Mental Health

A telehealth primary care visit more than doubled the well-visit show rate for a cohort of hard-to-reach adolescents, results of a small pilot study show.

Brian P. Jenssen, MD, MSHP, department of pediatrics, University of Pennsylvania, Philadelphia, led the pilot study and the project team, which included physicians, researchers, and experts in innovation, quality improvement, and data analytics.

Findings were published online in Annals of Family Medicine.

Keeping adolescents in consistent primary care can be challenging for many reasons. The study authors note, “Only 50% of adolescents have had a health supervision visit in the past year, missing a critical opportunity for clinicians to influence health, development, screening, and counseling.”

Interest high in hard-to-reach group

This study included a particularly hard-to-reach group of 18-year-old patients at an urban primary care clinic who were lost to follow-up and had Medicaid insurance. They had not completed a well visit in more than 2 years and had a history of no-show visits.

Interest in the pilot program was high. The authors write: “We contacted patients (or their caregivers) to gauge interest in a virtual well visit with a goal to fill five telehealth slots in one evening block with one clinician. Due to high patient interest and demand, we expanded to 15 slots over three evenings, filling the slots after contacting just 24 patients.”

Professional organizations have recommended a telehealth/in-person hybrid care model to meet hard-to-reach adolescents “wherever they are,” the authors note, but the concept has not been well studied.

Under the hybrid model, the first visit is through telehealth and in-person follow-up is scheduled as needed.

Navigators contacted patients to remind them of the appointment, and helped activate the patient portal and complete previsit screening questions for depression and other health risks.

Telehealth visits were billed as preventive visits and in-person follow-up visits as no-charge nurse visits, and these payments were supported by Medicaid.
 

Sharp increase in show rate

In the pilot study, of the 15 patients scheduled for the telehealth visit, 11 connected virtually (73% show rate). Of those, nine needed in-person follow-up, and five completed the follow-up.

Before the intervention, the average well-visit show rate for this patient group was 33%.

Clinicians counseled all the patients about substance use and safe sex. One patient screened positive for depression and was then connected to services. Two patients were started on birth control.

During the in-person follow-up, all patients received vaccinations (influenza, meningococcal, and/or COVID-19) and were screened for sexually transmitted infection. Eight patients completed the satisfaction survey and all said they liked the convenience of the telehealth visit.
 

Telehealth may reduce barriers for teens

Anthony Cheng, MD, a family medicine physician at Oregon Health & Science University in Portland, who was not part of the study, said he found the hybrid model promising.

One reason is that telehealth eliminates the need for transportation to medical appointments, which can be a barrier for adolescents.

Among the top causes of death for young people are mental health issues and addressing those, Dr. Cheng noted, is well-suited to a telehealth visit.

“There’s so much we can do if we can establish a relationship and maintain a relationship with our patients as young adults,” he said. “People do better when they have a regular source of care.”

He added that adolescents also have grown up communicating via screens so it’s often more comfortable for them to communicate with health care providers this way.

Dr. Cheng said adopting such a model may be difficult for providers reluctant to switch from the practice model with which they are most comfortable.

“We prefer to do things we have the most confidence in,” he said. “It does take an investment to train staff and build your own clinical comfort. If that experience wasn’t good over the past 3 years, you may be anxious to get back to your normal way of doing business.”

The authors and Dr. Cheng have no relevant financial relationships to disclose.

A telehealth primary care visit more than doubled the well-visit show rate for a cohort of hard-to-reach adolescents, results of a small pilot study show.

Brian P. Jenssen, MD, MSHP, department of pediatrics, University of Pennsylvania, Philadelphia, led the pilot study and the project team, which included physicians, researchers, and experts in innovation, quality improvement, and data analytics.

Findings were published online in Annals of Family Medicine.

Keeping adolescents in consistent primary care can be challenging for many reasons. The study authors note, “Only 50% of adolescents have had a health supervision visit in the past year, missing a critical opportunity for clinicians to influence health, development, screening, and counseling.”

Interest high in hard-to-reach group

This study included a particularly hard-to-reach group of 18-year-old patients at an urban primary care clinic who were lost to follow-up and had Medicaid insurance. They had not completed a well visit in more than 2 years and had a history of no-show visits.

Interest in the pilot program was high. The authors write: “We contacted patients (or their caregivers) to gauge interest in a virtual well visit with a goal to fill five telehealth slots in one evening block with one clinician. Due to high patient interest and demand, we expanded to 15 slots over three evenings, filling the slots after contacting just 24 patients.”

Professional organizations have recommended a telehealth/in-person hybrid care model to meet hard-to-reach adolescents “wherever they are,” the authors note, but the concept has not been well studied.

Under the hybrid model, the first visit is through telehealth and in-person follow-up is scheduled as needed.

