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Resident doctor who attempted suicide three times fights for change
In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.
In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.
The article took Dr. Bullock’s impact nationwide. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”
Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.
“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
Suicide attempts during medical training
Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.
When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”
He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.
After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.
When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.
By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said.
Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.
Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.
He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.
Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”
Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping.
Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.
In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
Advocating for changes in medical training
Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally.
During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”
Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.
In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.
While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF.
Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.
Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization.
Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.
“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
Overcoming stigma to change the system
All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.
Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.
Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”
Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”
In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.
“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”
A version of this article first appeared on Medscape.com.
In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.
In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.
The article took Dr. Bullock’s impact nationwide. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”
Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.
“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
Suicide attempts during medical training
Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.
When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”
He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.
After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.
When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.
By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said.
Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.
Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.
He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.
Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”
Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping.
Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.
In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
Advocating for changes in medical training
Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally.
During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”
Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.
In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.
While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF.
Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.
Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization.
Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.
“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
Overcoming stigma to change the system
All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.
Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.
Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”
Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”
In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.
“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”
A version of this article first appeared on Medscape.com.
In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.
In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.
The article took Dr. Bullock’s impact nationwide. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”
Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.
“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
Suicide attempts during medical training
Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.
When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”
He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.
After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.
When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.
By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said.
Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.
Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.
He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.
Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”
Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping.
Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.
In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
Advocating for changes in medical training
Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally.
During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”
Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.
In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.
While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF.
Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.
Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization.
Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.
“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
Overcoming stigma to change the system
All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.
Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.
Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”
Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”
In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.
“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”
A version of this article first appeared on Medscape.com.
Latest national suicide data released
including pandemic-related job loss, financial strain, and deteriorating mental health, according to new federal statistics.
The number of annual suicides in the United States increased steadily from 2003 through 2018, followed by a 2% decline between 2018 and 2019. There was concern that deaths due to suicide would increase in 2020, but this doesn’t appear to be the case.
The provisional numbers show 45,855 deaths by suicide in the United States in 2020 – 3% lower than in 2019 (47,511), and 5% below the 2018 peak of 48,344 suicides, report Sally Curtin, MA, and colleagues with the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention.
The data were published online Nov. 3 in the National Vital Statistics System (NVSS) Vital Statistics Rapid Release.
On a monthly basis, the number of suicides was lower in 2020 than in 2019 in March through October and December – with the largest drop happening in April 2020 at a time when deaths from COVID-19 were peaking, the authors note. In April 2020, suicide deaths were 14% lower than in April 2019 (3,468 vs. 4,029).
The provisional age-adjusted suicide rate was 3% lower in 2020 (13.5 per 100,000) than in 2019 (13.9 per 100,000). It was 2% lower among men (21.9 compared with 22.4), and 8% lower for women (5.5 compared with 6.0).
Suicide rates among younger adults aged 10 to 34 years rose slightly between 2019 and 2020 but was only significant in those 25 to 34, with a 5% increase between 2019 and 2020.
Individuals aged 35 to 74 years had significant declines in suicide with the largest drop in those aged 45 to 54 years and 55 to 64 years.
Women in all race and Hispanic-origin groups showed declines in suicide rates between 2019 and 2020, but the decline was significant only among non-Hispanic white women (10%).
Suicide rates declined for non-Hispanic white and non-Hispanic Asian men but increased among non-Hispanic black, non-Hispanic American Indian or Alaska Native, and Hispanic men.
This analysis is based on more than 99% of expected death records. Based on previous patterns between provisional and final data, these provisional findings are expected to be consistent with final 2020 data, the authors say.
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
including pandemic-related job loss, financial strain, and deteriorating mental health, according to new federal statistics.
The number of annual suicides in the United States increased steadily from 2003 through 2018, followed by a 2% decline between 2018 and 2019. There was concern that deaths due to suicide would increase in 2020, but this doesn’t appear to be the case.
The provisional numbers show 45,855 deaths by suicide in the United States in 2020 – 3% lower than in 2019 (47,511), and 5% below the 2018 peak of 48,344 suicides, report Sally Curtin, MA, and colleagues with the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention.
