MDedge Psychiatry

When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.

In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
 

‘Facebook depression’

Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?

Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.

“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.

“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
 

Teens’ fantasy life

There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.

This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.

However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.

The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.

Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).

“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
 

Language of distress

Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.

The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.

According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
 

Internet risks and dangers

Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”

Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.

Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.

Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.

A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.

The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.

“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.

But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.

Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).

Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
 

Support on social networks?

Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.

The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.

Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.

“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.

They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”

An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
 

Promoting access to care

In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.

“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”

These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.

On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.

The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.

Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
 

Professionals go digital

France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.

Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”

Dr. Morgiève said she has no conflicts of interest regarding the subject presented.

This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.

When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.

In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
 

‘Facebook depression’

Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?

Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.

“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.

“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
 

Teens’ fantasy life

There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.

This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.

However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.

The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.

Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).

“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
 

Language of distress

Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.

The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.

According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
 

Internet risks and dangers

Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”

Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.

Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.

Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.

A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.

The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.

“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.

But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.

Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).

Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
 

Support on social networks?

Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.

The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.

Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.

“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.

They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”

An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
 

Promoting access to care

In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.

“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”

These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.

On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.

The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.

Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
 

Professionals go digital

France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.

Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”

Dr. Morgiève said she has no conflicts of interest regarding the subject presented.

This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.

When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.

In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
 

‘Facebook depression’

Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?

Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.

“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.

“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
 

Teens’ fantasy life

There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.

This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.

However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.

The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.

Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).

“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
 

Language of distress

Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.

The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.

According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
 

Internet risks and dangers

Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”

Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.

Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.

Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.

A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.

The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.

“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.

But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.

Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).

Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
 

Support on social networks?

Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.

The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.

Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.

“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.

They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”

An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
 

Promoting access to care

In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.

“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”

These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.

On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.

The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.

Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
 

Professionals go digital

France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.

Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”

Dr. Morgiève said she has no conflicts of interest regarding the subject presented.

This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.

Posttraumatic stress disorder (PTSD) is associated with accelerated cognitive decline over time, new research suggests.

In an analysis of more than 12,000 middle-aged women who had experienced at least one trauma in their lives, those with PTSD symptoms showed an approximately twofold faster decline in cognition during follow-up compared with those who did not have PTSD symptoms.

These associations were not fully explained by other known cognition-related factors such as depression, the researchers noted.

“PTSD may increase the risk of dementia by accelerating cognitive decline at midlife,” coinvestigator Jiaxuan Liu, a doctoral candidate at Harvard TH Chan School of Public Health, Boston, said in an interview.

“Our findings may suggest the value of earlier cognitive screening among individuals with PTSD and the importance of PTSD prevention and treatment across the lifespan,” she added.

The results were published online in JAMA Network Open.

Vital public health issue

“Cognitive decline at midlife and older is of vital public health interest,” Ms. Liu said. “It is a risk factor for a variety of poor health outcomes and strongly predicts Alzheimer’s disease and other dementias.

Although PTSD has been linked to lower cognitive function and dementia incidence, it has not been known whether it is associated with decline in cognitive function, she added.

“In addition, both PTSD and dementia are more common in women than men, so it’s important to understand a possible link,” Ms. Liu said.

Because no large-scale study had examined whether PTSD is associated with cognitive decline in women, the current researchers examined PTSD symptoms and their association with repeated measures of cognitive function among a large civilian trauma-exposed cohort of women aged 50-70 years at study baseline.

Participants were drawn from the Nurses’ Health Study II, a longitudinal study of a cohort of 116,429 U.S. female nurses who were between 25 and 42 years old at enrollment in 1989. Participants completed biennial questionnaires, with follow-up on an ongoing basis.

The current analysis included 12,270 trauma-exposed women (mean age at baseline, 61.1 years) who completed assessments every 1 or 12 months for up to 24 months after baseline. The mean follow-up time was 0.9 years.

In the study population, 95.9% were non-Hispanic White, 1.3% were Hispanic, 1% were Asian, 0.6% were Black, and 1.2% were classified as “other.”
 

Higher depression scores

Lifetime trauma exposure and PTSD symptoms were assessed from March 1, 2008, to Feb. 28, 2010, using the Short Screening Scale for DSM-IV PTSD.

In total, 67% of the participants reported experiencing PTSD symptoms. The women were divided into four groups, on the basis of symptom number: no PTSD symptoms (n = 4,052), one to three PTSD symptoms (n = 5,058), four to five PTSD symptoms (n = 2,018), and six to seven PTSD symptoms (n = 1,052).

The Cogstate Brief Battery, a validated and self-administered online cognitive assessment, was completed by participants between Oct. 3, 2014, and July 30, 2019. The researchers measured cognitive function with two composite scores: psychomotor speed and attention, and learning and working memory.

Covariates potentially associated with cognitive decline included demographic, educational, and behavior-related health factors such as body mass index, physical activity, cigarette smoking, diet quality, and alcohol consumption.

The researchers conducted secondary analyses that adjusted for symptoms and history of depression as well as the consequences of potential practice effects of taking the test multiple times.

Behavior-related health factors “did not substantially differ by PTSD symptom level,” the investigators noted. However, compared with women who did not have PTSD symptoms, those who had such symptoms had higher depressive symptom scores and higher rates of clinician-diagnosed depression.

Both cognitive composite scores improved through the follow-up period, “likely because of practice effects,” the researchers wrote. But after adjusting for practice effects, they found a decline over time in both composite scores.
 

Dose-related trajectories

Results showed that having more PTSD symptoms was associated with dose-related poorer cognitive trajectories.

After adjustment for demographic characteristics, women with the highest symptom level (six to seven symptoms) had a significantly worse rate of change in both composite domains of learning and working memory (beta = −0.08 SD/y; 95% confidence interval [CI], −0.11 to −0.04 SD/y; P < .001) and of psychomotor speed and attention (beta = −0.05 SD/y; 95% CI, −0.09 to −0.01 SD/y; P  = .02) compared with women with no PTSD symptoms.

Women with four to five PTSD symptoms showed a worse rate of change in learning and working memory compared with those who had no symptoms, but not in psychomotor speed and attention. Women with one to three PTSD symptoms had cognitive scores similar to those of women without PTSD symptoms.

Notably, the associations of PTSD with cognitive change remained evident after additional adjustment for behavioral factors and health conditions – and were only “partially attenuated but still evident” after further adjustment for practice effects and comorbid depression, the investigators wrote.

“We thought PTSD might be associated with worse cognitive decline through health behaviors like smoking and alcohol drinking and higher risk of other health conditions like hypertension and depression,” Ms. Liu said.

However, those factors did not account for the current study’s findings, she noted.

“We could not determine why women with PTSD had faster cognitive decline than those without PTSD,” she said.

Ms. Liu suggested that PTSD “may have effects on the brain, such as altering brain structures and affecting brain immune function.” However, more research is needed “to investigate these mechanisms that might underlie the association we found between PTSD and cognitive decline,” she said.
 

Neurotoxic effect

In a comment, Howard Fillit, MD, cofounder and chief science officer of the Alzheimer’s Drug Discovery Foundation, said, “It is well known that stress is neurotoxic, and PTSD is a particularly serious form of stress.”

Dr. Fillit, clinical professor of geriatric medicine and palliative care, medicine, and neuroscience at Mount Sinai Hospital, New York, was not involved with the study.

“We tend to think of PTSD in postacute settings, such as soldiers returning from war,” he said. “This study contributes to our understanding of the long-term effects of PTSD on cognitive decline, measured objectively over time”

Dr. Fillit noted that an important implication is that, by increasing the risk for cognitive decline, PTSD also increases risk for Alzheimer’s disease. This leads to the “main take-home, which is that PTSD is a risk factor not only for cognitive decline but also for Alzheimer’s and related dementias,” he said.

However, this opens a potential therapeutic approach, Dr. Fillit added.

