiatric Institute. Patients had either the restricting or binge-eating/purging subtype of AN as diagnosed by the Eating Disorder Assessment–5 questionnaire. A semistructured 15-minute interview with the girls and their parents explored food restriction, dieting, loss of control/binge eating, purging, excessive/compulsive exercise, weight history, and amenorrhea.

Both parents and children were asked whether and when the children had been underweight or overweight, and whether and when primary amenorrhea (no menarche) or secondary amenorrhea (periods missed for 3 months) became evident. Dieting was defined as “deliberately changing eating patterns in any way to influence your shape or weight,” and restriction as “deliberately cutting down on the amount of food that you are eating, in order to change your shape or weight.” Loss-of-control eating was defined as “feeling unable to stop eating or control what or how much you are eating.”

In other characterizations, purging was defined as making yourself vomit on purpose, taking diuretics, or feeling driven to engage in these behaviors. Questions on exercise explored whether children might feel anxious when they do not exercise or inclined to exercise even if sick or injured, with excessive exercise defined as “Feeling like you must exercise, might continue exercising, sometimes in secret, if parents or doctors have told you to stop.”

Other questions focused on use of diuretics or laxatives and other strategies to compensate for calories consumed.

Responses revealed that restriction, underweight, dieting, and excessive exercise were present in most of the sample, while purging, loss-of-control eating, and overweight were reported by fewer than a third. With dieting typically emerging first around age 14, the other behaviors tended to manifest from age 14 to 14 and a half. The average age of formal diagnosis was just over 15 years. Parent-child dyads showed good agreement on the presence and timing of all behaviors except for dieting, for which children reported onset about 6 months earlier or longer duration compared with parents.

Although older age at the time of interview was associated with a lower body mass index percentile and higher eating disorder score, neither age of onset nor duration of disordered eating was associated with severity when researchers controlled for current age.
 

Telltale signs for parents

“For teens starting at a healthy weight, significant and intentional weight loss of more than 5-10 pounds can be a cause for concern,” Dr. Ranzenhofer said. Missed periods, refusing meals, skipping meals, fighting or arguing about eating, and withdrawal from normal activities and relationships are other signs of disordered eating. For overweight or obese teens, rapid weight loss and weight loss above and beyond that recommended are also concerning.

As for compulsive exercise, she said, “Altered exercise behavior might look like exercise that interferes with other activities, for example, being late to school or not doing homework in order to exercise.” Other red flags would be physical activity that varies considerably from that of peers, for instance, going running after a 2-hour sports practice and an inflexible routine that precludes being able to skip a day.

“All adolescents, male and female, should be screened regardless of weight trends – underweight, overweight, obese, or normal weight – regarding their body image and thoughts of dieting,” said Margaret E. Thew, DNP, FNP-BC, of the Medical College of Wisconsin, and medical director of the department of adolescent medicine at Children’s Wisconsin in Milwaukee, commenting on the study but not involved in it. “Most adolescents make decisions to lose weight after trying to ‘eat healthy’ but may take an aggressive approach when they don’t see the weight loss they hope to see.”

According to Ms. Thew, the study findings support the benefit of giving medical caregivers and parents training on the red flags regarding eating disorders to foster early detection. “These include starting a new fad diet, eliminating foods, ‘healthy eating,’ over-exercising, skipping meals, or no longer eating foods they previously loved.”

She added that times of transition are key junctures to watch: The transition from grade school to middle school, middle to high school, and high school to college. “These tend to provoke eating disorder onset or relapse of eating disorder thoughts and behaviors after diagnosis,” Ms. Thew said. “It would benefit the patient to screen for concerns about disordered eating and provide resources, including consultation with a dietitian, as appropriate.”

This study was supported by grants from the National Institute of Mental Health and the Hilda and Preston Davis Foundation. Coauthor Joanna E. Steinglass, MD, disclosed receiving royalties from UpToDate. Ms. Thew disclosed no competing interests with regard to her comments.

A genetic postmortem analysis of the brains of patients with schizophrenia suggests dysfunction of dopamine receptors in the caudate nucleus may cause the disorder.

Investigators identified a mechanism on the dopamine receptor, known as the autoreceptor, which regulates how much dopamine is released from the presynaptic neuron. Impairment of this autoreceptor leads to poorly controlled dopamine release and excessive dopamine flow.

The researchers found decreased expression of this autoreceptor accounts for the genetic evidence of schizophrenia risk, and, using a suite of statistical routines, they showed that this relationship is probably causative.

“Our research confirms the scientific hypothesis that too much dopamine plays a likely causative role in psychosis and precisely how this is based on genetic factors,” study investigator Daniel Weinberger, MD, director and CEO of the Lieber Institute for Brain Development, Baltimore, told this news organization.

“Drugs that treat psychosis symptoms by simply blocking dopamine receptors have harsh side effects. ... Theoretically, scientists could now develop therapies that target these malfunctioning autoreceptors to treat this devastating condition with fewer side effects,” he said.

The study was published online in Nature Neuroscience.
 

‘Privileged spot’

“Large international genetic studies known as genomewide association studies have identified hundreds of regions of the human genome housing potential risk genes for schizophrenia,” Dr. Weinberger said.

“However, these regions are still poorly resolved in terms of specific genes, and treatments and diagnostic techniques are far from what they should be.” Moreover, “treatments for schizophrenia address the symptoms of psychosis but not the cause,” he said.

“For more than 70 years, neuroscientists have suspected that dopamine plays a key role in schizophrenia, but what kind of role, exactly, has remained a mystery,” Dr. Weinberger noted. “It occupied a privileged spot in the principal hypothesis about schizophrenia for over 60 years – the so-called ‘dopamine hypothesis.’ ”

Antipsychotic drugs that reduce dopamine “are the principal medical treatments but they cause serious side effects, including an inability to experience pleasure and joy – a sad reality for patients and their families,” he continued.

The current study “set out to understand how dopamine acts in schizophrenia” using “analysis of the genetic and transcriptional landscape” of the postmortem caudate nucleus from 443 donors (245 neurotypical, 154 with schizophrenia, and 44 with bipolar disorder).

Brain samples were from individuals of diverse ancestry (210 were of African ancestry and 2,233 were of European ancestry).
 

New treatment target?

The researchers performed an analysis of transancestry expression quantitative trait loci, genetic variants that explain variations in gene expression levels, which express in the caudate, annotating “hundreds of caudate-specific cis-eQTLs.”

Then they integrated this analysis with gene expression that emerged from the latest genomewide association study and transcriptome-wide association study, identifying hundreds of genes that “showed a potential causal association with schizophrenia risk in the caudate nucleus,” including a specific isoform of the dopamine D2 receptor, which is upregulated in the caudate nucleus of those with schizophrenia.

“If autoreceptors don’t function properly the flow of dopamine in the brain is poorly controlled and too much dopamine flows for too long,” said Dr. Weinberger.

In particular, they observed “extensive differential gene expression” for schizophrenia in 2,701 genes in those with schizophrenia, compared with those without: glial cell–derived neurotrophic factor antisense RNA was a top-up gene and tyrosine hydroxylase, which is a rate-limiting enzyme in dopamine synthesis, was a down-regulated gene. Dopamine receptors DRD2 and DRD3 were differentially expressed.

Having done this, they looked at the effects of antipsychotic medications that target D2 regions on gene expression in the caudate by testing for differences between individuals with schizophrenia who were taking antipsychotics at the time of death, those not taking antipsychotics at the time of death (n = 104 and 49, respectively), and neurotypical individuals (n = 239).

There were 2,692 differentially expressed genes between individuals taking antipsychotics versus neurotypical individuals (false discovery rate < 0.05). By contrast, there were only 665 differentially expressed genes (FDR < .05) between those not taking antipsychotics and neurotypical individuals.

“We found that antipsychotic medication has an extensive influence on caudate gene expression,” the investigators noted.

They then developed a new approach to “infer gene networks from expression data.” This method is based on deep neural networks, obtaining a “low-dimensional representation of each gene’s expression across individuals.” The representation is then used to build a “gene neighborhood graph and assign genes to modules.”

This method identified “several modules enriched for genes associated with schizophrenia risk.” The expression representations captured in this approach placed genes in “biologically meaningful neighborhoods, which can provide insight into potential interactions if these genes are targeted for therapeutic intervention,” the authors summarized.

“Now that our new research has identified the specific mechanism by which dopamine plays a causative role in schizophrenia, we hope we have opened the door for more targeted drugs or diagnostic tests that could make life better for patients and their families,” Dr. Weinberger said.
 

No causal link?

Commenting on the study, Rifaat El-Mallakh, MD, director of the mood disorders research program, department of psychiatry and behavioral sciences, University of Louisville (Ky.), called it an “excellent study performed by an excellent research group” that “fills an important lacuna in our research database.”

However, Dr. El-Mallakh, who was not involved in the research, disagreed that the findings show causality. “The data that can be gleaned from this study is limited and the design has significant limitations. As with all genetic studies, this is an association study. It tells us nothing about the cause-effect relationship between the genes and the illness.

“We do not know why genes are associated with the illness. Genetic overrepresentation can have multiple causes, and more so when the data is a convenience sample. As noted by the authors, much of what they observed was probably related to medication effect. I don’t think this study specifically tells us anything clinically,” he added.

The study was supported by the LIBD, the BrainSeq Consortium, an National Institutes of Health fellowship to two of the authors, and a NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation to one of the authors. Dr. Weinberger has reported no relevant financial relationships. Dr. El-Mallakh declared no specific financial relationships relevant to the study but has reported being a speaker for several companies that manufacture antipsychotics.

A version of this article first appeared on Medscape.com.

A genetic postmortem analysis of the brains of patients with schizophrenia suggests dysfunction of dopamine receptors in the caudate nucleus may cause the disorder.

Investigators identified a mechanism on the dopamine receptor, known as the autoreceptor, which regulates how much dopamine is released from the presynaptic neuron. Impairment of this autoreceptor leads to poorly controlled dopamine release and excessive dopamine flow.

The researchers found decreased expression of this autoreceptor accounts for the genetic evidence of schizophrenia risk, and, using a suite of statistical routines, they showed that this relationship is probably causative.

“Our research confirms the scientific hypothesis that too much dopamine plays a likely causative role in psychosis and precisely how this is based on genetic factors,” study investigator Daniel Weinberger, MD, director and CEO of the Lieber Institute for Brain Development, Baltimore, told this news organization.

“Drugs that treat psychosis symptoms by simply blocking dopamine receptors have harsh side effects. ... Theoretically, scientists could now develop therapies that target these malfunctioning autoreceptors to treat this devastating condition with fewer side effects,” he said.

The study was published online in Nature Neuroscience.
 

‘Privileged spot’

“Large international genetic studies known as genomewide association studies have identified hundreds of regions of the human genome housing potential risk genes for schizophrenia,” Dr. Weinberger said.

“However, these regions are still poorly resolved in terms of specific genes, and treatments and diagnostic techniques are far from what they should be.” Moreover, “treatments for schizophrenia address the symptoms of psychosis but not the cause,” he said.

“For more than 70 years, neuroscientists have suspected that dopamine plays a key role in schizophrenia, but what kind of role, exactly, has remained a mystery,” Dr. Weinberger noted. “It occupied a privileged spot in the principal hypothesis about schizophrenia for over 60 years – the so-called ‘dopamine hypothesis.’ ”

Antipsychotic drugs that reduce dopamine “are the principal medical treatments but they cause serious side effects, including an inability to experience pleasure and joy – a sad reality for patients and their families,” he continued.

The current study “set out to understand how dopamine acts in schizophrenia” using “analysis of the genetic and transcriptional landscape” of the postmortem caudate nucleus from 443 donors (245 neurotypical, 154 with schizophrenia, and 44 with bipolar disorder).

Brain samples were from individuals of diverse ancestry (210 were of African ancestry and 2,233 were of European ancestry).
 

New treatment target?