The data were published online Nov. 3 in the National Vital Statistics System (NVSS) Vital Statistics Rapid Release.
On a monthly basis, the number of suicides was lower in 2020 than in 2019 in March through October and December – with the largest drop happening in April 2020 at a time when deaths from COVID-19 were peaking, the authors note. In April 2020, suicide deaths were 14% lower than in April 2019 (3,468 vs. 4,029).
The provisional age-adjusted suicide rate was 3% lower in 2020 (13.5 per 100,000) than in 2019 (13.9 per 100,000). It was 2% lower among men (21.9 compared with 22.4), and 8% lower for women (5.5 compared with 6.0).
Suicide rates among younger adults aged 10 to 34 years rose slightly between 2019 and 2020 but was only significant in those 25 to 34, with a 5% increase between 2019 and 2020.
Individuals aged 35 to 74 years had significant declines in suicide with the largest drop in those aged 45 to 54 years and 55 to 64 years.
Women in all race and Hispanic-origin groups showed declines in suicide rates between 2019 and 2020, but the decline was significant only among non-Hispanic white women (10%).
Suicide rates declined for non-Hispanic white and non-Hispanic Asian men but increased among non-Hispanic black, non-Hispanic American Indian or Alaska Native, and Hispanic men.
This analysis is based on more than 99% of expected death records. Based on previous patterns between provisional and final data, these provisional findings are expected to be consistent with final 2020 data, the authors say.
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
including pandemic-related job loss, financial strain, and deteriorating mental health, according to new federal statistics.
The number of annual suicides in the United States increased steadily from 2003 through 2018, followed by a 2% decline between 2018 and 2019. There was concern that deaths due to suicide would increase in 2020, but this doesn’t appear to be the case.
The provisional numbers show 45,855 deaths by suicide in the United States in 2020 – 3% lower than in 2019 (47,511), and 5% below the 2018 peak of 48,344 suicides, report Sally Curtin, MA, and colleagues with the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention.
The data were published online Nov. 3 in the National Vital Statistics System (NVSS) Vital Statistics Rapid Release.
On a monthly basis, the number of suicides was lower in 2020 than in 2019 in March through October and December – with the largest drop happening in April 2020 at a time when deaths from COVID-19 were peaking, the authors note. In April 2020, suicide deaths were 14% lower than in April 2019 (3,468 vs. 4,029).
The provisional age-adjusted suicide rate was 3% lower in 2020 (13.5 per 100,000) than in 2019 (13.9 per 100,000). It was 2% lower among men (21.9 compared with 22.4), and 8% lower for women (5.5 compared with 6.0).
Suicide rates among younger adults aged 10 to 34 years rose slightly between 2019 and 2020 but was only significant in those 25 to 34, with a 5% increase between 2019 and 2020.
Individuals aged 35 to 74 years had significant declines in suicide with the largest drop in those aged 45 to 54 years and 55 to 64 years.
Women in all race and Hispanic-origin groups showed declines in suicide rates between 2019 and 2020, but the decline was significant only among non-Hispanic white women (10%).
Suicide rates declined for non-Hispanic white and non-Hispanic Asian men but increased among non-Hispanic black, non-Hispanic American Indian or Alaska Native, and Hispanic men.
This analysis is based on more than 99% of expected death records. Based on previous patterns between provisional and final data, these provisional findings are expected to be consistent with final 2020 data, the authors say.
The study had no commercial funding. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FDA not recognizing efficacy of psychopharmacologic therapies
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
FROM PSYCHOPHARMACOLOGY UPDATE
Open notes: Big benefits, few harms in psychiatry, experts say
There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.
As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record.
“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.
“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.
The study was published online in PLOS ONE.
Empowering patients
Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.
The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.
There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.
There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.
The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.
Confirmatory findings
The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes.
Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.
However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.
“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. ,” she added.
“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.
“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”
Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.
As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record.
“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.
“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.
The study was published online in PLOS ONE.
Empowering patients
Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.
The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.
There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.
There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.
The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.
Confirmatory findings
The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes.
Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.
However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.