Because cortisol and other stress hormones drive the stress response, finding ways to block the neurotoxic effects of these hormones “might be a target to prevent cognitive decline and decrease Alzheimer’s disease risk,” he said.

The study was supported by grants from the National Institute of Mental Health and the National Institutes of Health. Ms. Liu and Dr. Fillit report no relevant financial relationships.

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

Posttraumatic stress disorder (PTSD) is associated with accelerated cognitive decline over time, new research suggests.

In an analysis of more than 12,000 middle-aged women who had experienced at least one trauma in their lives, those with PTSD symptoms showed an approximately twofold faster decline in cognition during follow-up compared with those who did not have PTSD symptoms.

These associations were not fully explained by other known cognition-related factors such as depression, the researchers noted.

“PTSD may increase the risk of dementia by accelerating cognitive decline at midlife,” coinvestigator Jiaxuan Liu, a doctoral candidate at Harvard TH Chan School of Public Health, Boston, said in an interview.

“Our findings may suggest the value of earlier cognitive screening among individuals with PTSD and the importance of PTSD prevention and treatment across the lifespan,” she added.

The results were published online in JAMA Network Open.

Vital public health issue

“Cognitive decline at midlife and older is of vital public health interest,” Ms. Liu said. “It is a risk factor for a variety of poor health outcomes and strongly predicts Alzheimer’s disease and other dementias.

Although PTSD has been linked to lower cognitive function and dementia incidence, it has not been known whether it is associated with decline in cognitive function, she added.

“In addition, both PTSD and dementia are more common in women than men, so it’s important to understand a possible link,” Ms. Liu said.

Because no large-scale study had examined whether PTSD is associated with cognitive decline in women, the current researchers examined PTSD symptoms and their association with repeated measures of cognitive function among a large civilian trauma-exposed cohort of women aged 50-70 years at study baseline.

Participants were drawn from the Nurses’ Health Study II, a longitudinal study of a cohort of 116,429 U.S. female nurses who were between 25 and 42 years old at enrollment in 1989. Participants completed biennial questionnaires, with follow-up on an ongoing basis.

The current analysis included 12,270 trauma-exposed women (mean age at baseline, 61.1 years) who completed assessments every 1 or 12 months for up to 24 months after baseline. The mean follow-up time was 0.9 years.

In the study population, 95.9% were non-Hispanic White, 1.3% were Hispanic, 1% were Asian, 0.6% were Black, and 1.2% were classified as “other.”
 

Higher depression scores

Lifetime trauma exposure and PTSD symptoms were assessed from March 1, 2008, to Feb. 28, 2010, using the Short Screening Scale for DSM-IV PTSD.

In total, 67% of the participants reported experiencing PTSD symptoms. The women were divided into four groups, on the basis of symptom number: no PTSD symptoms (n = 4,052), one to three PTSD symptoms (n = 5,058), four to five PTSD symptoms (n = 2,018), and six to seven PTSD symptoms (n = 1,052).

The Cogstate Brief Battery, a validated and self-administered online cognitive assessment, was completed by participants between Oct. 3, 2014, and July 30, 2019. The researchers measured cognitive function with two composite scores: psychomotor speed and attention, and learning and working memory.

Covariates potentially associated with cognitive decline included demographic, educational, and behavior-related health factors such as body mass index, physical activity, cigarette smoking, diet quality, and alcohol consumption.

The researchers conducted secondary analyses that adjusted for symptoms and history of depression as well as the consequences of potential practice effects of taking the test multiple times.

Behavior-related health factors “did not substantially differ by PTSD symptom level,” the investigators noted. However, compared with women who did not have PTSD symptoms, those who had such symptoms had higher depressive symptom scores and higher rates of clinician-diagnosed depression.

Both cognitive composite scores improved through the follow-up period, “likely because of practice effects,” the researchers wrote. But after adjusting for practice effects, they found a decline over time in both composite scores.
 

Dose-related trajectories

Results showed that having more PTSD symptoms was associated with dose-related poorer cognitive trajectories.

After adjustment for demographic characteristics, women with the highest symptom level (six to seven symptoms) had a significantly worse rate of change in both composite domains of learning and working memory (beta = −0.08 SD/y; 95% confidence interval [CI], −0.11 to −0.04 SD/y; P < .001) and of psychomotor speed and attention (beta = −0.05 SD/y; 95% CI, −0.09 to −0.01 SD/y; P  = .02) compared with women with no PTSD symptoms.

Women with four to five PTSD symptoms showed a worse rate of change in learning and working memory compared with those who had no symptoms, but not in psychomotor speed and attention. Women with one to three PTSD symptoms had cognitive scores similar to those of women without PTSD symptoms.

Notably, the associations of PTSD with cognitive change remained evident after additional adjustment for behavioral factors and health conditions – and were only “partially attenuated but still evident” after further adjustment for practice effects and comorbid depression, the investigators wrote.

“We thought PTSD might be associated with worse cognitive decline through health behaviors like smoking and alcohol drinking and higher risk of other health conditions like hypertension and depression,” Ms. Liu said.

However, those factors did not account for the current study’s findings, she noted.

“We could not determine why women with PTSD had faster cognitive decline than those without PTSD,” she said.

Ms. Liu suggested that PTSD “may have effects on the brain, such as altering brain structures and affecting brain immune function.” However, more research is needed “to investigate these mechanisms that might underlie the association we found between PTSD and cognitive decline,” she said.
 

Neurotoxic effect

In a comment, Howard Fillit, MD, cofounder and chief science officer of the Alzheimer’s Drug Discovery Foundation, said, “It is well known that stress is neurotoxic, and PTSD is a particularly serious form of stress.”

Dr. Fillit, clinical professor of geriatric medicine and palliative care, medicine, and neuroscience at Mount Sinai Hospital, New York, was not involved with the study.

“We tend to think of PTSD in postacute settings, such as soldiers returning from war,” he said. “This study contributes to our understanding of the long-term effects of PTSD on cognitive decline, measured objectively over time”

Dr. Fillit noted that an important implication is that, by increasing the risk for cognitive decline, PTSD also increases risk for Alzheimer’s disease. This leads to the “main take-home, which is that PTSD is a risk factor not only for cognitive decline but also for Alzheimer’s and related dementias,” he said.

However, this opens a potential therapeutic approach, Dr. Fillit added.

Because cortisol and other stress hormones drive the stress response, finding ways to block the neurotoxic effects of these hormones “might be a target to prevent cognitive decline and decrease Alzheimer’s disease risk,” he said.

The study was supported by grants from the National Institute of Mental Health and the National Institutes of Health. Ms. Liu and Dr. Fillit report no relevant financial relationships.

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

Posttraumatic stress disorder (PTSD) is associated with accelerated cognitive decline over time, new research suggests.

In an analysis of more than 12,000 middle-aged women who had experienced at least one trauma in their lives, those with PTSD symptoms showed an approximately twofold faster decline in cognition during follow-up compared with those who did not have PTSD symptoms.

These associations were not fully explained by other known cognition-related factors such as depression, the researchers noted.

“PTSD may increase the risk of dementia by accelerating cognitive decline at midlife,” coinvestigator Jiaxuan Liu, a doctoral candidate at Harvard TH Chan School of Public Health, Boston, said in an interview.

“Our findings may suggest the value of earlier cognitive screening among individuals with PTSD and the importance of PTSD prevention and treatment across the lifespan,” she added.

The results were published online in JAMA Network Open.

Vital public health issue

“Cognitive decline at midlife and older is of vital public health interest,” Ms. Liu said. “It is a risk factor for a variety of poor health outcomes and strongly predicts Alzheimer’s disease and other dementias.

Although PTSD has been linked to lower cognitive function and dementia incidence, it has not been known whether it is associated with decline in cognitive function, she added.