The researchers performed an analysis of transancestry expression quantitative trait loci, genetic variants that explain variations in gene expression levels, which express in the caudate, annotating “hundreds of caudate-specific cis-eQTLs.”

Then they integrated this analysis with gene expression that emerged from the latest genomewide association study and transcriptome-wide association study, identifying hundreds of genes that “showed a potential causal association with schizophrenia risk in the caudate nucleus,” including a specific isoform of the dopamine D2 receptor, which is upregulated in the caudate nucleus of those with schizophrenia.

“If autoreceptors don’t function properly the flow of dopamine in the brain is poorly controlled and too much dopamine flows for too long,” said Dr. Weinberger.

In particular, they observed “extensive differential gene expression” for schizophrenia in 2,701 genes in those with schizophrenia, compared with those without: glial cell–derived neurotrophic factor antisense RNA was a top-up gene and tyrosine hydroxylase, which is a rate-limiting enzyme in dopamine synthesis, was a down-regulated gene. Dopamine receptors DRD2 and DRD3 were differentially expressed.

Having done this, they looked at the effects of antipsychotic medications that target D2 regions on gene expression in the caudate by testing for differences between individuals with schizophrenia who were taking antipsychotics at the time of death, those not taking antipsychotics at the time of death (n = 104 and 49, respectively), and neurotypical individuals (n = 239).

There were 2,692 differentially expressed genes between individuals taking antipsychotics versus neurotypical individuals (false discovery rate < 0.05). By contrast, there were only 665 differentially expressed genes (FDR < .05) between those not taking antipsychotics and neurotypical individuals.

“We found that antipsychotic medication has an extensive influence on caudate gene expression,” the investigators noted.

They then developed a new approach to “infer gene networks from expression data.” This method is based on deep neural networks, obtaining a “low-dimensional representation of each gene’s expression across individuals.” The representation is then used to build a “gene neighborhood graph and assign genes to modules.”

This method identified “several modules enriched for genes associated with schizophrenia risk.” The expression representations captured in this approach placed genes in “biologically meaningful neighborhoods, which can provide insight into potential interactions if these genes are targeted for therapeutic intervention,” the authors summarized.

“Now that our new research has identified the specific mechanism by which dopamine plays a causative role in schizophrenia, we hope we have opened the door for more targeted drugs or diagnostic tests that could make life better for patients and their families,” Dr. Weinberger said.
 

No causal link?

Commenting on the study, Rifaat El-Mallakh, MD, director of the mood disorders research program, department of psychiatry and behavioral sciences, University of Louisville (Ky.), called it an “excellent study performed by an excellent research group” that “fills an important lacuna in our research database.”

However, Dr. El-Mallakh, who was not involved in the research, disagreed that the findings show causality. “The data that can be gleaned from this study is limited and the design has significant limitations. As with all genetic studies, this is an association study. It tells us nothing about the cause-effect relationship between the genes and the illness.

“We do not know why genes are associated with the illness. Genetic overrepresentation can have multiple causes, and more so when the data is a convenience sample. As noted by the authors, much of what they observed was probably related to medication effect. I don’t think this study specifically tells us anything clinically,” he added.

The study was supported by the LIBD, the BrainSeq Consortium, an National Institutes of Health fellowship to two of the authors, and a NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation to one of the authors. Dr. Weinberger has reported no relevant financial relationships. Dr. El-Mallakh declared no specific financial relationships relevant to the study but has reported being a speaker for several companies that manufacture antipsychotics.

A version of this article first appeared on Medscape.com.

A genetic postmortem analysis of the brains of patients with schizophrenia suggests dysfunction of dopamine receptors in the caudate nucleus may cause the disorder.

Investigators identified a mechanism on the dopamine receptor, known as the autoreceptor, which regulates how much dopamine is released from the presynaptic neuron. Impairment of this autoreceptor leads to poorly controlled dopamine release and excessive dopamine flow.

The researchers found decreased expression of this autoreceptor accounts for the genetic evidence of schizophrenia risk, and, using a suite of statistical routines, they showed that this relationship is probably causative.

“Our research confirms the scientific hypothesis that too much dopamine plays a likely causative role in psychosis and precisely how this is based on genetic factors,” study investigator Daniel Weinberger, MD, director and CEO of the Lieber Institute for Brain Development, Baltimore, told this news organization.

“Drugs that treat psychosis symptoms by simply blocking dopamine receptors have harsh side effects. ... Theoretically, scientists could now develop therapies that target these malfunctioning autoreceptors to treat this devastating condition with fewer side effects,” he said.

The study was published online in Nature Neuroscience.
 

‘Privileged spot’

“Large international genetic studies known as genomewide association studies have identified hundreds of regions of the human genome housing potential risk genes for schizophrenia,” Dr. Weinberger said.

“However, these regions are still poorly resolved in terms of specific genes, and treatments and diagnostic techniques are far from what they should be.” Moreover, “treatments for schizophrenia address the symptoms of psychosis but not the cause,” he said.

“For more than 70 years, neuroscientists have suspected that dopamine plays a key role in schizophrenia, but what kind of role, exactly, has remained a mystery,” Dr. Weinberger noted. “It occupied a privileged spot in the principal hypothesis about schizophrenia for over 60 years – the so-called ‘dopamine hypothesis.’ ”

Antipsychotic drugs that reduce dopamine “are the principal medical treatments but they cause serious side effects, including an inability to experience pleasure and joy – a sad reality for patients and their families,” he continued.

The current study “set out to understand how dopamine acts in schizophrenia” using “analysis of the genetic and transcriptional landscape” of the postmortem caudate nucleus from 443 donors (245 neurotypical, 154 with schizophrenia, and 44 with bipolar disorder).

Brain samples were from individuals of diverse ancestry (210 were of African ancestry and 2,233 were of European ancestry).
 

New treatment target?

The researchers performed an analysis of transancestry expression quantitative trait loci, genetic variants that explain variations in gene expression levels, which express in the caudate, annotating “hundreds of caudate-specific cis-eQTLs.”

Then they integrated this analysis with gene expression that emerged from the latest genomewide association study and transcriptome-wide association study, identifying hundreds of genes that “showed a potential causal association with schizophrenia risk in the caudate nucleus,” including a specific isoform of the dopamine D2 receptor, which is upregulated in the caudate nucleus of those with schizophrenia.

“If autoreceptors don’t function properly the flow of dopamine in the brain is poorly controlled and too much dopamine flows for too long,” said Dr. Weinberger.

In particular, they observed “extensive differential gene expression” for schizophrenia in 2,701 genes in those with schizophrenia, compared with those without: glial cell–derived neurotrophic factor antisense RNA was a top-up gene and tyrosine hydroxylase, which is a rate-limiting enzyme in dopamine synthesis, was a down-regulated gene. Dopamine receptors DRD2 and DRD3 were differentially expressed.

Having done this, they looked at the effects of antipsychotic medications that target D2 regions on gene expression in the caudate by testing for differences between individuals with schizophrenia who were taking antipsychotics at the time of death, those not taking antipsychotics at the time of death (n = 104 and 49, respectively), and neurotypical individuals (n = 239).

There were 2,692 differentially expressed genes between individuals taking antipsychotics versus neurotypical individuals (false discovery rate < 0.05). By contrast, there were only 665 differentially expressed genes (FDR < .05) between those not taking antipsychotics and neurotypical individuals.

“We found that antipsychotic medication has an extensive influence on caudate gene expression,” the investigators noted.

They then developed a new approach to “infer gene networks from expression data.” This method is based on deep neural networks, obtaining a “low-dimensional representation of each gene’s expression across individuals.” The representation is then used to build a “gene neighborhood graph and assign genes to modules.”

This method identified “several modules enriched for genes associated with schizophrenia risk.” The expression representations captured in this approach placed genes in “biologically meaningful neighborhoods, which can provide insight into potential interactions if these genes are targeted for therapeutic intervention,” the authors summarized.

“Now that our new research has identified the specific mechanism by which dopamine plays a causative role in schizophrenia, we hope we have opened the door for more targeted drugs or diagnostic tests that could make life better for patients and their families,” Dr. Weinberger said.
 

No causal link?

Commenting on the study, Rifaat El-Mallakh, MD, director of the mood disorders research program, department of psychiatry and behavioral sciences, University of Louisville (Ky.), called it an “excellent study performed by an excellent research group” that “fills an important lacuna in our research database.”

However, Dr. El-Mallakh, who was not involved in the research, disagreed that the findings show causality. “The data that can be gleaned from this study is limited and the design has significant limitations. As with all genetic studies, this is an association study. It tells us nothing about the cause-effect relationship between the genes and the illness.

“We do not know why genes are associated with the illness. Genetic overrepresentation can have multiple causes, and more so when the data is a convenience sample. As noted by the authors, much of what they observed was probably related to medication effect. I don’t think this study specifically tells us anything clinically,” he added.

The study was supported by the LIBD, the BrainSeq Consortium, an National Institutes of Health fellowship to two of the authors, and a NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation to one of the authors. Dr. Weinberger has reported no relevant financial relationships. Dr. El-Mallakh declared no specific financial relationships relevant to the study but has reported being a speaker for several companies that manufacture antipsychotics.

A version of this article first appeared on Medscape.com.

Bribery really is the solution to all of life’s problems

Breaking news: The United States has a bit of an obesity epidemic. Okay, maybe not so breaking news. But it’s a problem we’ve been struggling with for a very long time. Part of the issue is that there really is no secret to weight loss. Pretty much anything can work if you’re committed. The millions of diets floating around are testament to this idea.

The problem of losing weight is amplified if you don’t rake in the big bucks. Lower-income individuals often can’t afford healthy superfoods, and they’re often too busy to spend time at classes, exercising, or following programs. A group of researchers at New York University has offered up an alternate solution to encourage weight loss in low-income people: Pay them.

Specifically, pay them for losing weight. A reward, if you will. The researchers recruited several hundred lower-income people and split them into three groups. All participants received a free 1-year membership to a gym and weight-loss program, as well as food journals and fitness devices, but one group received payment (on average, about $300 overall) for attending meetings, exercising a certain amount every week, or weighing themselves twice a week. About 40% of people in this group lost 5% of their body weight after 6 months, twice as many as in the group that did not receive payment for performing these tasks.

The big winners, however, were those in the third group. They also received the free stuff, but the researchers offered them a more simple and direct bribe: Lose 5% of your weight over 6 months and we’ll pay you. The reward? About $450 on average, and it worked very well, with half this group losing the weight after 6 months. That said, after a year something like a fifth of this group put the weight back on, bringing them in line with the group that was paid to perform tasks. Still, both groups outperformed the control group, which received no money.

The takeaway from this research is pretty obvious. Pay people a fair price to do something, and they’ll do it. This is a lesson that has absolutely no relevance in the modern world. Nope, none whatsoever. We all receive completely fair wages. We all have plenty of money to pay for things. Everything is fine.
 

More green space, less medicine

Have you heard of the 3-30-300 rule? Proposed by urban forester Cecil Konijnendijk, it’s become the rule of thumb for urban planners and other foresters into getting more green space in populated areas. A recent study has found that people who lived within this 3-30-300 rule had better mental health and less medication use.

rawpixel

If you’re not an urban forester, however, you may not know what the 3-30-300 rule is. But it’s pretty simple, people should be able to see at least three trees from their home, have 30% tree canopy in their neighborhood, and have 300 Spartans to defend against the Persian army.

We may have made that last one up. It’s actually have a green space or park within 300 meters of your home.

In the new study, only 4.7% of people surveyed lived in an area that followed all three rules. About 62% of the surveyed lived with a green space at least 300 meters away, 43% had at least three trees within 15 meters from their home, and a rather pitiful 9% had adequate tree canopy coverage in their neighborhood.

Greater adherence to the 3-30-300 rule was associated with fewer visits to the psychologist, with 8.3% of the participants reporting a psychologist visit in the last year. The data come from a sample of a little over 3,000 Barcelona residents aged 15-97 who were randomly selected to participate in the Barcelona Public Health Agency Survey.