“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. ,” she added.
“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.
“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”
Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
There are multiple benefits and few harms from sharing clinical notes in patients with mental illness, results of a poll of international experts show.
As of April 5, 2021, new federal rules in the United States mandate that all patients are offered online access to their electronic health record.
“Given that sharing notes in psychiatry is likely to be more complicated than in some other specialties, we were unsure whether experts would consider the practice more harmful than beneficial,” Charlotte Blease, PhD, of Beth Israel Deaconess Medical Center in Boston, told this news organization.
“However, the results of our poll suggest clinicians’ anxieties about sharing mental health notes with patients may be misplaced. We found clear consensus among experts that the benefits of online access to clinical notes could outweigh the risks,” Dr. Blease said in a news release.
The study was published online in PLOS ONE.
Empowering patients
Investigators used an online Delphi poll, an established methodology used to investigate emerging health care policy – including in psychiatry – to solicit the views of an international panel of experts on the mental health effects of sharing clinical notes.
The panel included clinicians, chief medical information officers, patient advocates, and informatics experts with extensive experience and research knowledge about patient access to mental health notes.
There was consensus among the panel that offering online access to mental health notes could enhance patients’ understanding about their diagnosis, care plan, and rationale for treatments.
There was also consensus that access to clinical notes could enhance patient recall about what was communicated and improve mental health patients’ sense of control over their health care.
The panel also agreed that blocking mental health notes could lead to greater harms including increased feelings of stigmatization.
Confirmatory findings
The poll results support an earlier study by Dr. Blease and colleagues that evaluated the experiences of patients in accessing their online clinical notes.
Among these patients with major depressive disorder, schizophrenia, schizoaffective disorder, or bipolar-related disorder, “access helped to clarify why medications had been prescribed, improved understanding about side effects, and 20% of patients reported doing a better job taking their meds as prescribed,” said Dr. Blease.
However, the expert panel in the Delphi poll predicted that with “open notes” some patients might demand changes to their clinical notes, and that mental health clinicians might be less detailed/accurate in documenting negative aspects of the patient relationship, details about patients’ personalities, or symptoms of paranoia in patients.
“If some patients feel more judged or offended by what they read, this may undermine the therapeutic relationship. ,” she added.
“In some clinical cases where there is more focus on emergency care than in forming a therapeutic relationship, for example emergency department visits, we know almost nothing about the risks and benefits associated with OpenNotes,” senior author John Torous, MD, with Beth Israel Deaconess Medical Center and Harvard Medical School, said in an interview.
“One thing is clear,” Dr. Blease said. “Patient access to their online medical records is now mainstream, and we need more clinician education on how to write notes that patients will read, and more guidance among patients on the benefits and risks of accessing their notes.”
Support for this research was provided by a J. F. Keane Scholar Award and a Swedish Research Council on Health, Working Life, and Welfare grant. The authors have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Antidepressant may cut COVID-19–related hospitalization, mortality: TOGETHER
The antidepressant fluvoxamine (Luvox) may prevent hospitalization and death in outpatients with COVID-19, new research suggests.
Results from the placebo-controlled, multisite, phase 3 TOGETHER trial showed that in COVID-19 outpatients at high risk for complications, hospitalizations were cut by 66% and deaths were reduced by 91% in those who tolerated fluvoxamine.
“Our trial has found that fluvoxamine, an inexpensive existing drug, reduces the need for advanced disease care in this high-risk population,” wrote the investigators, led by Gilmar Reis, MD, PhD, research division, Cardresearch, Belo Horizonte, Brazil.
The findings were published online Oct. 27 in The Lancet Global Health.
Alternative mechanisms
Fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), is an antidepressant commonly prescribed for obsessive-compulsive disorder.
Besides its known effects on serotonin, the drug acts in other molecular pathways to dampen the production of inflammatory cytokines. Those alternative mechanisms are the ones believed to help patients with COVID-19, said coinvestigator Angela Reiersen, MD, child psychiatrist at Washington University, St. Louis.