“In addition, both PTSD and dementia are more common in women than men, so it’s important to understand a possible link,” Ms. Liu said.

Because no large-scale study had examined whether PTSD is associated with cognitive decline in women, the current researchers examined PTSD symptoms and their association with repeated measures of cognitive function among a large civilian trauma-exposed cohort of women aged 50-70 years at study baseline.

Participants were drawn from the Nurses’ Health Study II, a longitudinal study of a cohort of 116,429 U.S. female nurses who were between 25 and 42 years old at enrollment in 1989. Participants completed biennial questionnaires, with follow-up on an ongoing basis.

The current analysis included 12,270 trauma-exposed women (mean age at baseline, 61.1 years) who completed assessments every 1 or 12 months for up to 24 months after baseline. The mean follow-up time was 0.9 years.

In the study population, 95.9% were non-Hispanic White, 1.3% were Hispanic, 1% were Asian, 0.6% were Black, and 1.2% were classified as “other.”
 

Higher depression scores

Lifetime trauma exposure and PTSD symptoms were assessed from March 1, 2008, to Feb. 28, 2010, using the Short Screening Scale for DSM-IV PTSD.

In total, 67% of the participants reported experiencing PTSD symptoms. The women were divided into four groups, on the basis of symptom number: no PTSD symptoms (n = 4,052), one to three PTSD symptoms (n = 5,058), four to five PTSD symptoms (n = 2,018), and six to seven PTSD symptoms (n = 1,052).

The Cogstate Brief Battery, a validated and self-administered online cognitive assessment, was completed by participants between Oct. 3, 2014, and July 30, 2019. The researchers measured cognitive function with two composite scores: psychomotor speed and attention, and learning and working memory.

Covariates potentially associated with cognitive decline included demographic, educational, and behavior-related health factors such as body mass index, physical activity, cigarette smoking, diet quality, and alcohol consumption.

The researchers conducted secondary analyses that adjusted for symptoms and history of depression as well as the consequences of potential practice effects of taking the test multiple times.

Behavior-related health factors “did not substantially differ by PTSD symptom level,” the investigators noted. However, compared with women who did not have PTSD symptoms, those who had such symptoms had higher depressive symptom scores and higher rates of clinician-diagnosed depression.

Both cognitive composite scores improved through the follow-up period, “likely because of practice effects,” the researchers wrote. But after adjusting for practice effects, they found a decline over time in both composite scores.
 

Dose-related trajectories

Results showed that having more PTSD symptoms was associated with dose-related poorer cognitive trajectories.

After adjustment for demographic characteristics, women with the highest symptom level (six to seven symptoms) had a significantly worse rate of change in both composite domains of learning and working memory (beta = −0.08 SD/y; 95% confidence interval [CI], −0.11 to −0.04 SD/y; P < .001) and of psychomotor speed and attention (beta = −0.05 SD/y; 95% CI, −0.09 to −0.01 SD/y; P  = .02) compared with women with no PTSD symptoms.

Women with four to five PTSD symptoms showed a worse rate of change in learning and working memory compared with those who had no symptoms, but not in psychomotor speed and attention. Women with one to three PTSD symptoms had cognitive scores similar to those of women without PTSD symptoms.

Notably, the associations of PTSD with cognitive change remained evident after additional adjustment for behavioral factors and health conditions – and were only “partially attenuated but still evident” after further adjustment for practice effects and comorbid depression, the investigators wrote.

“We thought PTSD might be associated with worse cognitive decline through health behaviors like smoking and alcohol drinking and higher risk of other health conditions like hypertension and depression,” Ms. Liu said.

However, those factors did not account for the current study’s findings, she noted.

“We could not determine why women with PTSD had faster cognitive decline than those without PTSD,” she said.

Ms. Liu suggested that PTSD “may have effects on the brain, such as altering brain structures and affecting brain immune function.” However, more research is needed “to investigate these mechanisms that might underlie the association we found between PTSD and cognitive decline,” she said.
 

Neurotoxic effect

In a comment, Howard Fillit, MD, cofounder and chief science officer of the Alzheimer’s Drug Discovery Foundation, said, “It is well known that stress is neurotoxic, and PTSD is a particularly serious form of stress.”

Dr. Fillit, clinical professor of geriatric medicine and palliative care, medicine, and neuroscience at Mount Sinai Hospital, New York, was not involved with the study.

“We tend to think of PTSD in postacute settings, such as soldiers returning from war,” he said. “This study contributes to our understanding of the long-term effects of PTSD on cognitive decline, measured objectively over time”

Dr. Fillit noted that an important implication is that, by increasing the risk for cognitive decline, PTSD also increases risk for Alzheimer’s disease. This leads to the “main take-home, which is that PTSD is a risk factor not only for cognitive decline but also for Alzheimer’s and related dementias,” he said.

However, this opens a potential therapeutic approach, Dr. Fillit added.

Because cortisol and other stress hormones drive the stress response, finding ways to block the neurotoxic effects of these hormones “might be a target to prevent cognitive decline and decrease Alzheimer’s disease risk,” he said.

The study was supported by grants from the National Institute of Mental Health and the National Institutes of Health. Ms. Liu and Dr. Fillit report no relevant financial relationships.

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

Scientists at Johns Hopkins University have identified a mechanism in the brain behind age-related memory loss, expanding our knowledge of the inner workings of the aging brain and possibly opening the door to new Alzheimer’s treatments.

The researchers looked at the hippocampus, a part of the brain thought to store long-term memories.

Neurons there are responsible for a pair of memory functions – called pattern separation and pattern completion – that work together in young, healthy brains. These functions can swing out of balance with age, impacting memory.

The Johns Hopkins team may have discovered what causes this imbalance. Their findings – reported in a paper in the journal Current Biology – may not only help us improve dementia treatments, but even prevent or delay a loss of thinking skills in the first place, the researchers say.
 

Pattern separation vs. pattern completion

To understand how the hippocampus changes with age, the researchers looked at rats’ brains. In rats and in humans, pattern separation and pattern completion are present, controlled by neurons in the hippocampus.

As the name suggests, pattern completion is when you take a few details or fragments of information – a few notes of music, or the start of a famous movie quote – and your brain retrieves the full memory. Pattern separation, on the other hand, is being able to tell similar observations or experiences apart (like two visits to the same restaurant) to be stored as separate memories.

These functions occur along a gradient across a tiny region called CA3. That gradient, the study found, disappears with aging, said lead study author Hey-Kyoung Lee, PhD, an assistant research scientist at the university’s Zanvyl Krieger Mind/Brain Institute. “The main consequence of the loss,” Dr. Lee said, “is that pattern completion becomes more dominant in rats as they age.”
 

What’s happening in the brain

Neurons responsible for pattern completion occupy the “distal” end of CA3, while those in charge of pattern separation reside at the “proximal” end. Dr. Lee said prior studies had not examined the proximal and distal regions separately, as she and her team did in this study.

What was surprising, said Dr. Lee, “was that hyperactivity in aging was observed toward the proximal CA3 region, not the expected distal region.” Contrary to their expectations, that hyperactivity did not enhance function in that area but rather dampened it. Hence: “There is diminished pattern separation and augmented pattern completion,” she said.

As pattern completion dominates, pattern separation fades, Dr. Lee said. This may make it harder for older adults to separate memories – they may recall a certain restaurant they’d been to but not be able to separate what happened during one visit versus another.
 

Why do some older adults stay sharp?

That memory impairment does not happen to everyone, and it doesn’t happen to all rats either. In fact, the researchers found that some older rats performed spatial-learning tasks as well as young rats did – even though their brains were already beginning to favor pattern completion.

If we can better understand why this happens, we may uncover new therapies for age-related memory loss, Dr. Lee said.