“There is an urgent need to provide citizens with more green space,” said Mark Nieuwenhuijsen, lead author of the study. “We may need to tear out asphalt and plant more trees, which would not only improve health, but also reduce heat island effects and contribute to carbon capture.”

The main goal and message is that more green space is good for everyone. So if you’re feeling a little overwhelmed, take a breather and sit somewhere green. Or call those 300 Spartans and get them to start knocking some buildings down.
 

Said the toilet to the engineer: Do you hear what I hear?

A mythical hero’s journey took Dorothy along the yellow brick road to find the Wizard of Oz. Huckleberry Finn used a raft to float down the Mississippi River. Luke Skywalker did most of his traveling between planets. For the rest of us, the journey may be just a bit shorter.

Maia Gatlin

Also a bit less heroic. Unless, of course, you’re prepping for a colonoscopy. Yup, we’re headed to the toilet, but not just any toilet. This toilet was the subject of a presentation at the annual meeting of the Acoustical Society of America, titled “The feces thesis: Using machine learning to detect diarrhea,” and that presentation was the hero’s journey of Maia Gatlin, PhD, a research engineer at the Georgia Institute of Technology.

She and her team attached a noninvasive microphone sensor to a toilet, and now they can identify bowel diseases without collecting any identifiable information.

The audio sample of an excretion event is “transformed into a spectrogram, which essentially captures the sound in an image. Different events produce different features in the audio and the spectrogram. For example, urination creates a consistent tone, while defecation may have a singular tone. In contrast, diarrhea is more random,” they explained in the written statement.

They used a machine learning algorithm to classify each spectrogram based on its features. “The algorithm’s performance was tested against data with and without background noises to make sure it was learning the right sound features, regardless of the sensor’s environment,” Dr. Gatlin and associates wrote.

Their goal is to use the toilet sensor in areas where cholera is common to prevent the spread of disease. After that, who knows? “Perhaps someday, our algorithm can be used with existing in-home smart devices to monitor one’s own bowel movements and health!” she suggested.

That would be a heroic toilet indeed.

Bribery really is the solution to all of life’s problems

Breaking news: The United States has a bit of an obesity epidemic. Okay, maybe not so breaking news. But it’s a problem we’ve been struggling with for a very long time. Part of the issue is that there really is no secret to weight loss. Pretty much anything can work if you’re committed. The millions of diets floating around are testament to this idea.

The problem of losing weight is amplified if you don’t rake in the big bucks. Lower-income individuals often can’t afford healthy superfoods, and they’re often too busy to spend time at classes, exercising, or following programs. A group of researchers at New York University has offered up an alternate solution to encourage weight loss in low-income people: Pay them.

Specifically, pay them for losing weight. A reward, if you will. The researchers recruited several hundred lower-income people and split them into three groups. All participants received a free 1-year membership to a gym and weight-loss program, as well as food journals and fitness devices, but one group received payment (on average, about $300 overall) for attending meetings, exercising a certain amount every week, or weighing themselves twice a week. About 40% of people in this group lost 5% of their body weight after 6 months, twice as many as in the group that did not receive payment for performing these tasks.

The big winners, however, were those in the third group. They also received the free stuff, but the researchers offered them a more simple and direct bribe: Lose 5% of your weight over 6 months and we’ll pay you. The reward? About $450 on average, and it worked very well, with half this group losing the weight after 6 months. That said, after a year something like a fifth of this group put the weight back on, bringing them in line with the group that was paid to perform tasks. Still, both groups outperformed the control group, which received no money.

The takeaway from this research is pretty obvious. Pay people a fair price to do something, and they’ll do it. This is a lesson that has absolutely no relevance in the modern world. Nope, none whatsoever. We all receive completely fair wages. We all have plenty of money to pay for things. Everything is fine.
 

More green space, less medicine

Have you heard of the 3-30-300 rule? Proposed by urban forester Cecil Konijnendijk, it’s become the rule of thumb for urban planners and other foresters into getting more green space in populated areas. A recent study has found that people who lived within this 3-30-300 rule had better mental health and less medication use.

rawpixel

If you’re not an urban forester, however, you may not know what the 3-30-300 rule is. But it’s pretty simple, people should be able to see at least three trees from their home, have 30% tree canopy in their neighborhood, and have 300 Spartans to defend against the Persian army.

We may have made that last one up. It’s actually have a green space or park within 300 meters of your home.

In the new study, only 4.7% of people surveyed lived in an area that followed all three rules. About 62% of the surveyed lived with a green space at least 300 meters away, 43% had at least three trees within 15 meters from their home, and a rather pitiful 9% had adequate tree canopy coverage in their neighborhood.

Greater adherence to the 3-30-300 rule was associated with fewer visits to the psychologist, with 8.3% of the participants reporting a psychologist visit in the last year. The data come from a sample of a little over 3,000 Barcelona residents aged 15-97 who were randomly selected to participate in the Barcelona Public Health Agency Survey.

“There is an urgent need to provide citizens with more green space,” said Mark Nieuwenhuijsen, lead author of the study. “We may need to tear out asphalt and plant more trees, which would not only improve health, but also reduce heat island effects and contribute to carbon capture.”

The main goal and message is that more green space is good for everyone. So if you’re feeling a little overwhelmed, take a breather and sit somewhere green. Or call those 300 Spartans and get them to start knocking some buildings down.
 

Said the toilet to the engineer: Do you hear what I hear?

A mythical hero’s journey took Dorothy along the yellow brick road to find the Wizard of Oz. Huckleberry Finn used a raft to float down the Mississippi River. Luke Skywalker did most of his traveling between planets. For the rest of us, the journey may be just a bit shorter.

Maia Gatlin

Also a bit less heroic. Unless, of course, you’re prepping for a colonoscopy. Yup, we’re headed to the toilet, but not just any toilet. This toilet was the subject of a presentation at the annual meeting of the Acoustical Society of America, titled “The feces thesis: Using machine learning to detect diarrhea,” and that presentation was the hero’s journey of Maia Gatlin, PhD, a research engineer at the Georgia Institute of Technology.

She and her team attached a noninvasive microphone sensor to a toilet, and now they can identify bowel diseases without collecting any identifiable information.

The audio sample of an excretion event is “transformed into a spectrogram, which essentially captures the sound in an image. Different events produce different features in the audio and the spectrogram. For example, urination creates a consistent tone, while defecation may have a singular tone. In contrast, diarrhea is more random,” they explained in the written statement.

They used a machine learning algorithm to classify each spectrogram based on its features. “The algorithm’s performance was tested against data with and without background noises to make sure it was learning the right sound features, regardless of the sensor’s environment,” Dr. Gatlin and associates wrote.

Their goal is to use the toilet sensor in areas where cholera is common to prevent the spread of disease. After that, who knows? “Perhaps someday, our algorithm can be used with existing in-home smart devices to monitor one’s own bowel movements and health!” she suggested.

That would be a heroic toilet indeed.

Bribery really is the solution to all of life’s problems

Breaking news: The United States has a bit of an obesity epidemic. Okay, maybe not so breaking news. But it’s a problem we’ve been struggling with for a very long time. Part of the issue is that there really is no secret to weight loss. Pretty much anything can work if you’re committed. The millions of diets floating around are testament to this idea.

The problem of losing weight is amplified if you don’t rake in the big bucks. Lower-income individuals often can’t afford healthy superfoods, and they’re often too busy to spend time at classes, exercising, or following programs. A group of researchers at New York University has offered up an alternate solution to encourage weight loss in low-income people: Pay them.

Specifically, pay them for losing weight. A reward, if you will. The researchers recruited several hundred lower-income people and split them into three groups. All participants received a free 1-year membership to a gym and weight-loss program, as well as food journals and fitness devices, but one group received payment (on average, about $300 overall) for attending meetings, exercising a certain amount every week, or weighing themselves twice a week. About 40% of people in this group lost 5% of their body weight after 6 months, twice as many as in the group that did not receive payment for performing these tasks.

The big winners, however, were those in the third group. They also received the free stuff, but the researchers offered them a more simple and direct bribe: Lose 5% of your weight over 6 months and we’ll pay you. The reward? About $450 on average, and it worked very well, with half this group losing the weight after 6 months. That said, after a year something like a fifth of this group put the weight back on, bringing them in line with the group that was paid to perform tasks. Still, both groups outperformed the control group, which received no money.

The takeaway from this research is pretty obvious. Pay people a fair price to do something, and they’ll do it. This is a lesson that has absolutely no relevance in the modern world. Nope, none whatsoever. We all receive completely fair wages. We all have plenty of money to pay for things. Everything is fine.
 

More green space, less medicine

Have you heard of the 3-30-300 rule? Proposed by urban forester Cecil Konijnendijk, it’s become the rule of thumb for urban planners and other foresters into getting more green space in populated areas. A recent study has found that people who lived within this 3-30-300 rule had better mental health and less medication use.

rawpixel

If you’re not an urban forester, however, you may not know what the 3-30-300 rule is. But it’s pretty simple, people should be able to see at least three trees from their home, have 30% tree canopy in their neighborhood, and have 300 Spartans to defend against the Persian army.

We may have made that last one up. It’s actually have a green space or park within 300 meters of your home.

In the new study, only 4.7% of people surveyed lived in an area that followed all three rules. About 62% of the surveyed lived with a green space at least 300 meters away, 43% had at least three trees within 15 meters from their home, and a rather pitiful 9% had adequate tree canopy coverage in their neighborhood.

Greater adherence to the 3-30-300 rule was associated with fewer visits to the psychologist, with 8.3% of the participants reporting a psychologist visit in the last year. The data come from a sample of a little over 3,000 Barcelona residents aged 15-97 who were randomly selected to participate in the Barcelona Public Health Agency Survey.

“There is an urgent need to provide citizens with more green space,” said Mark Nieuwenhuijsen, lead author of the study. “We may need to tear out asphalt and plant more trees, which would not only improve health, but also reduce heat island effects and contribute to carbon capture.”

The main goal and message is that more green space is good for everyone. So if you’re feeling a little overwhelmed, take a breather and sit somewhere green. Or call those 300 Spartans and get them to start knocking some buildings down.
 

Said the toilet to the engineer: Do you hear what I hear?

A mythical hero’s journey took Dorothy along the yellow brick road to find the Wizard of Oz. Huckleberry Finn used a raft to float down the Mississippi River. Luke Skywalker did most of his traveling between planets. For the rest of us, the journey may be just a bit shorter.

Maia Gatlin

Also a bit less heroic. Unless, of course, you’re prepping for a colonoscopy. Yup, we’re headed to the toilet, but not just any toilet. This toilet was the subject of a presentation at the annual meeting of the Acoustical Society of America, titled “The feces thesis: Using machine learning to detect diarrhea,” and that presentation was the hero’s journey of Maia Gatlin, PhD, a research engineer at the Georgia Institute of Technology.

She and her team attached a noninvasive microphone sensor to a toilet, and now they can identify bowel diseases without collecting any identifiable information.

The audio sample of an excretion event is “transformed into a spectrogram, which essentially captures the sound in an image. Different events produce different features in the audio and the spectrogram. For example, urination creates a consistent tone, while defecation may have a singular tone. In contrast, diarrhea is more random,” they explained in the written statement.

They used a machine learning algorithm to classify each spectrogram based on its features. “The algorithm’s performance was tested against data with and without background noises to make sure it was learning the right sound features, regardless of the sensor’s environment,” Dr. Gatlin and associates wrote.

Their goal is to use the toilet sensor in areas where cholera is common to prevent the spread of disease. After that, who knows? “Perhaps someday, our algorithm can be used with existing in-home smart devices to monitor one’s own bowel movements and health!” she suggested.

That would be a heroic toilet indeed.

Heart failure associated with illicit use of the psychostimulant methamphetamine (methHF) is increasing in the United States and around the world across racial, ethnic, and socioeconomic groups, a literature review indicates.