Based on cell culture and mouse studies showing effects of the molecule’s binding to the sigma-1 receptor in the endoplasmic reticulum, Dr. Reiersen came up with the idea of testing if fluvoxamine could keep COVID-19 from progressing in newly infected patients.
Dr. Reiersen and psychiatrist Eric Lenze, MD, also from Washington University, led the phase 2 trial that initially suggested fluvoxamine’s promise as an outpatient medication. They are coinvestigators on the new phase 3 adaptive platform trial called TOGETHER, which was conducted by an international team of investigators in Brazil, Canada, and the United States.
For this latest study, researchers at McMaster University, Hamilton, Ont., partnered with the research clinic Cardresearch in Brazil to recruit unvaccinated, high-risk adults within 7 days of developing flu-like symptoms from COVID-19. They analyzed 1,497 newly symptomatic COVID-19 patients at 11 clinical sites in Brazil.
Patients entered the trial between January and August 2021 and were assigned to receive 100 mg fluvoxamine or placebo pills twice a day for 10 days. Investigators monitored participants through 28 days post treatment, noting whether complications developed requiring hospitalization or more than 6 hours of emergency care.
In the placebo group, 119 of 756 patients (15.7%) worsened to this extent. In comparison, 79 of 741 (10.7%) fluvoxamine-treated patients met these primary criteria. This represented a 32% reduction in hospitalizations and emergency visits.
Additional analysis requested
As Lancet Global Health reviewed these findings from the submitted manuscript, journal reviewers requested an additional “pre-protocol analysis” that was not specified in the trial’s original protocol. The request was to examine the subgroup of patients with good adherence (74% of treated group, 82% of placebo group).
Among these three quarters of patients who took at least 80% of their doses, benefits were better.
Fluvoxamine cut serious complications in this group by 66% and reduced mortality by 91%. In the placebo group, 12 people died compared with one who received the study drug.
from complications of the infection.
However, clinicians should note that the drug can cause side effects such as nausea, dizziness, and insomnia, she added. In addition, because it prevents the body from metabolizing caffeine, patients should limit their daily intake to half of a small cup of coffee or one can of soda or one tea while taking the drug.
Previous research has shown that fluvoxamine affects the metabolism of some drugs, such as theophylline, clozapine, olanzapine, and tizanidine.
Despite huge challenges with studying generic drugs as early COVID-19 treatment, the TOGETHER trial shows it is possible to produce quality evidence during a pandemic on a shoestring budget, noted co-principal investigator Edward Mills, PhD, professor in the department of health research methods, evidence, and impact at McMaster University.
To screen more than 12,000 patients and enroll 4,000 to test nine interventions, “our total budget was less than $8 million,” Dr. Mills said. The trial was funded by Fast Grants and the Rainwater Charitable Foundation.
‘A $10 medicine’
Commenting on the findings, David Boulware, MD, MPH, an infectious disease physician-researcher at the University of Minnesota in Minneapolis, noted fluvoxamine is “a $10 medicine that’s available and has a very good safety record.”
By comparison, a 5-day course of Merck’s antiviral molnupiravir, another oral drug that the company says can cut hospitalizations in COVID-19 outpatients, costs $700. However, the data have not been peer reviewed – and molnupiravir is not currently available and has unknown long-term safety implications, Dr. Boulware said.
Pharmaceutical companies typically spend tens of thousands of dollars on a trial evaluating a single drug, he noted.
In addition, the National Institutes of Health’s ACTIV-6 study, a nationwide trial on the effect of fluvoxamine and other repurposed generic drugs on thousands of COVID-19 outpatients, is a $110 million effort, according to Dr. Boulware, who cochairs its steering committee.
ACTIV-6 is currently enrolling outpatients with COVID-19 to test a lower dose of fluvoxamine, at 50 mg twice daily instead of the 100-mg dose used in the TOGETHER trial, as well as ivermectin and inhaled fluticasone. The COVID-OUT trial is also recruiting newly diagnosed COVID-19 patients to test various combinations of fluvoxamine, ivermectin, and the diabetes drug metformin.