Coauthor Michela Gallagher’s team previously demonstrated that the anti-epilepsy drug levetiracetam improves memory performance by reducing hyperactivity in the hippocampus.

The extra detail this study adds may allow scientists to better aim such drugs in the future, Dr. Lee speculated. “It would give us better control of where we could possibly target the deficits we see.”

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

Scientists at Johns Hopkins University have identified a mechanism in the brain behind age-related memory loss, expanding our knowledge of the inner workings of the aging brain and possibly opening the door to new Alzheimer’s treatments.

The researchers looked at the hippocampus, a part of the brain thought to store long-term memories.

Neurons there are responsible for a pair of memory functions – called pattern separation and pattern completion – that work together in young, healthy brains. These functions can swing out of balance with age, impacting memory.

The Johns Hopkins team may have discovered what causes this imbalance. Their findings – reported in a paper in the journal Current Biology – may not only help us improve dementia treatments, but even prevent or delay a loss of thinking skills in the first place, the researchers say.
 

Pattern separation vs. pattern completion

To understand how the hippocampus changes with age, the researchers looked at rats’ brains. In rats and in humans, pattern separation and pattern completion are present, controlled by neurons in the hippocampus.

As the name suggests, pattern completion is when you take a few details or fragments of information – a few notes of music, or the start of a famous movie quote – and your brain retrieves the full memory. Pattern separation, on the other hand, is being able to tell similar observations or experiences apart (like two visits to the same restaurant) to be stored as separate memories.

These functions occur along a gradient across a tiny region called CA3. That gradient, the study found, disappears with aging, said lead study author Hey-Kyoung Lee, PhD, an assistant research scientist at the university’s Zanvyl Krieger Mind/Brain Institute. “The main consequence of the loss,” Dr. Lee said, “is that pattern completion becomes more dominant in rats as they age.”
 

What’s happening in the brain

Neurons responsible for pattern completion occupy the “distal” end of CA3, while those in charge of pattern separation reside at the “proximal” end. Dr. Lee said prior studies had not examined the proximal and distal regions separately, as she and her team did in this study.

What was surprising, said Dr. Lee, “was that hyperactivity in aging was observed toward the proximal CA3 region, not the expected distal region.” Contrary to their expectations, that hyperactivity did not enhance function in that area but rather dampened it. Hence: “There is diminished pattern separation and augmented pattern completion,” she said.

As pattern completion dominates, pattern separation fades, Dr. Lee said. This may make it harder for older adults to separate memories – they may recall a certain restaurant they’d been to but not be able to separate what happened during one visit versus another.
 

Why do some older adults stay sharp?

That memory impairment does not happen to everyone, and it doesn’t happen to all rats either. In fact, the researchers found that some older rats performed spatial-learning tasks as well as young rats did – even though their brains were already beginning to favor pattern completion.

If we can better understand why this happens, we may uncover new therapies for age-related memory loss, Dr. Lee said.

Coauthor Michela Gallagher’s team previously demonstrated that the anti-epilepsy drug levetiracetam improves memory performance by reducing hyperactivity in the hippocampus.

The extra detail this study adds may allow scientists to better aim such drugs in the future, Dr. Lee speculated. “It would give us better control of where we could possibly target the deficits we see.”

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

Scientists at Johns Hopkins University have identified a mechanism in the brain behind age-related memory loss, expanding our knowledge of the inner workings of the aging brain and possibly opening the door to new Alzheimer’s treatments.

The researchers looked at the hippocampus, a part of the brain thought to store long-term memories.

Neurons there are responsible for a pair of memory functions – called pattern separation and pattern completion – that work together in young, healthy brains. These functions can swing out of balance with age, impacting memory.

The Johns Hopkins team may have discovered what causes this imbalance. Their findings – reported in a paper in the journal Current Biology – may not only help us improve dementia treatments, but even prevent or delay a loss of thinking skills in the first place, the researchers say.
 

Pattern separation vs. pattern completion

To understand how the hippocampus changes with age, the researchers looked at rats’ brains. In rats and in humans, pattern separation and pattern completion are present, controlled by neurons in the hippocampus.

As the name suggests, pattern completion is when you take a few details or fragments of information – a few notes of music, or the start of a famous movie quote – and your brain retrieves the full memory. Pattern separation, on the other hand, is being able to tell similar observations or experiences apart (like two visits to the same restaurant) to be stored as separate memories.

These functions occur along a gradient across a tiny region called CA3. That gradient, the study found, disappears with aging, said lead study author Hey-Kyoung Lee, PhD, an assistant research scientist at the university’s Zanvyl Krieger Mind/Brain Institute. “The main consequence of the loss,” Dr. Lee said, “is that pattern completion becomes more dominant in rats as they age.”
 

What’s happening in the brain

Neurons responsible for pattern completion occupy the “distal” end of CA3, while those in charge of pattern separation reside at the “proximal” end. Dr. Lee said prior studies had not examined the proximal and distal regions separately, as she and her team did in this study.

What was surprising, said Dr. Lee, “was that hyperactivity in aging was observed toward the proximal CA3 region, not the expected distal region.” Contrary to their expectations, that hyperactivity did not enhance function in that area but rather dampened it. Hence: “There is diminished pattern separation and augmented pattern completion,” she said.

As pattern completion dominates, pattern separation fades, Dr. Lee said. This may make it harder for older adults to separate memories – they may recall a certain restaurant they’d been to but not be able to separate what happened during one visit versus another.
 

Why do some older adults stay sharp?

That memory impairment does not happen to everyone, and it doesn’t happen to all rats either. In fact, the researchers found that some older rats performed spatial-learning tasks as well as young rats did – even though their brains were already beginning to favor pattern completion.

If we can better understand why this happens, we may uncover new therapies for age-related memory loss, Dr. Lee said.

Coauthor Michela Gallagher’s team previously demonstrated that the anti-epilepsy drug levetiracetam improves memory performance by reducing hyperactivity in the hippocampus.

The extra detail this study adds may allow scientists to better aim such drugs in the future, Dr. Lee speculated. “It would give us better control of where we could possibly target the deficits we see.”

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

How satisfied are physicians that they are fairly compensated for their dedication, skills, and time? That’s a subject that seems to steer many physicians to heated emotions and to a variety of issues with today’s medical field – not all of which directly affect their pay.

Medscape’s Physician Compensation Report 2022: “Incomes Gain, Pay Gaps Remain” generally shows encouraging trends. Physician income rose from a year earlier, when it stagnated as COVID-19 restrictions led patients to stay home and medical practices to cut hours or close. And for the first time in Medscape’s 11 years of reporting on physician compensation, average income rose for every medical specialty surveyed.

Heartening findings, right? Yet the tone of comments to the report was anything but peppy. Many commenters were highly distressed or even angry about their compensation. One physician even complained his plumber earns more than he does.

A family physician lamented that he has “made less in the past 3 years, with more hassles and work” and he “can’t wait to retire next year.” Meanwhile, he complained, the U.S. health system is “the costliest, yet wasteful, with worse outcomes; reactive, not preventative; and has the costliest drugs and social issues.”
 

Do NPs and PAs encroach on your income?

The conversation about fair compensation launched some commenters into a discussion about competition from nurse practitioners (NPs) and physician assistants (PAs). Some physicians expressed wariness at best, and anger at worst, about NPs and PAs evolving beyond traditional doctor support roles into certain direct patient support.

One-fourth of respondents in the compensation report said their income was negatively affected by competition from NPs, PAs, and other nonphysician providers. For example, with states like Arkansas expanding independent practice for certified registered nurse anesthetists (CRNAs), one commenter complained, “we are no longer needed.”