MethHF is associated with increased severity for HF, longer inpatient stay, and more readmissions, compared with non-MethHF, the data show.

Clinicians “need to consider methamphetamine as a potential etiology for heart failure and include a substance use history when evaluating patients. Treating methamphetamine use disorder improves heart failure outcomes,” first author Veena Manja, MD, PhD, with Stanford (Calif.) University, said in an interview.

The study was published online in the journal Heart.
 

Poor outcomes, ‘staggering’ costs

This “thoughtful” review is “important and necessary,” Jonathan Davis, MD, director of the heart failure program, Zuckerberg San Francisco General Hospital, wrote in an editorial in the journal.

Dr. Davis noted that patients with Meth HF are at increased risk for poor outcomes and death and the health care costs related to MethHF are “staggering.”

As an example, inpatient data for California show annual charges related to MethHF rose by 840% from 2008 to 2018, from $41.5 million to $390.2 million, compared with 82% for all HF, which rose from $3.5 billion to $6.8 billion.

Illicit use of methamphetamine – also known as “crystal meth,” “ice,” and “speed” – has been linked to hypertension, MI, stroke, aortic dissection, and sudden death. But until now, there was no comprehensive systematic review of published studies on MethHF.

“Our goal was to compile current knowledge on the topic, increase awareness of this condition and identify areas for future research,” Dr. Manja said.

The researchers reviewed 21 observational studies, mostly from the United States (14 from California), between 1997 and 2020. The mean age of adults with MethHF ranged in age from 35 to 60 and more than half were male (57%).

Illicit methamphetamine was inhaled, injected, swallowed, smoked, and snorted. The reported frequency ranged from daily to every other week, and the total monthly dose ranged from 0.35 g to 24.5 g.

The average duration of meth use before HF diagnosis was 5 years. However, 18% of users developed HF within 1 year of starting to use illicit methamphetamine. In some cases, HF was diagnosed after a single use.

The researchers also note that MethHF with preserved left ventricular ejection fraction, seen in up to 44% of cases, is a distinct entity that may progress to reduced LVEF with continued use.

MethHF is also associated with a greater likelihood of other substance abuse, PTSD, depression, and other heart and kidney disease.

Factors associated with improved MethHF outcomes include female sex, meth abstinence, and adherence to guideline-directed HF therapy.

Improvement in MethHF outcomes is possible even if abstinence is not consistent, a finding that lends support to harm reduction principles of “meeting patients where they are instead of insisting on complete abstinence,” the researchers said.
 

Large gaps in knowledge

They were unable to combine the results into a meta-analysis because of heterogeneity in study design, population, comparator, and outcome assessment. Also, the overall risk of bias is moderate because of the presence of confounders, selection bias and poor matching, and the overall certainty in the evidence is very low,.

No study evaluated the incidence or prevalence of HF among methamphetamine users and inconsistent history taking and testing in patients with HF impeded accurate MethHF prevalence assessment.

Several studies, however, document an increasing incidence of MethHF, particularly over the past decade.

One study from California reported a 585% increase in MethHF hospital admissions between 2008 and 2018. An analysis of the National Inpatient Survey found a 12-fold increase in annual MethHF hospitalizations between 2002 and 2014.

“The results of this systematic review highlight large gaps in our knowledge” of MethHF, Dr. Manja said in an interview.

“We need to understand the epidemiology, prevalence, factors that confer susceptibility to cardiovascular outcomes, and need research into treatment targeted toward this disease,” Dr. Manja added. “We should consider options to integrate substance use treatment in HF/cardiology/primary care clinics and design a multidisciplinary patient-centered approach.”

Dr. Davis agreed. This work “highlights that the standard of care academically and clinically must be a broad team across the care spectrum to simultaneously address methamphetamine use, heart failure, and social determinants of health.”

This research had no specific funding. Dr. Manja and Dr. Davis reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

Heart failure associated with illicit use of the psychostimulant methamphetamine (methHF) is increasing in the United States and around the world across racial, ethnic, and socioeconomic groups, a literature review indicates.

MethHF is associated with increased severity for HF, longer inpatient stay, and more readmissions, compared with non-MethHF, the data show.

Clinicians “need to consider methamphetamine as a potential etiology for heart failure and include a substance use history when evaluating patients. Treating methamphetamine use disorder improves heart failure outcomes,” first author Veena Manja, MD, PhD, with Stanford (Calif.) University, said in an interview.

The study was published online in the journal Heart.
 

Poor outcomes, ‘staggering’ costs

This “thoughtful” review is “important and necessary,” Jonathan Davis, MD, director of the heart failure program, Zuckerberg San Francisco General Hospital, wrote in an editorial in the journal.

Dr. Davis noted that patients with Meth HF are at increased risk for poor outcomes and death and the health care costs related to MethHF are “staggering.”

As an example, inpatient data for California show annual charges related to MethHF rose by 840% from 2008 to 2018, from $41.5 million to $390.2 million, compared with 82% for all HF, which rose from $3.5 billion to $6.8 billion.

Illicit use of methamphetamine – also known as “crystal meth,” “ice,” and “speed” – has been linked to hypertension, MI, stroke, aortic dissection, and sudden death. But until now, there was no comprehensive systematic review of published studies on MethHF.

“Our goal was to compile current knowledge on the topic, increase awareness of this condition and identify areas for future research,” Dr. Manja said.

The researchers reviewed 21 observational studies, mostly from the United States (14 from California), between 1997 and 2020. The mean age of adults with MethHF ranged in age from 35 to 60 and more than half were male (57%).

Illicit methamphetamine was inhaled, injected, swallowed, smoked, and snorted. The reported frequency ranged from daily to every other week, and the total monthly dose ranged from 0.35 g to 24.5 g.

The average duration of meth use before HF diagnosis was 5 years. However, 18% of users developed HF within 1 year of starting to use illicit methamphetamine. In some cases, HF was diagnosed after a single use.

The researchers also note that MethHF with preserved left ventricular ejection fraction, seen in up to 44% of cases, is a distinct entity that may progress to reduced LVEF with continued use.

MethHF is also associated with a greater likelihood of other substance abuse, PTSD, depression, and other heart and kidney disease.

Factors associated with improved MethHF outcomes include female sex, meth abstinence, and adherence to guideline-directed HF therapy.

Improvement in MethHF outcomes is possible even if abstinence is not consistent, a finding that lends support to harm reduction principles of “meeting patients where they are instead of insisting on complete abstinence,” the researchers said.
 

Large gaps in knowledge

They were unable to combine the results into a meta-analysis because of heterogeneity in study design, population, comparator, and outcome assessment. Also, the overall risk of bias is moderate because of the presence of confounders, selection bias and poor matching, and the overall certainty in the evidence is very low,.

No study evaluated the incidence or prevalence of HF among methamphetamine users and inconsistent history taking and testing in patients with HF impeded accurate MethHF prevalence assessment.

Several studies, however, document an increasing incidence of MethHF, particularly over the past decade.

One study from California reported a 585% increase in MethHF hospital admissions between 2008 and 2018. An analysis of the National Inpatient Survey found a 12-fold increase in annual MethHF hospitalizations between 2002 and 2014.

“The results of this systematic review highlight large gaps in our knowledge” of MethHF, Dr. Manja said in an interview.

“We need to understand the epidemiology, prevalence, factors that confer susceptibility to cardiovascular outcomes, and need research into treatment targeted toward this disease,” Dr. Manja added. “We should consider options to integrate substance use treatment in HF/cardiology/primary care clinics and design a multidisciplinary patient-centered approach.”

Dr. Davis agreed. This work “highlights that the standard of care academically and clinically must be a broad team across the care spectrum to simultaneously address methamphetamine use, heart failure, and social determinants of health.”

This research had no specific funding. Dr. Manja and Dr. Davis reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

Heart failure associated with illicit use of the psychostimulant methamphetamine (methHF) is increasing in the United States and around the world across racial, ethnic, and socioeconomic groups, a literature review indicates.

MethHF is associated with increased severity for HF, longer inpatient stay, and more readmissions, compared with non-MethHF, the data show.

Clinicians “need to consider methamphetamine as a potential etiology for heart failure and include a substance use history when evaluating patients. Treating methamphetamine use disorder improves heart failure outcomes,” first author Veena Manja, MD, PhD, with Stanford (Calif.) University, said in an interview.

The study was published online in the journal Heart.
 

Poor outcomes, ‘staggering’ costs

This “thoughtful” review is “important and necessary,” Jonathan Davis, MD, director of the heart failure program, Zuckerberg San Francisco General Hospital, wrote in an editorial in the journal.

Dr. Davis noted that patients with Meth HF are at increased risk for poor outcomes and death and the health care costs related to MethHF are “staggering.”

As an example, inpatient data for California show annual charges related to MethHF rose by 840% from 2008 to 2018, from $41.5 million to $390.2 million, compared with 82% for all HF, which rose from $3.5 billion to $6.8 billion.

Illicit use of methamphetamine – also known as “crystal meth,” “ice,” and “speed” – has been linked to hypertension, MI, stroke, aortic dissection, and sudden death. But until now, there was no comprehensive systematic review of published studies on MethHF.

“Our goal was to compile current knowledge on the topic, increase awareness of this condition and identify areas for future research,” Dr. Manja said.

The researchers reviewed 21 observational studies, mostly from the United States (14 from California), between 1997 and 2020. The mean age of adults with MethHF ranged in age from 35 to 60 and more than half were male (57%).

Illicit methamphetamine was inhaled, injected, swallowed, smoked, and snorted. The reported frequency ranged from daily to every other week, and the total monthly dose ranged from 0.35 g to 24.5 g.

The average duration of meth use before HF diagnosis was 5 years. However, 18% of users developed HF within 1 year of starting to use illicit methamphetamine. In some cases, HF was diagnosed after a single use.

The researchers also note that MethHF with preserved left ventricular ejection fraction, seen in up to 44% of cases, is a distinct entity that may progress to reduced LVEF with continued use.

MethHF is also associated with a greater likelihood of other substance abuse, PTSD, depression, and other heart and kidney disease.

Factors associated with improved MethHF outcomes include female sex, meth abstinence, and adherence to guideline-directed HF therapy.

Improvement in MethHF outcomes is possible even if abstinence is not consistent, a finding that lends support to harm reduction principles of “meeting patients where they are instead of insisting on complete abstinence,” the researchers said.
 

Large gaps in knowledge

They were unable to combine the results into a meta-analysis because of heterogeneity in study design, population, comparator, and outcome assessment. Also, the overall risk of bias is moderate because of the presence of confounders, selection bias and poor matching, and the overall certainty in the evidence is very low,.

No study evaluated the incidence or prevalence of HF among methamphetamine users and inconsistent history taking and testing in patients with HF impeded accurate MethHF prevalence assessment.

Several studies, however, document an increasing incidence of MethHF, particularly over the past decade.

One study from California reported a 585% increase in MethHF hospital admissions between 2008 and 2018. An analysis of the National Inpatient Survey found a 12-fold increase in annual MethHF hospitalizations between 2002 and 2014.

“The results of this systematic review highlight large gaps in our knowledge” of MethHF, Dr. Manja said in an interview.

“We need to understand the epidemiology, prevalence, factors that confer susceptibility to cardiovascular outcomes, and need research into treatment targeted toward this disease,” Dr. Manja added. “We should consider options to integrate substance use treatment in HF/cardiology/primary care clinics and design a multidisciplinary patient-centered approach.”

Dr. Davis agreed. This work “highlights that the standard of care academically and clinically must be a broad team across the care spectrum to simultaneously address methamphetamine use, heart failure, and social determinants of health.”

This research had no specific funding. Dr. Manja and Dr. Davis reported no relevant disclosures.

A version of this article first appeared on Medscape.com.

Being male, being older, and having a clear intent to die were among the key independent predictors of psychiatric hospital admission after self-harm, based on data from more than 1,800 individuals.