Unanswered safety, efficacy questions
In an accompanying editorial in The Lancet Global Health, Otavio Berwanger, MD, cardiologist and clinical trialist, Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil, commends the investigators for rapidly generating evidence during the COVID-19 pandemic.
However, despite the important findings, “some questions related to efficacy and safety of fluvoxamine for patients with COVID-19 remain open,” Dr. Berwanger wrote.
The effects of the drug on reducing both mortality and hospitalizations also “still need addressing,” he noted.
“In addition, it remains to be established whether fluvoxamine has an additive effect to other therapies such as monoclonal antibodies and budesonide, and what is the optimal fluvoxamine therapeutic scheme,” wrote Dr. Berwanger.
In an interview, he noted that 74% of the Brazil population have currently received at least one dose of a COVID-19 vaccine and 52% have received two doses. In addition, deaths have gone down from 4,000 per day during the March-April second wave to about 400 per day. “That is still unfortunate and far from ideal,” he said. In total, they have had about 600,000 deaths because of COVID-19.
Asked whether public health authorities are now recommending fluvoxamine as an early treatment for COVID-19 based on the TOGETHER trial data, Dr. Berwanger answered, “Not yet.
“I believe medical and scientific societies will need to critically appraise the manuscript in order to inform their decisions and recommendations. This interesting trial adds another important piece of information in this regard,” he said.
Dr. Reiersen and Dr. Lenze are inventors on a patent application related to methods for treating COVID-19, which was filed by Washington University. Dr. Mills reports no relevant financial relationships, as does Dr. Boulware – except that the TOGETHER trial funders are also funding the University of Minnesota COVID-OUT trial. Dr. Berwanger reports having received research grants outside of the submitted work that were paid to his institution by AstraZeneca, Bayer, Amgen, Servier, Novartis, Pfizer, and Boehringer Ingelheim.
A version of this article first appeared on Medscape.com.
The antidepressant fluvoxamine (Luvox) may prevent hospitalization and death in outpatients with COVID-19, new research suggests.
Results from the placebo-controlled, multisite, phase 3 TOGETHER trial showed that in COVID-19 outpatients at high risk for complications, hospitalizations were cut by 66% and deaths were reduced by 91% in those who tolerated fluvoxamine.
“Our trial has found that fluvoxamine, an inexpensive existing drug, reduces the need for advanced disease care in this high-risk population,” wrote the investigators, led by Gilmar Reis, MD, PhD, research division, Cardresearch, Belo Horizonte, Brazil.
The findings were published online Oct. 27 in The Lancet Global Health.
Alternative mechanisms
Fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), is an antidepressant commonly prescribed for obsessive-compulsive disorder.
Besides its known effects on serotonin, the drug acts in other molecular pathways to dampen the production of inflammatory cytokines. Those alternative mechanisms are the ones believed to help patients with COVID-19, said coinvestigator Angela Reiersen, MD, child psychiatrist at Washington University, St. Louis.
Based on cell culture and mouse studies showing effects of the molecule’s binding to the sigma-1 receptor in the endoplasmic reticulum, Dr. Reiersen came up with the idea of testing if fluvoxamine could keep COVID-19 from progressing in newly infected patients.
Dr. Reiersen and psychiatrist Eric Lenze, MD, also from Washington University, led the phase 2 trial that initially suggested fluvoxamine’s promise as an outpatient medication. They are coinvestigators on the new phase 3 adaptive platform trial called TOGETHER, which was conducted by an international team of investigators in Brazil, Canada, and the United States.
For this latest study, researchers at McMaster University, Hamilton, Ont., partnered with the research clinic Cardresearch in Brazil to recruit unvaccinated, high-risk adults within 7 days of developing flu-like symptoms from COVID-19. They analyzed 1,497 newly symptomatic COVID-19 patients at 11 clinical sites in Brazil.
Patients entered the trial between January and August 2021 and were assigned to receive 100 mg fluvoxamine or placebo pills twice a day for 10 days. Investigators monitored participants through 28 days post treatment, noting whether complications developed requiring hospitalization or more than 6 hours of emergency care.