Added another physician, “primary care, especially internal medicine, is just going away for doctors. We wasted, by all accounts, 4 full years of our working lives because NPs are ‘just as good.’ ”

Greater independence for NPs and PAs strengthens the hands of health insurers and “will end up hastening the demise of primary care as we have known it,” another reader predicted. Other physicians’ takes: “For the institution, it’s much cheaper to hire NPs than to hire doctors” and “overall, physician negotiating power will decrease in the future.”
 

Medicare reimbursement rates grate

Although 7 in 10 respondents in the compensation report said they would continue to accept new Medicare or Medicaid patients, comments reveal resentment about the practical need to work with Medicare and its resentment rates.

“An open question to Medicare: Are you doing the dumbest thing possible by paying low wages and giving huge administrative burdens for internal medicine on purpose?” one physician wrote. “Or are you really that short-sighted?”

Another reader cited an analysis from the American College of Surgeons of Medicare’s 1998 surgical CPT codes. If Medicare had left those codes alone beyond annual inflation adjustments, the study found, reimbursement rates by 2019 would be half of what they became.

Another way of looking at the code reimbursement increases is a 50% pay cut over 20 years for doctors and medical practices, that reader insisted. “The rising cost of employee wages, particularly of the last two-and-a-half years of COVID-19, combined with the effective pay cuts over the last 20 years, equals time to quit!”

Another commenter concurred. “In the 1990s, most full-time docs were making almost double what you see [in the report], and everything cost almost half of what it does now. So, MD purchasing power is between half and one-quarter of what it was in the early 1990s.”
 

Are self-pay models better?

Do physicians have a better chance at consistently fair income under a self-pay practice that avoids dealing with insurance companies?

One commenter hypothesized that psychiatrists once trailed internists in income but today earn more because many “quit working for insurance and went to a cash business 15 years ago.” Many family physicians did something similar by switching to a direct primary care model, he said.

This physician said he has done the same “with great results” for patients as well: shorter office visits, faster booking of appointments, no deductibles owed. Best of all, “I love practicing medicine again, and my patients love the great health care they receive.”

Another commenter agreed. “Two words: cash practice.” But another objected, “I guess only the very rich can afford to cover your business costs.”

Regardless of the payment model, another physician argued for private practice over employed positions. “Save on the bureaucratic expenses. Go back to private practice and get rid of electronic records.”

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

How satisfied are physicians that they are fairly compensated for their dedication, skills, and time? That’s a subject that seems to steer many physicians to heated emotions and to a variety of issues with today’s medical field – not all of which directly affect their pay.

Medscape’s Physician Compensation Report 2022: “Incomes Gain, Pay Gaps Remain” generally shows encouraging trends. Physician income rose from a year earlier, when it stagnated as COVID-19 restrictions led patients to stay home and medical practices to cut hours or close. And for the first time in Medscape’s 11 years of reporting on physician compensation, average income rose for every medical specialty surveyed.

Heartening findings, right? Yet the tone of comments to the report was anything but peppy. Many commenters were highly distressed or even angry about their compensation. One physician even complained his plumber earns more than he does.

A family physician lamented that he has “made less in the past 3 years, with more hassles and work” and he “can’t wait to retire next year.” Meanwhile, he complained, the U.S. health system is “the costliest, yet wasteful, with worse outcomes; reactive, not preventative; and has the costliest drugs and social issues.”
 

Do NPs and PAs encroach on your income?

The conversation about fair compensation launched some commenters into a discussion about competition from nurse practitioners (NPs) and physician assistants (PAs). Some physicians expressed wariness at best, and anger at worst, about NPs and PAs evolving beyond traditional doctor support roles into certain direct patient support.

One-fourth of respondents in the compensation report said their income was negatively affected by competition from NPs, PAs, and other nonphysician providers. For example, with states like Arkansas expanding independent practice for certified registered nurse anesthetists (CRNAs), one commenter complained, “we are no longer needed.”

Added another physician, “primary care, especially internal medicine, is just going away for doctors. We wasted, by all accounts, 4 full years of our working lives because NPs are ‘just as good.’ ”

Greater independence for NPs and PAs strengthens the hands of health insurers and “will end up hastening the demise of primary care as we have known it,” another reader predicted. Other physicians’ takes: “For the institution, it’s much cheaper to hire NPs than to hire doctors” and “overall, physician negotiating power will decrease in the future.”
 

Medicare reimbursement rates grate

Although 7 in 10 respondents in the compensation report said they would continue to accept new Medicare or Medicaid patients, comments reveal resentment about the practical need to work with Medicare and its resentment rates.

“An open question to Medicare: Are you doing the dumbest thing possible by paying low wages and giving huge administrative burdens for internal medicine on purpose?” one physician wrote. “Or are you really that short-sighted?”

Another reader cited an analysis from the American College of Surgeons of Medicare’s 1998 surgical CPT codes. If Medicare had left those codes alone beyond annual inflation adjustments, the study found, reimbursement rates by 2019 would be half of what they became.

Another way of looking at the code reimbursement increases is a 50% pay cut over 20 years for doctors and medical practices, that reader insisted. “The rising cost of employee wages, particularly of the last two-and-a-half years of COVID-19, combined with the effective pay cuts over the last 20 years, equals time to quit!”

Another commenter concurred. “In the 1990s, most full-time docs were making almost double what you see [in the report], and everything cost almost half of what it does now. So, MD purchasing power is between half and one-quarter of what it was in the early 1990s.”
 

Are self-pay models better?

Do physicians have a better chance at consistently fair income under a self-pay practice that avoids dealing with insurance companies?

One commenter hypothesized that psychiatrists once trailed internists in income but today earn more because many “quit working for insurance and went to a cash business 15 years ago.” Many family physicians did something similar by switching to a direct primary care model, he said.

This physician said he has done the same “with great results” for patients as well: shorter office visits, faster booking of appointments, no deductibles owed. Best of all, “I love practicing medicine again, and my patients love the great health care they receive.”

Another commenter agreed. “Two words: cash practice.” But another objected, “I guess only the very rich can afford to cover your business costs.”

Regardless of the payment model, another physician argued for private practice over employed positions. “Save on the bureaucratic expenses. Go back to private practice and get rid of electronic records.”

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

How satisfied are physicians that they are fairly compensated for their dedication, skills, and time? That’s a subject that seems to steer many physicians to heated emotions and to a variety of issues with today’s medical field – not all of which directly affect their pay.

Medscape’s Physician Compensation Report 2022: “Incomes Gain, Pay Gaps Remain” generally shows encouraging trends. Physician income rose from a year earlier, when it stagnated as COVID-19 restrictions led patients to stay home and medical practices to cut hours or close. And for the first time in Medscape’s 11 years of reporting on physician compensation, average income rose for every medical specialty surveyed.

Heartening findings, right? Yet the tone of comments to the report was anything but peppy. Many commenters were highly distressed or even angry about their compensation. One physician even complained his plumber earns more than he does.

A family physician lamented that he has “made less in the past 3 years, with more hassles and work” and he “can’t wait to retire next year.” Meanwhile, he complained, the U.S. health system is “the costliest, yet wasteful, with worse outcomes; reactive, not preventative; and has the costliest drugs and social issues.”
 

Do NPs and PAs encroach on your income?

The conversation about fair compensation launched some commenters into a discussion about competition from nurse practitioners (NPs) and physician assistants (PAs). Some physicians expressed wariness at best, and anger at worst, about NPs and PAs evolving beyond traditional doctor support roles into certain direct patient support.

One-fourth of respondents in the compensation report said their income was negatively affected by competition from NPs, PAs, and other nonphysician providers. For example, with states like Arkansas expanding independent practice for certified registered nurse anesthetists (CRNAs), one commenter complained, “we are no longer needed.”