Clinicians who assess suicidal patients in the emergency department setting face the challenge of whether to admit the patient to inpatient or outpatient care, and data on predictors of compulsory admission are limited, wrote Laurent Michaud, MD, of the University of Lausanne, Switzerland, and colleagues.

To better identify predictors of hospitalization after self-harm, the researchers reviewed data from 1,832 patients aged 18 years and older admitted to four emergency departments in Switzerland between December 2016 and November 2019 .

Self-harm (SH) was defined in this study as “all nonfatal intentional acts of self-poisoning or self-injury, irrespective of degree of suicidal intent or other types of motivation,” the researchers noted. The study included 2,142 episodes of self-harm.

The researchers conducted two analyses. They compared episodes followed by any hospitalization and those with outpatient follow-up (1,083 episodes vs. 1,059 episodes) and episodes followed by compulsory hospitalization (357 episodes) with all other episodes followed by either outpatient care or voluntary hospitalization (1,785 episodes).

Overall, women were significantly more likely to be referred to outpatient follow-up compared with men (61.8% vs. 38.1%), and hospitalized patients were significantly older than outpatients (mean age of 41 years vs. 36 years, P < .001 for both).

“Not surprisingly, major psychopathological conditions such as depression, mania, dementia, and schizophrenia were predictive of hospitalization,” the researchers noted.

Other sociodemographic factors associated with hospitalization included living alone, no children, problematic socioeconomic status, and unemployment. Clinical factors associated with hospitalization included physical pain, more lethal suicide attempt method, and clear intent to die.

In a multivariate analysis, independent predictors of any hospitalization included male gender, older age, assessment in the Neuchatel location vs. Lausanne, depression vs. personality disorders, substance use, or anxiety disorder, difficult socioeconomic status, a clear vs. unclear intent to die, and a serious suicide attempt vs. less serious.

Differences in hospitalization based on hospital setting was a striking finding, the researchers wrote in their discussion. These differences may be largely explained by the organization of local mental health services and specific institutional cultures; the workload of staff and availability of beds also may have played a role in decisions to hospitalize, they said.

The findings were limited by several factors including the lack of data on the realization level of a self-harm episode and significant events such as a breakup, the researchers explained. Other limitations included missing data, multiple analyses that could increase the risk of false positives, the reliance on clinical diagnosis rather than formal instruments, and the cross-sectional study design, they said.

However, the results have clinical implications, as the clinical factors identified could be used to target subgroups of suicidal populations and refine treatment strategies, they concluded.

The study was supported by institutional funding and the Swiss Federal Office of Public Health. The researchers had no financial conflicts to disclose.

Being male, being older, and having a clear intent to die were among the key independent predictors of psychiatric hospital admission after self-harm, based on data from more than 1,800 individuals.

Clinicians who assess suicidal patients in the emergency department setting face the challenge of whether to admit the patient to inpatient or outpatient care, and data on predictors of compulsory admission are limited, wrote Laurent Michaud, MD, of the University of Lausanne, Switzerland, and colleagues.

To better identify predictors of hospitalization after self-harm, the researchers reviewed data from 1,832 patients aged 18 years and older admitted to four emergency departments in Switzerland between December 2016 and November 2019 .

Self-harm (SH) was defined in this study as “all nonfatal intentional acts of self-poisoning or self-injury, irrespective of degree of suicidal intent or other types of motivation,” the researchers noted. The study included 2,142 episodes of self-harm.

The researchers conducted two analyses. They compared episodes followed by any hospitalization and those with outpatient follow-up (1,083 episodes vs. 1,059 episodes) and episodes followed by compulsory hospitalization (357 episodes) with all other episodes followed by either outpatient care or voluntary hospitalization (1,785 episodes).

Overall, women were significantly more likely to be referred to outpatient follow-up compared with men (61.8% vs. 38.1%), and hospitalized patients were significantly older than outpatients (mean age of 41 years vs. 36 years, P < .001 for both).

“Not surprisingly, major psychopathological conditions such as depression, mania, dementia, and schizophrenia were predictive of hospitalization,” the researchers noted.

Other sociodemographic factors associated with hospitalization included living alone, no children, problematic socioeconomic status, and unemployment. Clinical factors associated with hospitalization included physical pain, more lethal suicide attempt method, and clear intent to die.

In a multivariate analysis, independent predictors of any hospitalization included male gender, older age, assessment in the Neuchatel location vs. Lausanne, depression vs. personality disorders, substance use, or anxiety disorder, difficult socioeconomic status, a clear vs. unclear intent to die, and a serious suicide attempt vs. less serious.

Differences in hospitalization based on hospital setting was a striking finding, the researchers wrote in their discussion. These differences may be largely explained by the organization of local mental health services and specific institutional cultures; the workload of staff and availability of beds also may have played a role in decisions to hospitalize, they said.

The findings were limited by several factors including the lack of data on the realization level of a self-harm episode and significant events such as a breakup, the researchers explained. Other limitations included missing data, multiple analyses that could increase the risk of false positives, the reliance on clinical diagnosis rather than formal instruments, and the cross-sectional study design, they said.

However, the results have clinical implications, as the clinical factors identified could be used to target subgroups of suicidal populations and refine treatment strategies, they concluded.

The study was supported by institutional funding and the Swiss Federal Office of Public Health. The researchers had no financial conflicts to disclose.

Being male, being older, and having a clear intent to die were among the key independent predictors of psychiatric hospital admission after self-harm, based on data from more than 1,800 individuals.

Clinicians who assess suicidal patients in the emergency department setting face the challenge of whether to admit the patient to inpatient or outpatient care, and data on predictors of compulsory admission are limited, wrote Laurent Michaud, MD, of the University of Lausanne, Switzerland, and colleagues.

To better identify predictors of hospitalization after self-harm, the researchers reviewed data from 1,832 patients aged 18 years and older admitted to four emergency departments in Switzerland between December 2016 and November 2019 .

Self-harm (SH) was defined in this study as “all nonfatal intentional acts of self-poisoning or self-injury, irrespective of degree of suicidal intent or other types of motivation,” the researchers noted. The study included 2,142 episodes of self-harm.

The researchers conducted two analyses. They compared episodes followed by any hospitalization and those with outpatient follow-up (1,083 episodes vs. 1,059 episodes) and episodes followed by compulsory hospitalization (357 episodes) with all other episodes followed by either outpatient care or voluntary hospitalization (1,785 episodes).

Overall, women were significantly more likely to be referred to outpatient follow-up compared with men (61.8% vs. 38.1%), and hospitalized patients were significantly older than outpatients (mean age of 41 years vs. 36 years, P < .001 for both).

“Not surprisingly, major psychopathological conditions such as depression, mania, dementia, and schizophrenia were predictive of hospitalization,” the researchers noted.

Other sociodemographic factors associated with hospitalization included living alone, no children, problematic socioeconomic status, and unemployment. Clinical factors associated with hospitalization included physical pain, more lethal suicide attempt method, and clear intent to die.

In a multivariate analysis, independent predictors of any hospitalization included male gender, older age, assessment in the Neuchatel location vs. Lausanne, depression vs. personality disorders, substance use, or anxiety disorder, difficult socioeconomic status, a clear vs. unclear intent to die, and a serious suicide attempt vs. less serious.

Differences in hospitalization based on hospital setting was a striking finding, the researchers wrote in their discussion. These differences may be largely explained by the organization of local mental health services and specific institutional cultures; the workload of staff and availability of beds also may have played a role in decisions to hospitalize, they said.

The findings were limited by several factors including the lack of data on the realization level of a self-harm episode and significant events such as a breakup, the researchers explained. Other limitations included missing data, multiple analyses that could increase the risk of false positives, the reliance on clinical diagnosis rather than formal instruments, and the cross-sectional study design, they said.

However, the results have clinical implications, as the clinical factors identified could be used to target subgroups of suicidal populations and refine treatment strategies, they concluded.

The study was supported by institutional funding and the Swiss Federal Office of Public Health. The researchers had no financial conflicts to disclose.

With youth obesity on the rise – an estimated 1 in 5 youths are impacted by obesity, according to the Centers for Disease Control and Prevention – conversations about healthy weight are becoming more commonplace, not only in the pediatrician’s office, but at home, too. But the language we use around this sensitive topic is important, as youths are acutely aware that words have a direct impact on their mental health.

Sixteen-year-old Avery DiCocco of Northbrook, Ill., knows how vulnerable teenagers feel. 

“I think it definitely matters the way that parents and doctors address weight,” she said. “You never know who may be insecure, and using negative words could go a lot further than they think with impacting self-esteem.” 

A new study published in Pediatrics brings light to the words that parents (and providers) use when speaking to youths (ages 10-17) about their weight.

Researchers from the University of Connecticut Rudd Center for Food Policy & Health, Hartford, led an online survey of youths and their parents. Those who took part were asked about 27  terms related to body weight. Parents were asked to comment on their use of these words, while youths commented on the emotional response. The researchers said 1,936 parents and 2,032 adolescents were surveyed between September and December 2021.

Although results skewed toward the use of more positive words, such as “healthy weight,” over terms like “obese,” “fat” or “large,” there was variation across ethnicity, sexual orientation, and weight status. For example, it was noted in the study, funded by WW International, that preference for the word “curvy” was higher among Hispanic/Latino youths, sexual minority youths, and those with a body mass index in the 95th percentile, compared with their White, heterosexual, and lower-weight peers.
 

Words matter

In 2017, the American Academy of Pediatrics came out with a policy statement on weight stigma and the need for doctors to use more neutral language and less stigmatizing terms in practice when discussing weight among youths.

But one of the reasons this new study is important, said Gregory Germain, MD, associate chief of pediatrics at Yale New Haven (Conn.) Children’s Hospital, is that this study focuses on parents who interact with their kids much more often than a pediatrician who sees them a few times a year.

“Parental motivation, discussion, interaction on a consistent basis – that dialogue is so critical in kids with obesity,” said Germain, who stresses that all adults, coaches, and educators should consider this study as well.

“When we think about those detrimental impacts on mental health when more stigmatizing language is used, just us being more mindful in how we are talking to youth can make such a profound impact,” said Rebecca Kamody, PhD, a clinical psychologist at Yale University, with a research and clinical focus on eating and weight disorders.

“In essence, this is a low-hanging fruit intervention,” she said. 

Dr. Kamody recommends we take a lesson from “cultural humility” in psychology to understand how to approach this with kids, calling for “the humbleness as parents or providers in asking someone what they want used to make it the safest place for a discussion with our youth.”
 

One piece of the puzzle 

Dr. Germain and Dr. Kamody agreed that language in discussing this topic is important but that we need to recognize that this topic in general is extremely tricky.

For one, “there are these very real metabolic complications of having high weight at a young age,” said Kamody, who stresses the need for balance to make real change.

Dr. Germain agreed. “Finding a fine line between discussing obesity and not kicking your kid into disordered eating is important.”

The researchers also recognize the limits of an online study, where self-reporting parents may not want to admit using negative weight terminology, but certainly believe it’s a start in identifying some of the undesirable patterns that may be occurring when it comes to weight.

“The overarching message is a positive one, that with our preteens and teenage kids, we need to watch our language, to create a nonjudgmental and safe environment to discuss weight and any issue involved with taking care of themselves,” said Dr. Germain.

A version of this article first appeared on Medscape.com.

With youth obesity on the rise – an estimated 1 in 5 youths are impacted by obesity, according to the Centers for Disease Control and Prevention – conversations about healthy weight are becoming more commonplace, not only in the pediatrician’s office, but at home, too. But the language we use around this sensitive topic is important, as youths are acutely aware that words have a direct impact on their mental health.

Sixteen-year-old Avery DiCocco of Northbrook, Ill., knows how vulnerable teenagers feel. 

“I think it definitely matters the way that parents and doctors address weight,” she said. “You never know who may be insecure, and using negative words could go a lot further than they think with impacting self-esteem.” 