In the placebo group, 119 of 756 patients (15.7%) worsened to this extent. In comparison, 79 of 741 (10.7%) fluvoxamine-treated patients met these primary criteria. This represented a 32% reduction in hospitalizations and emergency visits.
Additional analysis requested
As Lancet Global Health reviewed these findings from the submitted manuscript, journal reviewers requested an additional “pre-protocol analysis” that was not specified in the trial’s original protocol. The request was to examine the subgroup of patients with good adherence (74% of treated group, 82% of placebo group).
Among these three quarters of patients who took at least 80% of their doses, benefits were better.
Fluvoxamine cut serious complications in this group by 66% and reduced mortality by 91%. In the placebo group, 12 people died compared with one who received the study drug.
from complications of the infection.
However, clinicians should note that the drug can cause side effects such as nausea, dizziness, and insomnia, she added. In addition, because it prevents the body from metabolizing caffeine, patients should limit their daily intake to half of a small cup of coffee or one can of soda or one tea while taking the drug.
Previous research has shown that fluvoxamine affects the metabolism of some drugs, such as theophylline, clozapine, olanzapine, and tizanidine.
Despite huge challenges with studying generic drugs as early COVID-19 treatment, the TOGETHER trial shows it is possible to produce quality evidence during a pandemic on a shoestring budget, noted co-principal investigator Edward Mills, PhD, professor in the department of health research methods, evidence, and impact at McMaster University.
To screen more than 12,000 patients and enroll 4,000 to test nine interventions, “our total budget was less than $8 million,” Dr. Mills said. The trial was funded by Fast Grants and the Rainwater Charitable Foundation.
‘A $10 medicine’
Commenting on the findings, David Boulware, MD, MPH, an infectious disease physician-researcher at the University of Minnesota in Minneapolis, noted fluvoxamine is “a $10 medicine that’s available and has a very good safety record.”
By comparison, a 5-day course of Merck’s antiviral molnupiravir, another oral drug that the company says can cut hospitalizations in COVID-19 outpatients, costs $700. However, the data have not been peer reviewed – and molnupiravir is not currently available and has unknown long-term safety implications, Dr. Boulware said.
Pharmaceutical companies typically spend tens of thousands of dollars on a trial evaluating a single drug, he noted.
In addition, the National Institutes of Health’s ACTIV-6 study, a nationwide trial on the effect of fluvoxamine and other repurposed generic drugs on thousands of COVID-19 outpatients, is a $110 million effort, according to Dr. Boulware, who cochairs its steering committee.
ACTIV-6 is currently enrolling outpatients with COVID-19 to test a lower dose of fluvoxamine, at 50 mg twice daily instead of the 100-mg dose used in the TOGETHER trial, as well as ivermectin and inhaled fluticasone. The COVID-OUT trial is also recruiting newly diagnosed COVID-19 patients to test various combinations of fluvoxamine, ivermectin, and the diabetes drug metformin.
Unanswered safety, efficacy questions
In an accompanying editorial in The Lancet Global Health, Otavio Berwanger, MD, cardiologist and clinical trialist, Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil, commends the investigators for rapidly generating evidence during the COVID-19 pandemic.
However, despite the important findings, “some questions related to efficacy and safety of fluvoxamine for patients with COVID-19 remain open,” Dr. Berwanger wrote.
The effects of the drug on reducing both mortality and hospitalizations also “still need addressing,” he noted.
“In addition, it remains to be established whether fluvoxamine has an additive effect to other therapies such as monoclonal antibodies and budesonide, and what is the optimal fluvoxamine therapeutic scheme,” wrote Dr. Berwanger.
In an interview, he noted that 74% of the Brazil population have currently received at least one dose of a COVID-19 vaccine and 52% have received two doses. In addition, deaths have gone down from 4,000 per day during the March-April second wave to about 400 per day. “That is still unfortunate and far from ideal,” he said. In total, they have had about 600,000 deaths because of COVID-19.
Asked whether public health authorities are now recommending fluvoxamine as an early treatment for COVID-19 based on the TOGETHER trial data, Dr. Berwanger answered, “Not yet.