Added another physician, “primary care, especially internal medicine, is just going away for doctors. We wasted, by all accounts, 4 full years of our working lives because NPs are ‘just as good.’ ”

Greater independence for NPs and PAs strengthens the hands of health insurers and “will end up hastening the demise of primary care as we have known it,” another reader predicted. Other physicians’ takes: “For the institution, it’s much cheaper to hire NPs than to hire doctors” and “overall, physician negotiating power will decrease in the future.”
 

Medicare reimbursement rates grate

Although 7 in 10 respondents in the compensation report said they would continue to accept new Medicare or Medicaid patients, comments reveal resentment about the practical need to work with Medicare and its resentment rates.

“An open question to Medicare: Are you doing the dumbest thing possible by paying low wages and giving huge administrative burdens for internal medicine on purpose?” one physician wrote. “Or are you really that short-sighted?”

Another reader cited an analysis from the American College of Surgeons of Medicare’s 1998 surgical CPT codes. If Medicare had left those codes alone beyond annual inflation adjustments, the study found, reimbursement rates by 2019 would be half of what they became.

Another way of looking at the code reimbursement increases is a 50% pay cut over 20 years for doctors and medical practices, that reader insisted. “The rising cost of employee wages, particularly of the last two-and-a-half years of COVID-19, combined with the effective pay cuts over the last 20 years, equals time to quit!”

Another commenter concurred. “In the 1990s, most full-time docs were making almost double what you see [in the report], and everything cost almost half of what it does now. So, MD purchasing power is between half and one-quarter of what it was in the early 1990s.”
 

Are self-pay models better?

Do physicians have a better chance at consistently fair income under a self-pay practice that avoids dealing with insurance companies?

One commenter hypothesized that psychiatrists once trailed internists in income but today earn more because many “quit working for insurance and went to a cash business 15 years ago.” Many family physicians did something similar by switching to a direct primary care model, he said.

This physician said he has done the same “with great results” for patients as well: shorter office visits, faster booking of appointments, no deductibles owed. Best of all, “I love practicing medicine again, and my patients love the great health care they receive.”

Another commenter agreed. “Two words: cash practice.” But another objected, “I guess only the very rich can afford to cover your business costs.”

Regardless of the payment model, another physician argued for private practice over employed positions. “Save on the bureaucratic expenses. Go back to private practice and get rid of electronic records.”

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

Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

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

Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

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

Bone densitometry scans may be a novel, noninvasive, and scalable way to identify older women at risk of developing dementia, new research suggests.

In an analysis of more than 900 study participants, women in their 70s with more advanced abdominal aortic calcification (AAC) seen on lateral spine images during dual-energy x-ray absorptiometry (DXA) had a two- to fourfold higher risk for late-life dementia than those with low AAC.

This finding was independent of cardiovascular risk factors and apolipoprotein E (APOE ) genotype.

“While these results are exciting, we now need to undertake further large screening studies in older men and women using this approach to show that the findings are generalizable to older men and can identify people with greater cognitive decline,” coinvestigator Marc Sim, PhD, Edith Cowan University, Joondalup, Australia, said in an interview.

“This will hopefully open the door to studies of early disease-modifying interventions,” Sim said.

The findings were published online in The Lancet Regional Health – Western Pacific. 
 

AAC and cognition

Late-life dementia occurring after age 80 is increasingly common because of both vascular and nonvascular risk factors.

Two recent studies in middle-aged and older men and women showed that AAC identified on bone densitometry was associated with poorer cognition, suggesting it may be related to cognitive decline and increased dementia risk.

This provided the rationale for the current study, Dr. Sim noted.

The researchers assessed AAC using DXA lateral spine images captured in the late 1990s in a prospective cohort of 958 older women who were participating in an osteoporosis study.

AAC was classified into established low, moderate, and extensive categories. At baseline, all women were aged 70 and older, and 45% had low AAC, 36% had moderate AAC, and 19% had extensive AAC.

Over 14.5 years, 150 women (15.7%) had a late-life hospitalization and/or died.
 

Improved risk prediction

Results showed that, compared with women who had low AAC, women with moderate and extensive AAC were more likely to experience late-life dementia hospitalization (9.3% low, 15.5% moderate, and 18.3% extensive) and death (2.8%, 8.3%, and 9.4%, respectively).

After multivariable adjustment, women with moderate AAC had a two- and threefold increased relative risk for late-life dementia hospitalization or death, compared with their peers who had low AAC.

Women with extensive AAC had a two- and fourfold increase in the adjusted relative risk for late-life dementia hospitalization or death.

“To our knowledge this is the first time it has been shown that AAC from these scans is related to late-life dementia,” Dr. Sim said.

“We demonstrated that AAC improved risk prediction in addition to cardiovascular risk factors and APOE genotype, a genetic risk factor for Alzheimer’s disease, the major form of dementia,” he added.

Dr. Sim noted “these additional lateral spine images” can be taken at the same time that hip and spine bone density tests are done.

“This provides an opportunity to identify AAC in large numbers of people,” he said.

He cautioned, however, that further studies with detailed dementia-related phenotypes, brain imaging, and measures of cognition are needed to confirm whether AAC will add value to dementia risk prediction.
 

‘Not surprising’

Commenting on the findings for this article, Claire Sexton, DPhil, senior director of scientific programs and outreach at the Alzheimer’s Association, Chicago, noted that AAC is a marker of atherosclerosis and is associated with vascular health outcomes.

Therefore, it is “not surprising it would be associated with dementia too. There’s been previous research linking atherosclerosis and Alzheimer’s disease,” Dr. Sexton said.  

“What’s novel about this research is that it’s looking at AAC specifically, which can be identified through a relatively simple test that is already in widespread use,” she added.

Dr. Sexton noted that “much more research” is now needed in larger, more diverse populations in order to better understand the link between AAC and dementia – and whether bone density testing may be an appropriate dementia-screening tool.

“The good news is vascular conditions like atherosclerosis can be managed through lifestyle changes like eating a healthy diet and getting regular exercise. And research tells us what’s good for the heart is good for the brain,” Dr. Sexton said.

The study was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee Grant, and the National Health and Medical Research Council of Australia. Dr. Sim and Dr. Sexton have reported no relevant financial relationships.

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

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

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

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

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

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”

Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.

Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.

Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
 

Internalized sexism

As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.

Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.¹ This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?

Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.

An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.

At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.

Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.

“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.²

Intensive mothering

When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”

Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”³ Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.

Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”³ She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.³ Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.

In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.⁴

Whatever type of parenting a woman chooses, you can be sure that she, not the father, will be held accountable. There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.

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

References

1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.

2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.

3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.

4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.

Consumers, employers, and just about everyone else interested in health care prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

As of July 1, health insurers and self-insured employers must post on websites just about every price they’ve negotiated with providers for health care services, item by item. About the only thing excluded are the prices paid for prescription drugs, except those administered in hospitals or doctors’ offices.

The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing, compared with others.

The new rules are far broader than those that went into effect in 2021 requiring hospitals to post their negotiated rates for the public to see. Now insurers must post the amounts paid for “every physician in network, every hospital, every surgery center, every nursing facility,” said Jeffrey Leibach, a partner at the consulting firm Guidehouse.

“When you start doing the math, you’re talking trillions of records,” he said. The fines the federal government could impose for noncompliance are also heftier than the penalties that hospitals face.

Federal officials learned from the hospital experience and gave insurers more direction on what was expected, said Mr. Leibach. Insurers or self-insured employers could be fined as much as $100 a day for each violation, for each affected enrollee if they fail to provide the data.

“Get your calculator out: All of a sudden you are in the millions pretty fast,” Mr. Leibach said.

Determined consumers, especially those with high-deductible health plans, may try to dig in right away and use the data to try comparing what they will have to pay at different hospitals, clinics, or doctor offices for specific services.

But each database’s enormous size may mean that most people “will find it very hard to use the data in a nuanced way,” said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy.

At least at first.