A new study published in Pediatrics brings light to the words that parents (and providers) use when speaking to youths (ages 10-17) about their weight.

Researchers from the University of Connecticut Rudd Center for Food Policy & Health, Hartford, led an online survey of youths and their parents. Those who took part were asked about 27  terms related to body weight. Parents were asked to comment on their use of these words, while youths commented on the emotional response. The researchers said 1,936 parents and 2,032 adolescents were surveyed between September and December 2021.

Although results skewed toward the use of more positive words, such as “healthy weight,” over terms like “obese,” “fat” or “large,” there was variation across ethnicity, sexual orientation, and weight status. For example, it was noted in the study, funded by WW International, that preference for the word “curvy” was higher among Hispanic/Latino youths, sexual minority youths, and those with a body mass index in the 95th percentile, compared with their White, heterosexual, and lower-weight peers.
 

Words matter

In 2017, the American Academy of Pediatrics came out with a policy statement on weight stigma and the need for doctors to use more neutral language and less stigmatizing terms in practice when discussing weight among youths.

But one of the reasons this new study is important, said Gregory Germain, MD, associate chief of pediatrics at Yale New Haven (Conn.) Children’s Hospital, is that this study focuses on parents who interact with their kids much more often than a pediatrician who sees them a few times a year.

“Parental motivation, discussion, interaction on a consistent basis – that dialogue is so critical in kids with obesity,” said Germain, who stresses that all adults, coaches, and educators should consider this study as well.

“When we think about those detrimental impacts on mental health when more stigmatizing language is used, just us being more mindful in how we are talking to youth can make such a profound impact,” said Rebecca Kamody, PhD, a clinical psychologist at Yale University, with a research and clinical focus on eating and weight disorders.

“In essence, this is a low-hanging fruit intervention,” she said. 

Dr. Kamody recommends we take a lesson from “cultural humility” in psychology to understand how to approach this with kids, calling for “the humbleness as parents or providers in asking someone what they want used to make it the safest place for a discussion with our youth.”
 

One piece of the puzzle 

Dr. Germain and Dr. Kamody agreed that language in discussing this topic is important but that we need to recognize that this topic in general is extremely tricky.

For one, “there are these very real metabolic complications of having high weight at a young age,” said Kamody, who stresses the need for balance to make real change.

Dr. Germain agreed. “Finding a fine line between discussing obesity and not kicking your kid into disordered eating is important.”

The researchers also recognize the limits of an online study, where self-reporting parents may not want to admit using negative weight terminology, but certainly believe it’s a start in identifying some of the undesirable patterns that may be occurring when it comes to weight.

“The overarching message is a positive one, that with our preteens and teenage kids, we need to watch our language, to create a nonjudgmental and safe environment to discuss weight and any issue involved with taking care of themselves,” said Dr. Germain.

A version of this article first appeared on Medscape.com.

With youth obesity on the rise – an estimated 1 in 5 youths are impacted by obesity, according to the Centers for Disease Control and Prevention – conversations about healthy weight are becoming more commonplace, not only in the pediatrician’s office, but at home, too. But the language we use around this sensitive topic is important, as youths are acutely aware that words have a direct impact on their mental health.

Sixteen-year-old Avery DiCocco of Northbrook, Ill., knows how vulnerable teenagers feel. 

“I think it definitely matters the way that parents and doctors address weight,” she said. “You never know who may be insecure, and using negative words could go a lot further than they think with impacting self-esteem.” 

A new study published in Pediatrics brings light to the words that parents (and providers) use when speaking to youths (ages 10-17) about their weight.

Researchers from the University of Connecticut Rudd Center for Food Policy & Health, Hartford, led an online survey of youths and their parents. Those who took part were asked about 27  terms related to body weight. Parents were asked to comment on their use of these words, while youths commented on the emotional response. The researchers said 1,936 parents and 2,032 adolescents were surveyed between September and December 2021.

Although results skewed toward the use of more positive words, such as “healthy weight,” over terms like “obese,” “fat” or “large,” there was variation across ethnicity, sexual orientation, and weight status. For example, it was noted in the study, funded by WW International, that preference for the word “curvy” was higher among Hispanic/Latino youths, sexual minority youths, and those with a body mass index in the 95th percentile, compared with their White, heterosexual, and lower-weight peers.
 

Words matter

In 2017, the American Academy of Pediatrics came out with a policy statement on weight stigma and the need for doctors to use more neutral language and less stigmatizing terms in practice when discussing weight among youths.

But one of the reasons this new study is important, said Gregory Germain, MD, associate chief of pediatrics at Yale New Haven (Conn.) Children’s Hospital, is that this study focuses on parents who interact with their kids much more often than a pediatrician who sees them a few times a year.

“Parental motivation, discussion, interaction on a consistent basis – that dialogue is so critical in kids with obesity,” said Germain, who stresses that all adults, coaches, and educators should consider this study as well.

“When we think about those detrimental impacts on mental health when more stigmatizing language is used, just us being more mindful in how we are talking to youth can make such a profound impact,” said Rebecca Kamody, PhD, a clinical psychologist at Yale University, with a research and clinical focus on eating and weight disorders.

“In essence, this is a low-hanging fruit intervention,” she said. 

Dr. Kamody recommends we take a lesson from “cultural humility” in psychology to understand how to approach this with kids, calling for “the humbleness as parents or providers in asking someone what they want used to make it the safest place for a discussion with our youth.”
 

One piece of the puzzle 

Dr. Germain and Dr. Kamody agreed that language in discussing this topic is important but that we need to recognize that this topic in general is extremely tricky.

For one, “there are these very real metabolic complications of having high weight at a young age,” said Kamody, who stresses the need for balance to make real change.

Dr. Germain agreed. “Finding a fine line between discussing obesity and not kicking your kid into disordered eating is important.”

The researchers also recognize the limits of an online study, where self-reporting parents may not want to admit using negative weight terminology, but certainly believe it’s a start in identifying some of the undesirable patterns that may be occurring when it comes to weight.

“The overarching message is a positive one, that with our preteens and teenage kids, we need to watch our language, to create a nonjudgmental and safe environment to discuss weight and any issue involved with taking care of themselves,” said Dr. Germain.

A version of this article first appeared on Medscape.com.

Eric Andrew Salata, MD, a 54-year-old internist based in Naples, Florida, made headlines 2 weeks ago when he was arrested by local police and charged with sexual battery on two of his patients, according to a police statement.

A week later, a Collier County Sheriff’s deputy found Dr. Salata’s body near his Naples home with a gunshot wound to the head, according to police. The medical examiner later ruled it a suicide.

Dr. Salata co-owned Pura Vida Medical Spa in Naples with his wife Jill Salata, a certified family nurse practitioner. They specialized in cosmetic treatment and surgery.

Naples police said that they arrested Dr. Salata after two female patients accused the doctor of allegedly drugging and raping them while they were still unconscious.

Both victims described being given nitrous oxide, also called laughing gas, for sedation and pain from the cosmetic procedure. The first victim, age 51, said Dr. Salata prescribed alprazolam (Xanax) to take before the procedure and then also gave her nitrous oxide and tequila, causing her to black out, according to NBC2 News.

The second victim, age 72, told police that as the nitrous oxide was wearing off, she found Dr. Salata performing sexual intercourse. The victim felt shocked after the sedation subsided about what had taken place, contacted police, and submitted to a sexual assault examination, according to the police statement.

At Dr. Salata’s November 22 hearing before Judge Michael Provost, a prosecutor asked the judge whether Dr. Salata should surrender his firearms; Provost reportedly dismissed the idea.

“It is disappointing and frustrating that Dr. Salata has escaped justice,” said one victim’s attorney, Adam Horowitz, in a blog post. “Yet, we are relieved that no other women will be assaulted by Dr. Salata again. It took tremendous courage for my client to tell her truth. She was ready to hold him accountable in court.”

Horowitz says he plans to file a civil lawsuit on behalf of his client against Dr. Salata’s estate. The Naples police are continuing their investigation into the victims’ cases, which now includes a third woman, said spokesman Lt. Bryan McGinn.

Meanwhile, the Pura Vida Medical Spa has closed permanently and its website has been deleted. One reviewer named Soul F. wrote on the spa’s Yelp page: “And now may God have mercy on this rapist’s soul. Amen.”

A version of this article first appeared on Medscape.com.

Eric Andrew Salata, MD, a 54-year-old internist based in Naples, Florida, made headlines 2 weeks ago when he was arrested by local police and charged with sexual battery on two of his patients, according to a police statement.

A week later, a Collier County Sheriff’s deputy found Dr. Salata’s body near his Naples home with a gunshot wound to the head, according to police. The medical examiner later ruled it a suicide.

Dr. Salata co-owned Pura Vida Medical Spa in Naples with his wife Jill Salata, a certified family nurse practitioner. They specialized in cosmetic treatment and surgery.

Naples police said that they arrested Dr. Salata after two female patients accused the doctor of allegedly drugging and raping them while they were still unconscious.

Both victims described being given nitrous oxide, also called laughing gas, for sedation and pain from the cosmetic procedure. The first victim, age 51, said Dr. Salata prescribed alprazolam (Xanax) to take before the procedure and then also gave her nitrous oxide and tequila, causing her to black out, according to NBC2 News.

The second victim, age 72, told police that as the nitrous oxide was wearing off, she found Dr. Salata performing sexual intercourse. The victim felt shocked after the sedation subsided about what had taken place, contacted police, and submitted to a sexual assault examination, according to the police statement.

At Dr. Salata’s November 22 hearing before Judge Michael Provost, a prosecutor asked the judge whether Dr. Salata should surrender his firearms; Provost reportedly dismissed the idea.

“It is disappointing and frustrating that Dr. Salata has escaped justice,” said one victim’s attorney, Adam Horowitz, in a blog post. “Yet, we are relieved that no other women will be assaulted by Dr. Salata again. It took tremendous courage for my client to tell her truth. She was ready to hold him accountable in court.”

Horowitz says he plans to file a civil lawsuit on behalf of his client against Dr. Salata’s estate. The Naples police are continuing their investigation into the victims’ cases, which now includes a third woman, said spokesman Lt. Bryan McGinn.

Meanwhile, the Pura Vida Medical Spa has closed permanently and its website has been deleted. One reviewer named Soul F. wrote on the spa’s Yelp page: “And now may God have mercy on this rapist’s soul. Amen.”

A version of this article first appeared on Medscape.com.

Eric Andrew Salata, MD, a 54-year-old internist based in Naples, Florida, made headlines 2 weeks ago when he was arrested by local police and charged with sexual battery on two of his patients, according to a police statement.

A week later, a Collier County Sheriff’s deputy found Dr. Salata’s body near his Naples home with a gunshot wound to the head, according to police. The medical examiner later ruled it a suicide.

Dr. Salata co-owned Pura Vida Medical Spa in Naples with his wife Jill Salata, a certified family nurse practitioner. They specialized in cosmetic treatment and surgery.

Naples police said that they arrested Dr. Salata after two female patients accused the doctor of allegedly drugging and raping them while they were still unconscious.

Both victims described being given nitrous oxide, also called laughing gas, for sedation and pain from the cosmetic procedure. The first victim, age 51, said Dr. Salata prescribed alprazolam (Xanax) to take before the procedure and then also gave her nitrous oxide and tequila, causing her to black out, according to NBC2 News.

The second victim, age 72, told police that as the nitrous oxide was wearing off, she found Dr. Salata performing sexual intercourse. The victim felt shocked after the sedation subsided about what had taken place, contacted police, and submitted to a sexual assault examination, according to the police statement.

At Dr. Salata’s November 22 hearing before Judge Michael Provost, a prosecutor asked the judge whether Dr. Salata should surrender his firearms; Provost reportedly dismissed the idea.

“It is disappointing and frustrating that Dr. Salata has escaped justice,” said one victim’s attorney, Adam Horowitz, in a blog post. “Yet, we are relieved that no other women will be assaulted by Dr. Salata again. It took tremendous courage for my client to tell her truth. She was ready to hold him accountable in court.”