“I believe medical and scientific societies will need to critically appraise the manuscript in order to inform their decisions and recommendations. This interesting trial adds another important piece of information in this regard,” he said.
Dr. Reiersen and Dr. Lenze are inventors on a patent application related to methods for treating COVID-19, which was filed by Washington University. Dr. Mills reports no relevant financial relationships, as does Dr. Boulware – except that the TOGETHER trial funders are also funding the University of Minnesota COVID-OUT trial. Dr. Berwanger reports having received research grants outside of the submitted work that were paid to his institution by AstraZeneca, Bayer, Amgen, Servier, Novartis, Pfizer, and Boehringer Ingelheim.
A version of this article first appeared on Medscape.com.
The antidepressant fluvoxamine (Luvox) may prevent hospitalization and death in outpatients with COVID-19, new research suggests.
Results from the placebo-controlled, multisite, phase 3 TOGETHER trial showed that in COVID-19 outpatients at high risk for complications, hospitalizations were cut by 66% and deaths were reduced by 91% in those who tolerated fluvoxamine.
“Our trial has found that fluvoxamine, an inexpensive existing drug, reduces the need for advanced disease care in this high-risk population,” wrote the investigators, led by Gilmar Reis, MD, PhD, research division, Cardresearch, Belo Horizonte, Brazil.
The findings were published online Oct. 27 in The Lancet Global Health.
Alternative mechanisms
Fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), is an antidepressant commonly prescribed for obsessive-compulsive disorder.
Besides its known effects on serotonin, the drug acts in other molecular pathways to dampen the production of inflammatory cytokines. Those alternative mechanisms are the ones believed to help patients with COVID-19, said coinvestigator Angela Reiersen, MD, child psychiatrist at Washington University, St. Louis.
Based on cell culture and mouse studies showing effects of the molecule’s binding to the sigma-1 receptor in the endoplasmic reticulum, Dr. Reiersen came up with the idea of testing if fluvoxamine could keep COVID-19 from progressing in newly infected patients.
Dr. Reiersen and psychiatrist Eric Lenze, MD, also from Washington University, led the phase 2 trial that initially suggested fluvoxamine’s promise as an outpatient medication. They are coinvestigators on the new phase 3 adaptive platform trial called TOGETHER, which was conducted by an international team of investigators in Brazil, Canada, and the United States.
For this latest study, researchers at McMaster University, Hamilton, Ont., partnered with the research clinic Cardresearch in Brazil to recruit unvaccinated, high-risk adults within 7 days of developing flu-like symptoms from COVID-19. They analyzed 1,497 newly symptomatic COVID-19 patients at 11 clinical sites in Brazil.
Patients entered the trial between January and August 2021 and were assigned to receive 100 mg fluvoxamine or placebo pills twice a day for 10 days. Investigators monitored participants through 28 days post treatment, noting whether complications developed requiring hospitalization or more than 6 hours of emergency care.
In the placebo group, 119 of 756 patients (15.7%) worsened to this extent. In comparison, 79 of 741 (10.7%) fluvoxamine-treated patients met these primary criteria. This represented a 32% reduction in hospitalizations and emergency visits.
Additional analysis requested
As Lancet Global Health reviewed these findings from the submitted manuscript, journal reviewers requested an additional “pre-protocol analysis” that was not specified in the trial’s original protocol. The request was to examine the subgroup of patients with good adherence (74% of treated group, 82% of placebo group).
Among these three quarters of patients who took at least 80% of their doses, benefits were better.
Fluvoxamine cut serious complications in this group by 66% and reduced mortality by 91%. In the placebo group, 12 people died compared with one who received the study drug.
from complications of the infection.
However, clinicians should note that the drug can cause side effects such as nausea, dizziness, and insomnia, she added. In addition, because it prevents the body from metabolizing caffeine, patients should limit their daily intake to half of a small cup of coffee or one can of soda or one tea while taking the drug.
Previous research has shown that fluvoxamine affects the metabolism of some drugs, such as theophylline, clozapine, olanzapine, and tizanidine.