Entrepreneurs are expected to quickly translate the information into more user-friendly formats so it can be incorporated into new or existing services that estimate costs for patients. And starting Jan. 1, the rules require insurers to provide online tools that will help people get up-front cost estimates for about 500 so-called “shoppable” services, meaning medical care they can schedule ahead of time.

Once those things happen, “you’ll at least have the options in front of you,” said Chris Severn, CEO of Turquoise Health, an online company that has posted price information made available under the rules for hospitals, although many hospitals have yet to comply.

With the addition of the insurers’ data, sites like his will be able to drill down further into cost variation from one place to another or among insurers.

“If you’re going to get an x-ray, you will be able to see that you can do it for $250 at this hospital, $75 at the imaging center down the road, or your specialist can do it in office for $25,” he said.

Everyone will know everyone else’s business: for example, how much insurers Aetna and Humana pay the same surgery center for a knee replacement.

The requirements stem from the Affordable Care Act and a 2019 executive order by then-President Donald Trump.

“These plans are supposed to be acting on behalf of employers in negotiating good rates, and the little insight we have on that shows it has not happened,” said Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, an affiliation of employers who offer job-based health benefits to workers. “I do believe the dynamics are going to change.”

Other observers are more circumspect.

“Maybe at best this will reduce the wide variance of prices out there,” said Zack Cooper, director of health policy at the Yale University Institution for Social and Policy Studies, New Haven, Conn. “But it won’t be unleashing a consumer revolution.”

Still, the biggest value of the July data release may well be to shed light on how successful insurers have been at negotiating prices. It comes on the heels of research that has shown tremendous variation in what is paid for health care. A recent study by Rand, for example, shows that employers that offer job-based insurance plans paid, on average, 224% more than Medicare for the same services.

Tens of thousands of employers who buy insurance coverage for their workers will get this more-complete pricing picture – and may not like what they see.

“What we’re learning from the hospital data is that insurers are really bad at negotiating,” said Gerard Anderson, a professor in the department of health policy at the Johns Hopkins Bloomberg, Baltimore, citing research that found that negotiated rates for hospital care can be higher than what the facilities accept from patients who are not using insurance and are paying cash.

That could add to the frustration that Ms. Mitchell and others say employers have with the current health insurance system. More might try to contract with providers directly, only using insurance companies for claims processing.

Other employers may bring their insurers back to the bargaining table.

“For the first time, an employer will be able to go to an insurance company and say: ‘You have not negotiated a good-enough deal, and we know that because we can see the same provider has negotiated a better deal with another company,’ ” said James Gelfand, president of the ERISA Industry Committee, a trade group of self-insured employers.

If that happens, he added, “patients will be able to save money.”

That’s not necessarily a given, however.

Because this kind of public release of pricing data hasn’t been tried widely in health care before, how it will affect future spending remains uncertain. If insurers are pushed back to the bargaining table or providers see where they stand relative to their peers, prices could drop. However, some providers could raise their prices if they see they are charging less than their peers.

“Downward pressure may not be a given,” said Kelley Schultz, vice president of commercial policy for AHIP, the industry’s trade lobby.

Ms. Baicker said that, even after the data is out, rates will continue to be heavily influenced by local conditions, such as the size of an insurer or employer – providers often give bigger discounts, for example, to the insurers or self-insured employers that can send them the most patients. The number of hospitals in a region also matters – if an area has only one, for instance, that usually means the facility can demand higher rates.

Another unknown: Will insurers meet the deadline and provide usable data?

Ms. Schultz, at AHIP, said the industry is well on the way, partly because the original deadline was extended by 6 months. She expects insurers to do better than the hospital industry. “We saw a lot of hospitals that just decided not to post files or make them difficult to find,” she said.

So far, more than 300 noncompliant hospitals received warning letters from the government. But they could face fines of $300 a day fines for failing to comply, which is less than what insurers potentially face, although the federal government has recently upped the ante to up to $5,500 a day for the largest facilities.

Even after the pricing data is public, “I don’t think things will change overnight,” said Mr. Leibach. “Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Consumers, employers, and just about everyone else interested in health care prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

As of July 1, health insurers and self-insured employers must post on websites just about every price they’ve negotiated with providers for health care services, item by item. About the only thing excluded are the prices paid for prescription drugs, except those administered in hospitals or doctors’ offices.

The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing, compared with others.

The new rules are far broader than those that went into effect in 2021 requiring hospitals to post their negotiated rates for the public to see. Now insurers must post the amounts paid for “every physician in network, every hospital, every surgery center, every nursing facility,” said Jeffrey Leibach, a partner at the consulting firm Guidehouse.

“When you start doing the math, you’re talking trillions of records,” he said. The fines the federal government could impose for noncompliance are also heftier than the penalties that hospitals face.

Federal officials learned from the hospital experience and gave insurers more direction on what was expected, said Mr. Leibach. Insurers or self-insured employers could be fined as much as $100 a day for each violation, for each affected enrollee if they fail to provide the data.

“Get your calculator out: All of a sudden you are in the millions pretty fast,” Mr. Leibach said.

Determined consumers, especially those with high-deductible health plans, may try to dig in right away and use the data to try comparing what they will have to pay at different hospitals, clinics, or doctor offices for specific services.

But each database’s enormous size may mean that most people “will find it very hard to use the data in a nuanced way,” said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy.

At least at first.

Entrepreneurs are expected to quickly translate the information into more user-friendly formats so it can be incorporated into new or existing services that estimate costs for patients. And starting Jan. 1, the rules require insurers to provide online tools that will help people get up-front cost estimates for about 500 so-called “shoppable” services, meaning medical care they can schedule ahead of time.

Once those things happen, “you’ll at least have the options in front of you,” said Chris Severn, CEO of Turquoise Health, an online company that has posted price information made available under the rules for hospitals, although many hospitals have yet to comply.

With the addition of the insurers’ data, sites like his will be able to drill down further into cost variation from one place to another or among insurers.

“If you’re going to get an x-ray, you will be able to see that you can do it for $250 at this hospital, $75 at the imaging center down the road, or your specialist can do it in office for $25,” he said.

Everyone will know everyone else’s business: for example, how much insurers Aetna and Humana pay the same surgery center for a knee replacement.

The requirements stem from the Affordable Care Act and a 2019 executive order by then-President Donald Trump.

“These plans are supposed to be acting on behalf of employers in negotiating good rates, and the little insight we have on that shows it has not happened,” said Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, an affiliation of employers who offer job-based health benefits to workers. “I do believe the dynamics are going to change.”

Other observers are more circumspect.

“Maybe at best this will reduce the wide variance of prices out there,” said Zack Cooper, director of health policy at the Yale University Institution for Social and Policy Studies, New Haven, Conn. “But it won’t be unleashing a consumer revolution.”

Still, the biggest value of the July data release may well be to shed light on how successful insurers have been at negotiating prices. It comes on the heels of research that has shown tremendous variation in what is paid for health care. A recent study by Rand, for example, shows that employers that offer job-based insurance plans paid, on average, 224% more than Medicare for the same services.

Tens of thousands of employers who buy insurance coverage for their workers will get this more-complete pricing picture – and may not like what they see.

“What we’re learning from the hospital data is that insurers are really bad at negotiating,” said Gerard Anderson, a professor in the department of health policy at the Johns Hopkins Bloomberg, Baltimore, citing research that found that negotiated rates for hospital care can be higher than what the facilities accept from patients who are not using insurance and are paying cash.

That could add to the frustration that Ms. Mitchell and others say employers have with the current health insurance system. More might try to contract with providers directly, only using insurance companies for claims processing.

Other employers may bring their insurers back to the bargaining table.

“For the first time, an employer will be able to go to an insurance company and say: ‘You have not negotiated a good-enough deal, and we know that because we can see the same provider has negotiated a better deal with another company,’ ” said James Gelfand, president of the ERISA Industry Committee, a trade group of self-insured employers.