Horowitz says he plans to file a civil lawsuit on behalf of his client against Dr. Salata’s estate. The Naples police are continuing their investigation into the victims’ cases, which now includes a third woman, said spokesman Lt. Bryan McGinn.

Meanwhile, the Pura Vida Medical Spa has closed permanently and its website has been deleted. One reviewer named Soul F. wrote on the spa’s Yelp page: “And now may God have mercy on this rapist’s soul. Amen.”

A version of this article first appeared on Medscape.com.

Over the past 30 years, Dr. Richard W. Cohen has used visualization techniques to help world class tennis players and recreational tennis players become the best they could be.

Visualization should be used in two ways to help players improve. First, to improve technique, after every practice session I have the player think about one shot they did not do well technically, and I have them, in vivo, shadow the shot on the court correctly before they leave the court. That night I tell the player to put themselves in a quiet, relaxed place and, in vitro, visualize themselves hitting the shot the correct way.

Almost always, the next day the players tell me they are hitting that one shot better and are motivated to again think about the one shot that was not technically correct and repeat the in vivo technique with similar great results.

The second way I use visualization for tennis players is to decrease their anxiety before matches. It is important to have some preparatory anxiety to perform optimally but having excessive anxiety will decrease performance. To alleviate excessive anxiety before matches, I have players watch their opponents hit the day before the match for at least 5 minutes to see their strengths and weaknesses. Then, the night before the match, I have them visualize how they will play a big point utilizing their strength into their opponent’s weakness. This rehearsal using imagery the night before a big match will decrease a player’s excessive anxiety and allow them to achieve their best effort in the match.

An example of this is if their opponent has a weak backhand that they can only slice. They visualize hitting wide to their forehand to get into their weak backhand and see themselves going forward and putting away a volley. Visualization used in these two ways helps improve stroke mechanics and match results in players of all levels. These visualization techniques can also be extended to other sports and to help improve life habits.

For example, Dr. Susan A. Cohen has seen that many patients have a decline in their dental health because of fear of going to the dentist to receive the treatment they need. Visualization techniques decrease the patient’s anxiety by rehearsing the possible traumatic events of the dental visit – e.g., the injection of anesthesia before the dental procedure. Visualization of calmness with systematic desensitization has helped decrease anxiety in patients.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for over 40 years and is on the editorial advisory board for Clinical Psychiatry News. He has won 18 USTA national tennis championships. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

Over the past 30 years, Dr. Richard W. Cohen has used visualization techniques to help world class tennis players and recreational tennis players become the best they could be.

Visualization should be used in two ways to help players improve. First, to improve technique, after every practice session I have the player think about one shot they did not do well technically, and I have them, in vivo, shadow the shot on the court correctly before they leave the court. That night I tell the player to put themselves in a quiet, relaxed place and, in vitro, visualize themselves hitting the shot the correct way.

Almost always, the next day the players tell me they are hitting that one shot better and are motivated to again think about the one shot that was not technically correct and repeat the in vivo technique with similar great results.

The second way I use visualization for tennis players is to decrease their anxiety before matches. It is important to have some preparatory anxiety to perform optimally but having excessive anxiety will decrease performance. To alleviate excessive anxiety before matches, I have players watch their opponents hit the day before the match for at least 5 minutes to see their strengths and weaknesses. Then, the night before the match, I have them visualize how they will play a big point utilizing their strength into their opponent’s weakness. This rehearsal using imagery the night before a big match will decrease a player’s excessive anxiety and allow them to achieve their best effort in the match.

An example of this is if their opponent has a weak backhand that they can only slice. They visualize hitting wide to their forehand to get into their weak backhand and see themselves going forward and putting away a volley. Visualization used in these two ways helps improve stroke mechanics and match results in players of all levels. These visualization techniques can also be extended to other sports and to help improve life habits.

For example, Dr. Susan A. Cohen has seen that many patients have a decline in their dental health because of fear of going to the dentist to receive the treatment they need. Visualization techniques decrease the patient’s anxiety by rehearsing the possible traumatic events of the dental visit – e.g., the injection of anesthesia before the dental procedure. Visualization of calmness with systematic desensitization has helped decrease anxiety in patients.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for over 40 years and is on the editorial advisory board for Clinical Psychiatry News. He has won 18 USTA national tennis championships. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

Over the past 30 years, Dr. Richard W. Cohen has used visualization techniques to help world class tennis players and recreational tennis players become the best they could be.

Visualization should be used in two ways to help players improve. First, to improve technique, after every practice session I have the player think about one shot they did not do well technically, and I have them, in vivo, shadow the shot on the court correctly before they leave the court. That night I tell the player to put themselves in a quiet, relaxed place and, in vitro, visualize themselves hitting the shot the correct way.

Almost always, the next day the players tell me they are hitting that one shot better and are motivated to again think about the one shot that was not technically correct and repeat the in vivo technique with similar great results.

The second way I use visualization for tennis players is to decrease their anxiety before matches. It is important to have some preparatory anxiety to perform optimally but having excessive anxiety will decrease performance. To alleviate excessive anxiety before matches, I have players watch their opponents hit the day before the match for at least 5 minutes to see their strengths and weaknesses. Then, the night before the match, I have them visualize how they will play a big point utilizing their strength into their opponent’s weakness. This rehearsal using imagery the night before a big match will decrease a player’s excessive anxiety and allow them to achieve their best effort in the match.

An example of this is if their opponent has a weak backhand that they can only slice. They visualize hitting wide to their forehand to get into their weak backhand and see themselves going forward and putting away a volley. Visualization used in these two ways helps improve stroke mechanics and match results in players of all levels. These visualization techniques can also be extended to other sports and to help improve life habits.

For example, Dr. Susan A. Cohen has seen that many patients have a decline in their dental health because of fear of going to the dentist to receive the treatment they need. Visualization techniques decrease the patient’s anxiety by rehearsing the possible traumatic events of the dental visit – e.g., the injection of anesthesia before the dental procedure. Visualization of calmness with systematic desensitization has helped decrease anxiety in patients.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for over 40 years and is on the editorial advisory board for Clinical Psychiatry News. He has won 18 USTA national tennis championships. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

Among adults undergoing Mohs micrographic surgery, individuals most prone to preprocedural anxiety were younger, female, and those with a history of anxiety confirmed by a health care provider (HCP), results from a single-center survey demonstrated.

“Higher patient-reported anxiety in hospital settings is significantly linked to lower patient satisfaction with the quality of care and higher patient-reported postoperative pain,” corresponding author Ally-Khan Somani, MD, PhD, and colleagues wrote in the study, which was published online in Dermatologic Surgery. “Identifying factors associated with perioperative patient anxiety could improve outcomes and patient satisfaction.”

Dr. Somani, director of dermatologic surgery and cutaneous oncology in the department of dermatology at the University of Indiana, Indianapolis, and coauthors surveyed 145 patients who underwent Mohs micrographic surgery (MMS) at the university from February 2018 to March 2020. They collected patient self-reported demographics, medical history, and administered a 10-point visual analog scale assessment of anxiety at multiple stages. They also sought HCP-perceived assessments of anxiety and used a stepwise regression mode to explore factors that potentially contributed to anxiety outcomes. The mean age of the 145 patients was 63 years, 60% were female, and 77% had no self-reported anxiety confirmed by a prior HCP’s diagnosis.

Two-thirds of patients (66%) received a pre-MMS consultation with the surgeon, 59% had a history of skin cancer removal surgery, and 86% had 1-2 layers removed during the current MMS.

Prior to MMS, the researchers found that significant risk factors for increased anxiety included younger age, female sex, and self-reported history of anxiety confirmed by an HCP (P < .05), while intraoperatively, HCP-perceived patient anxiety increased with younger patient age and more layers removed. Following MMS, patient anxiety increased significantly with more layers removed and higher self-reported preoperative anxiety levels. “Although existing research is divided regarding the efficacy of pre-MMS consultation for anxiety reduction, these findings suggest that patient-reported and HCP-perceived anxiety were not significantly affected by in-person pre-MMS consultation with the surgeon,” Dr. Somani and colleagues wrote. “Thus, routinely recommending consultations may not be the best approach for improving anxiety outcomes.”

They acknowledged certain limitations of their analysis, including its single-center design, enrollment of demographically similar patients, and the fact that no objective measurements of anxiety such as heart rate or blood pressure were taken.

“One of the main benefits of Mohs surgery is that we are able to operate under local anesthesia, but this also means that our patients are acutely aware of everything going on around them,” said Patricia M. Richey, MD, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and was asked to comment on the study.

“I think it is so important that this study is primarily focusing on the patient experience,” she said. “While this study did not find that a pre-op consult impacted patient anxiety levels, I do think we can infer that it is critical to connect with your patients on some level prior to surgery, as it helps you tailor your process to make the day more tolerable for them [such as] playing music, determining the need for an oral anxiolytic, etc.”

Neither the researchers nor Dr. Richey reported having financial disclosures.

Among adults undergoing Mohs micrographic surgery, individuals most prone to preprocedural anxiety were younger, female, and those with a history of anxiety confirmed by a health care provider (HCP), results from a single-center survey demonstrated.

“Higher patient-reported anxiety in hospital settings is significantly linked to lower patient satisfaction with the quality of care and higher patient-reported postoperative pain,” corresponding author Ally-Khan Somani, MD, PhD, and colleagues wrote in the study, which was published online in Dermatologic Surgery. “Identifying factors associated with perioperative patient anxiety could improve outcomes and patient satisfaction.”

Dr. Somani, director of dermatologic surgery and cutaneous oncology in the department of dermatology at the University of Indiana, Indianapolis, and coauthors surveyed 145 patients who underwent Mohs micrographic surgery (MMS) at the university from February 2018 to March 2020. They collected patient self-reported demographics, medical history, and administered a 10-point visual analog scale assessment of anxiety at multiple stages. They also sought HCP-perceived assessments of anxiety and used a stepwise regression mode to explore factors that potentially contributed to anxiety outcomes. The mean age of the 145 patients was 63 years, 60% were female, and 77% had no self-reported anxiety confirmed by a prior HCP’s diagnosis.

Two-thirds of patients (66%) received a pre-MMS consultation with the surgeon, 59% had a history of skin cancer removal surgery, and 86% had 1-2 layers removed during the current MMS.

Prior to MMS, the researchers found that significant risk factors for increased anxiety included younger age, female sex, and self-reported history of anxiety confirmed by an HCP (P < .05), while intraoperatively, HCP-perceived patient anxiety increased with younger patient age and more layers removed. Following MMS, patient anxiety increased significantly with more layers removed and higher self-reported preoperative anxiety levels. “Although existing research is divided regarding the efficacy of pre-MMS consultation for anxiety reduction, these findings suggest that patient-reported and HCP-perceived anxiety were not significantly affected by in-person pre-MMS consultation with the surgeon,” Dr. Somani and colleagues wrote. “Thus, routinely recommending consultations may not be the best approach for improving anxiety outcomes.”

They acknowledged certain limitations of their analysis, including its single-center design, enrollment of demographically similar patients, and the fact that no objective measurements of anxiety such as heart rate or blood pressure were taken.

“One of the main benefits of Mohs surgery is that we are able to operate under local anesthesia, but this also means that our patients are acutely aware of everything going on around them,” said Patricia M. Richey, MD, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and was asked to comment on the study.

“I think it is so important that this study is primarily focusing on the patient experience,” she said. “While this study did not find that a pre-op consult impacted patient anxiety levels, I do think we can infer that it is critical to connect with your patients on some level prior to surgery, as it helps you tailor your process to make the day more tolerable for them [such as] playing music, determining the need for an oral anxiolytic, etc.”

Neither the researchers nor Dr. Richey reported having financial disclosures.

Among adults undergoing Mohs micrographic surgery, individuals most prone to preprocedural anxiety were younger, female, and those with a history of anxiety confirmed by a health care provider (HCP), results from a single-center survey demonstrated.