Despite huge challenges with studying generic drugs as early COVID-19 treatment, the TOGETHER trial shows it is possible to produce quality evidence during a pandemic on a shoestring budget, noted co-principal investigator Edward Mills, PhD, professor in the department of health research methods, evidence, and impact at McMaster University.
To screen more than 12,000 patients and enroll 4,000 to test nine interventions, “our total budget was less than $8 million,” Dr. Mills said. The trial was funded by Fast Grants and the Rainwater Charitable Foundation.
‘A $10 medicine’
Commenting on the findings, David Boulware, MD, MPH, an infectious disease physician-researcher at the University of Minnesota in Minneapolis, noted fluvoxamine is “a $10 medicine that’s available and has a very good safety record.”
By comparison, a 5-day course of Merck’s antiviral molnupiravir, another oral drug that the company says can cut hospitalizations in COVID-19 outpatients, costs $700. However, the data have not been peer reviewed – and molnupiravir is not currently available and has unknown long-term safety implications, Dr. Boulware said.
Pharmaceutical companies typically spend tens of thousands of dollars on a trial evaluating a single drug, he noted.
In addition, the National Institutes of Health’s ACTIV-6 study, a nationwide trial on the effect of fluvoxamine and other repurposed generic drugs on thousands of COVID-19 outpatients, is a $110 million effort, according to Dr. Boulware, who cochairs its steering committee.
ACTIV-6 is currently enrolling outpatients with COVID-19 to test a lower dose of fluvoxamine, at 50 mg twice daily instead of the 100-mg dose used in the TOGETHER trial, as well as ivermectin and inhaled fluticasone. The COVID-OUT trial is also recruiting newly diagnosed COVID-19 patients to test various combinations of fluvoxamine, ivermectin, and the diabetes drug metformin.
Unanswered safety, efficacy questions
In an accompanying editorial in The Lancet Global Health, Otavio Berwanger, MD, cardiologist and clinical trialist, Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil, commends the investigators for rapidly generating evidence during the COVID-19 pandemic.
However, despite the important findings, “some questions related to efficacy and safety of fluvoxamine for patients with COVID-19 remain open,” Dr. Berwanger wrote.
The effects of the drug on reducing both mortality and hospitalizations also “still need addressing,” he noted.
“In addition, it remains to be established whether fluvoxamine has an additive effect to other therapies such as monoclonal antibodies and budesonide, and what is the optimal fluvoxamine therapeutic scheme,” wrote Dr. Berwanger.
In an interview, he noted that 74% of the Brazil population have currently received at least one dose of a COVID-19 vaccine and 52% have received two doses. In addition, deaths have gone down from 4,000 per day during the March-April second wave to about 400 per day. “That is still unfortunate and far from ideal,” he said. In total, they have had about 600,000 deaths because of COVID-19.
Asked whether public health authorities are now recommending fluvoxamine as an early treatment for COVID-19 based on the TOGETHER trial data, Dr. Berwanger answered, “Not yet.
“I believe medical and scientific societies will need to critically appraise the manuscript in order to inform their decisions and recommendations. This interesting trial adds another important piece of information in this regard,” he said.
Dr. Reiersen and Dr. Lenze are inventors on a patent application related to methods for treating COVID-19, which was filed by Washington University. Dr. Mills reports no relevant financial relationships, as does Dr. Boulware – except that the TOGETHER trial funders are also funding the University of Minnesota COVID-OUT trial. Dr. Berwanger reports having received research grants outside of the submitted work that were paid to his institution by AstraZeneca, Bayer, Amgen, Servier, Novartis, Pfizer, and Boehringer Ingelheim.
A version of this article first appeared on Medscape.com.
Chatbots can improve mental health in vulnerable populations
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
Cannabis use: Messages remain mixed across diagnoses
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
FROM PSYCHOPHARMACOLOGY UPDATE
Pandemic drives uptick in need for mental health services
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
But I am the therapist!
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
To meme or not to meme: The likability and ‘virability’ of memes
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.