If that happens, he added, “patients will be able to save money.”

That’s not necessarily a given, however.

Because this kind of public release of pricing data hasn’t been tried widely in health care before, how it will affect future spending remains uncertain. If insurers are pushed back to the bargaining table or providers see where they stand relative to their peers, prices could drop. However, some providers could raise their prices if they see they are charging less than their peers.

“Downward pressure may not be a given,” said Kelley Schultz, vice president of commercial policy for AHIP, the industry’s trade lobby.

Ms. Baicker said that, even after the data is out, rates will continue to be heavily influenced by local conditions, such as the size of an insurer or employer – providers often give bigger discounts, for example, to the insurers or self-insured employers that can send them the most patients. The number of hospitals in a region also matters – if an area has only one, for instance, that usually means the facility can demand higher rates.

Another unknown: Will insurers meet the deadline and provide usable data?

Ms. Schultz, at AHIP, said the industry is well on the way, partly because the original deadline was extended by 6 months. She expects insurers to do better than the hospital industry. “We saw a lot of hospitals that just decided not to post files or make them difficult to find,” she said.

So far, more than 300 noncompliant hospitals received warning letters from the government. But they could face fines of $300 a day fines for failing to comply, which is less than what insurers potentially face, although the federal government has recently upped the ante to up to $5,500 a day for the largest facilities.

Even after the pricing data is public, “I don’t think things will change overnight,” said Mr. Leibach. “Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Consumers, employers, and just about everyone else interested in health care prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

As of July 1, health insurers and self-insured employers must post on websites just about every price they’ve negotiated with providers for health care services, item by item. About the only thing excluded are the prices paid for prescription drugs, except those administered in hospitals or doctors’ offices.

The federally required data release could affect future prices or even how employers contract for health care. Many will see for the first time how well their insurers are doing, compared with others.

The new rules are far broader than those that went into effect in 2021 requiring hospitals to post their negotiated rates for the public to see. Now insurers must post the amounts paid for “every physician in network, every hospital, every surgery center, every nursing facility,” said Jeffrey Leibach, a partner at the consulting firm Guidehouse.

“When you start doing the math, you’re talking trillions of records,” he said. The fines the federal government could impose for noncompliance are also heftier than the penalties that hospitals face.

Federal officials learned from the hospital experience and gave insurers more direction on what was expected, said Mr. Leibach. Insurers or self-insured employers could be fined as much as $100 a day for each violation, for each affected enrollee if they fail to provide the data.

“Get your calculator out: All of a sudden you are in the millions pretty fast,” Mr. Leibach said.

Determined consumers, especially those with high-deductible health plans, may try to dig in right away and use the data to try comparing what they will have to pay at different hospitals, clinics, or doctor offices for specific services.

But each database’s enormous size may mean that most people “will find it very hard to use the data in a nuanced way,” said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy.

At least at first.

Entrepreneurs are expected to quickly translate the information into more user-friendly formats so it can be incorporated into new or existing services that estimate costs for patients. And starting Jan. 1, the rules require insurers to provide online tools that will help people get up-front cost estimates for about 500 so-called “shoppable” services, meaning medical care they can schedule ahead of time.

Once those things happen, “you’ll at least have the options in front of you,” said Chris Severn, CEO of Turquoise Health, an online company that has posted price information made available under the rules for hospitals, although many hospitals have yet to comply.

With the addition of the insurers’ data, sites like his will be able to drill down further into cost variation from one place to another or among insurers.

“If you’re going to get an x-ray, you will be able to see that you can do it for $250 at this hospital, $75 at the imaging center down the road, or your specialist can do it in office for $25,” he said.

Everyone will know everyone else’s business: for example, how much insurers Aetna and Humana pay the same surgery center for a knee replacement.

The requirements stem from the Affordable Care Act and a 2019 executive order by then-President Donald Trump.

“These plans are supposed to be acting on behalf of employers in negotiating good rates, and the little insight we have on that shows it has not happened,” said Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health, an affiliation of employers who offer job-based health benefits to workers. “I do believe the dynamics are going to change.”

Other observers are more circumspect.

“Maybe at best this will reduce the wide variance of prices out there,” said Zack Cooper, director of health policy at the Yale University Institution for Social and Policy Studies, New Haven, Conn. “But it won’t be unleashing a consumer revolution.”

Still, the biggest value of the July data release may well be to shed light on how successful insurers have been at negotiating prices. It comes on the heels of research that has shown tremendous variation in what is paid for health care. A recent study by Rand, for example, shows that employers that offer job-based insurance plans paid, on average, 224% more than Medicare for the same services.

Tens of thousands of employers who buy insurance coverage for their workers will get this more-complete pricing picture – and may not like what they see.

“What we’re learning from the hospital data is that insurers are really bad at negotiating,” said Gerard Anderson, a professor in the department of health policy at the Johns Hopkins Bloomberg, Baltimore, citing research that found that negotiated rates for hospital care can be higher than what the facilities accept from patients who are not using insurance and are paying cash.

That could add to the frustration that Ms. Mitchell and others say employers have with the current health insurance system. More might try to contract with providers directly, only using insurance companies for claims processing.

Other employers may bring their insurers back to the bargaining table.

“For the first time, an employer will be able to go to an insurance company and say: ‘You have not negotiated a good-enough deal, and we know that because we can see the same provider has negotiated a better deal with another company,’ ” said James Gelfand, president of the ERISA Industry Committee, a trade group of self-insured employers.

If that happens, he added, “patients will be able to save money.”

That’s not necessarily a given, however.

Because this kind of public release of pricing data hasn’t been tried widely in health care before, how it will affect future spending remains uncertain. If insurers are pushed back to the bargaining table or providers see where they stand relative to their peers, prices could drop. However, some providers could raise their prices if they see they are charging less than their peers.

“Downward pressure may not be a given,” said Kelley Schultz, vice president of commercial policy for AHIP, the industry’s trade lobby.

Ms. Baicker said that, even after the data is out, rates will continue to be heavily influenced by local conditions, such as the size of an insurer or employer – providers often give bigger discounts, for example, to the insurers or self-insured employers that can send them the most patients. The number of hospitals in a region also matters – if an area has only one, for instance, that usually means the facility can demand higher rates.

Another unknown: Will insurers meet the deadline and provide usable data?

Ms. Schultz, at AHIP, said the industry is well on the way, partly because the original deadline was extended by 6 months. She expects insurers to do better than the hospital industry. “We saw a lot of hospitals that just decided not to post files or make them difficult to find,” she said.

So far, more than 300 noncompliant hospitals received warning letters from the government. But they could face fines of $300 a day fines for failing to comply, which is less than what insurers potentially face, although the federal government has recently upped the ante to up to $5,500 a day for the largest facilities.

Even after the pricing data is public, “I don’t think things will change overnight,” said Mr. Leibach. “Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.

Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.

Smithore/Getty Images

In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.

Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.

Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.

The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.

“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.

However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.

The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.

However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
 

Consider range of causes for cannabis emergency visits

“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.

Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.

“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.

“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.

“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”

Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.

When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.

Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”

Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”

The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.

“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”

In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.

“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.

The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.

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

Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.

Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.

Smithore/Getty Images

In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.

Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.

Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.

The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.

“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.

However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.

The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.

However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
 

Consider range of causes for cannabis emergency visits

“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.

Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.

“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.

“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.

“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”

Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.

When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.

Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”

Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”

The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.

“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”

In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.

“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.

The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.

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

Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.

Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.

Smithore/Getty Images

In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.

Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.

Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.

The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.

“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.

However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.

The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.

However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
 

Consider range of causes for cannabis emergency visits

“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.

Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.

“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.

“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.

“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”

Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.

When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.

Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”

Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”

The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.

“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”

In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.

“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.

The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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