“Higher patient-reported anxiety in hospital settings is significantly linked to lower patient satisfaction with the quality of care and higher patient-reported postoperative pain,” corresponding author Ally-Khan Somani, MD, PhD, and colleagues wrote in the study, which was published online in Dermatologic Surgery. “Identifying factors associated with perioperative patient anxiety could improve outcomes and patient satisfaction.”

Dr. Somani, director of dermatologic surgery and cutaneous oncology in the department of dermatology at the University of Indiana, Indianapolis, and coauthors surveyed 145 patients who underwent Mohs micrographic surgery (MMS) at the university from February 2018 to March 2020. They collected patient self-reported demographics, medical history, and administered a 10-point visual analog scale assessment of anxiety at multiple stages. They also sought HCP-perceived assessments of anxiety and used a stepwise regression mode to explore factors that potentially contributed to anxiety outcomes. The mean age of the 145 patients was 63 years, 60% were female, and 77% had no self-reported anxiety confirmed by a prior HCP’s diagnosis.

Two-thirds of patients (66%) received a pre-MMS consultation with the surgeon, 59% had a history of skin cancer removal surgery, and 86% had 1-2 layers removed during the current MMS.

Prior to MMS, the researchers found that significant risk factors for increased anxiety included younger age, female sex, and self-reported history of anxiety confirmed by an HCP (P < .05), while intraoperatively, HCP-perceived patient anxiety increased with younger patient age and more layers removed. Following MMS, patient anxiety increased significantly with more layers removed and higher self-reported preoperative anxiety levels. “Although existing research is divided regarding the efficacy of pre-MMS consultation for anxiety reduction, these findings suggest that patient-reported and HCP-perceived anxiety were not significantly affected by in-person pre-MMS consultation with the surgeon,” Dr. Somani and colleagues wrote. “Thus, routinely recommending consultations may not be the best approach for improving anxiety outcomes.”

They acknowledged certain limitations of their analysis, including its single-center design, enrollment of demographically similar patients, and the fact that no objective measurements of anxiety such as heart rate or blood pressure were taken.

“One of the main benefits of Mohs surgery is that we are able to operate under local anesthesia, but this also means that our patients are acutely aware of everything going on around them,” said Patricia M. Richey, MD, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and was asked to comment on the study.

“I think it is so important that this study is primarily focusing on the patient experience,” she said. “While this study did not find that a pre-op consult impacted patient anxiety levels, I do think we can infer that it is critical to connect with your patients on some level prior to surgery, as it helps you tailor your process to make the day more tolerable for them [such as] playing music, determining the need for an oral anxiolytic, etc.”

Neither the researchers nor Dr. Richey reported having financial disclosures.

Drug overdose deaths in pregnant and postpartum women rose by about 81% from 2017 to 2020, researchers report in a JAMA research letter published online Dec. 6.

Pregnancy-associated overdose deaths were highest in 2020 as the COVID pandemic began, according to the researchers, Emilie Bruzelius, MPH, and Silvia S. Martins, MD, PHD, with the department of epidemiology, Columbia University School of Public Health in New York.

The deaths were identified using International Statistical Classification of Diseases and Related Health Problems (ICD-10) pregnancy-related codes and death certificate pregnancy checkbox status.

The checkbox, part of all states’ death certificates, asks whether the person was pregnant at the time of death, within 42 days of death (early postpartum) or within 43-365 days of death (late postpartum).
 

Sharp increase at start of COVID pandemic

The authors note that pregnancy-related overdose deaths have been climbing from 2007 to 2019, but increased sharply in 2020.

“Pregnant and postpartum persons are known to face barriers to accessing drug treatment and harm-reduction services, which when compounded by pandemic-associated stressors, health care shutdowns, and increasingly volatile unregulated drug supply may have increased fatal overdose risk,” the authors write.

Of the 7,642 pregnancy-related deaths in the study period, 1,249 were overdose-related, leading to a cumulative overdose death rate of 8.35 per 100,000. From 2017 to 2020, pregnancy-related overdose deaths rose from 6.56 to 11.85 per 100,000. That translates to an absolute change rate of 5.30 per 100,000 and a relative increase of 81%.

The trend mirrors a pattern in people of reproductive age overall, the authors write.

Overdose mortality among reproductive age women similarly increased from 14.37 to 19.76 per 100,000 (absolute change rate, 5.39 [95% confidence interval, 4.94-5.85] per 100,000; relative increase of 38%).
 

Fentanyl deaths increase

The researchers found large increases in deaths involving fentanyl and other synthetics and psychostimulants (methamphetamine and cocaine, for example).

Pregnancy-associated overdose deaths involving benzodiazepines, heroin, and prescription opioids, however, were mostly stable from 2017 to 2020.

Numbers of late postpartum overdose deaths were notable in the paper.

In that group, there were 3.95 deaths per 100,000, compared with those pregnant at the time of death (2.99 per 100,000 or those identified as early postpartum (1.39 per 100 000).

Davida Schiff, MD, director of the Perinatal and Family-based Substance Use Disorder Care Massachusetts General Hospital substance use disorders initiative in Boston, told this publication it’s important to realize from this study that late postpartum period is the highest-risk period and also the time “when many states that have not expanded Medicaid cut off insurance needed to access life-saving health care services.”“Pregnancy is an important touch point of increased health care access, yet pregnant and parenting people face unique social and legal consequences from their substance use,” Dr. Schiff said.

She added, “I’m left wondering how many of the deaths reported could have been avoided if fear of a punitive response when engaging with our health care system had not prevented them from seeking out the care they needed.”

Dr. Schiff said the study highlights the importance of the pregnancy-checkbox addition to death records to better characterize pregnancy-associated deaths that previously were likely undercounted.

The authors and Dr. Schiff declare no relevant financial relationships.

Drug overdose deaths in pregnant and postpartum women rose by about 81% from 2017 to 2020, researchers report in a JAMA research letter published online Dec. 6.

Pregnancy-associated overdose deaths were highest in 2020 as the COVID pandemic began, according to the researchers, Emilie Bruzelius, MPH, and Silvia S. Martins, MD, PHD, with the department of epidemiology, Columbia University School of Public Health in New York.

The deaths were identified using International Statistical Classification of Diseases and Related Health Problems (ICD-10) pregnancy-related codes and death certificate pregnancy checkbox status.

The checkbox, part of all states’ death certificates, asks whether the person was pregnant at the time of death, within 42 days of death (early postpartum) or within 43-365 days of death (late postpartum).
 

Sharp increase at start of COVID pandemic

The authors note that pregnancy-related overdose deaths have been climbing from 2007 to 2019, but increased sharply in 2020.

“Pregnant and postpartum persons are known to face barriers to accessing drug treatment and harm-reduction services, which when compounded by pandemic-associated stressors, health care shutdowns, and increasingly volatile unregulated drug supply may have increased fatal overdose risk,” the authors write.

Of the 7,642 pregnancy-related deaths in the study period, 1,249 were overdose-related, leading to a cumulative overdose death rate of 8.35 per 100,000. From 2017 to 2020, pregnancy-related overdose deaths rose from 6.56 to 11.85 per 100,000. That translates to an absolute change rate of 5.30 per 100,000 and a relative increase of 81%.

The trend mirrors a pattern in people of reproductive age overall, the authors write.

Overdose mortality among reproductive age women similarly increased from 14.37 to 19.76 per 100,000 (absolute change rate, 5.39 [95% confidence interval, 4.94-5.85] per 100,000; relative increase of 38%).
 

Fentanyl deaths increase

The researchers found large increases in deaths involving fentanyl and other synthetics and psychostimulants (methamphetamine and cocaine, for example).

Pregnancy-associated overdose deaths involving benzodiazepines, heroin, and prescription opioids, however, were mostly stable from 2017 to 2020.

Numbers of late postpartum overdose deaths were notable in the paper.

In that group, there were 3.95 deaths per 100,000, compared with those pregnant at the time of death (2.99 per 100,000 or those identified as early postpartum (1.39 per 100 000).

Davida Schiff, MD, director of the Perinatal and Family-based Substance Use Disorder Care Massachusetts General Hospital substance use disorders initiative in Boston, told this publication it’s important to realize from this study that late postpartum period is the highest-risk period and also the time “when many states that have not expanded Medicaid cut off insurance needed to access life-saving health care services.”“Pregnancy is an important touch point of increased health care access, yet pregnant and parenting people face unique social and legal consequences from their substance use,” Dr. Schiff said.

She added, “I’m left wondering how many of the deaths reported could have been avoided if fear of a punitive response when engaging with our health care system had not prevented them from seeking out the care they needed.”

Dr. Schiff said the study highlights the importance of the pregnancy-checkbox addition to death records to better characterize pregnancy-associated deaths that previously were likely undercounted.

The authors and Dr. Schiff declare no relevant financial relationships.

Drug overdose deaths in pregnant and postpartum women rose by about 81% from 2017 to 2020, researchers report in a JAMA research letter published online Dec. 6.

Pregnancy-associated overdose deaths were highest in 2020 as the COVID pandemic began, according to the researchers, Emilie Bruzelius, MPH, and Silvia S. Martins, MD, PHD, with the department of epidemiology, Columbia University School of Public Health in New York.

The deaths were identified using International Statistical Classification of Diseases and Related Health Problems (ICD-10) pregnancy-related codes and death certificate pregnancy checkbox status.

The checkbox, part of all states’ death certificates, asks whether the person was pregnant at the time of death, within 42 days of death (early postpartum) or within 43-365 days of death (late postpartum).
 

Sharp increase at start of COVID pandemic

The authors note that pregnancy-related overdose deaths have been climbing from 2007 to 2019, but increased sharply in 2020.

“Pregnant and postpartum persons are known to face barriers to accessing drug treatment and harm-reduction services, which when compounded by pandemic-associated stressors, health care shutdowns, and increasingly volatile unregulated drug supply may have increased fatal overdose risk,” the authors write.

Of the 7,642 pregnancy-related deaths in the study period, 1,249 were overdose-related, leading to a cumulative overdose death rate of 8.35 per 100,000. From 2017 to 2020, pregnancy-related overdose deaths rose from 6.56 to 11.85 per 100,000. That translates to an absolute change rate of 5.30 per 100,000 and a relative increase of 81%.

The trend mirrors a pattern in people of reproductive age overall, the authors write.

Overdose mortality among reproductive age women similarly increased from 14.37 to 19.76 per 100,000 (absolute change rate, 5.39 [95% confidence interval, 4.94-5.85] per 100,000; relative increase of 38%).
 

Fentanyl deaths increase

The researchers found large increases in deaths involving fentanyl and other synthetics and psychostimulants (methamphetamine and cocaine, for example).

Pregnancy-associated overdose deaths involving benzodiazepines, heroin, and prescription opioids, however, were mostly stable from 2017 to 2020.

Numbers of late postpartum overdose deaths were notable in the paper.

In that group, there were 3.95 deaths per 100,000, compared with those pregnant at the time of death (2.99 per 100,000 or those identified as early postpartum (1.39 per 100 000).

Davida Schiff, MD, director of the Perinatal and Family-based Substance Use Disorder Care Massachusetts General Hospital substance use disorders initiative in Boston, told this publication it’s important to realize from this study that late postpartum period is the highest-risk period and also the time “when many states that have not expanded Medicaid cut off insurance needed to access life-saving health care services.”“Pregnancy is an important touch point of increased health care access, yet pregnant and parenting people face unique social and legal consequences from their substance use,” Dr. Schiff said.

She added, “I’m left wondering how many of the deaths reported could have been avoided if fear of a punitive response when engaging with our health care system had not prevented them from seeking out the care they needed.”

Dr. Schiff said the study highlights the importance of the pregnancy-checkbox addition to death records to better characterize pregnancy-associated deaths that previously were likely undercounted.

The authors and Dr. Schiff declare no relevant financial relationships.