Navigators contacted patients to remind them of the appointment, and helped activate the patient portal and complete previsit screening questions for depression and other health risks.

Telehealth visits were billed as preventive visits and in-person follow-up visits as no-charge nurse visits, and these payments were supported by Medicaid.
 

Sharp increase in show rate

In the pilot study, of the 15 patients scheduled for the telehealth visit, 11 connected virtually (73% show rate). Of those, nine needed in-person follow-up, and five completed the follow-up.

Before the intervention, the average well-visit show rate for this patient group was 33%.

Clinicians counseled all the patients about substance use and safe sex. One patient screened positive for depression and was then connected to services. Two patients were started on birth control.

During the in-person follow-up, all patients received vaccinations (influenza, meningococcal, and/or COVID-19) and were screened for sexually transmitted infection. Eight patients completed the satisfaction survey and all said they liked the convenience of the telehealth visit.
 

Telehealth may reduce barriers for teens

Anthony Cheng, MD, a family medicine physician at Oregon Health & Science University in Portland, who was not part of the study, said he found the hybrid model promising.

One reason is that telehealth eliminates the need for transportation to medical appointments, which can be a barrier for adolescents.

Among the top causes of death for young people are mental health issues and addressing those, Dr. Cheng noted, is well-suited to a telehealth visit.

“There’s so much we can do if we can establish a relationship and maintain a relationship with our patients as young adults,” he said. “People do better when they have a regular source of care.”

He added that adolescents also have grown up communicating via screens so it’s often more comfortable for them to communicate with health care providers this way.

Dr. Cheng said adopting such a model may be difficult for providers reluctant to switch from the practice model with which they are most comfortable.

“We prefer to do things we have the most confidence in,” he said. “It does take an investment to train staff and build your own clinical comfort. If that experience wasn’t good over the past 3 years, you may be anxious to get back to your normal way of doing business.”

The authors and Dr. Cheng have no relevant financial relationships to disclose.

A telehealth primary care visit more than doubled the well-visit show rate for a cohort of hard-to-reach adolescents, results of a small pilot study show.

Brian P. Jenssen, MD, MSHP, department of pediatrics, University of Pennsylvania, Philadelphia, led the pilot study and the project team, which included physicians, researchers, and experts in innovation, quality improvement, and data analytics.

Findings were published online in Annals of Family Medicine.

Keeping adolescents in consistent primary care can be challenging for many reasons. The study authors note, “Only 50% of adolescents have had a health supervision visit in the past year, missing a critical opportunity for clinicians to influence health, development, screening, and counseling.”

Interest high in hard-to-reach group

This study included a particularly hard-to-reach group of 18-year-old patients at an urban primary care clinic who were lost to follow-up and had Medicaid insurance. They had not completed a well visit in more than 2 years and had a history of no-show visits.

Interest in the pilot program was high. The authors write: “We contacted patients (or their caregivers) to gauge interest in a virtual well visit with a goal to fill five telehealth slots in one evening block with one clinician. Due to high patient interest and demand, we expanded to 15 slots over three evenings, filling the slots after contacting just 24 patients.”

Professional organizations have recommended a telehealth/in-person hybrid care model to meet hard-to-reach adolescents “wherever they are,” the authors note, but the concept has not been well studied.

Under the hybrid model, the first visit is through telehealth and in-person follow-up is scheduled as needed.

Navigators contacted patients to remind them of the appointment, and helped activate the patient portal and complete previsit screening questions for depression and other health risks.

Telehealth visits were billed as preventive visits and in-person follow-up visits as no-charge nurse visits, and these payments were supported by Medicaid.
 

Sharp increase in show rate

In the pilot study, of the 15 patients scheduled for the telehealth visit, 11 connected virtually (73% show rate). Of those, nine needed in-person follow-up, and five completed the follow-up.

Before the intervention, the average well-visit show rate for this patient group was 33%.

Clinicians counseled all the patients about substance use and safe sex. One patient screened positive for depression and was then connected to services. Two patients were started on birth control.

During the in-person follow-up, all patients received vaccinations (influenza, meningococcal, and/or COVID-19) and were screened for sexually transmitted infection. Eight patients completed the satisfaction survey and all said they liked the convenience of the telehealth visit.
 

Telehealth may reduce barriers for teens

Anthony Cheng, MD, a family medicine physician at Oregon Health & Science University in Portland, who was not part of the study, said he found the hybrid model promising.

One reason is that telehealth eliminates the need for transportation to medical appointments, which can be a barrier for adolescents.

Among the top causes of death for young people are mental health issues and addressing those, Dr. Cheng noted, is well-suited to a telehealth visit.

“There’s so much we can do if we can establish a relationship and maintain a relationship with our patients as young adults,” he said. “People do better when they have a regular source of care.”

He added that adolescents also have grown up communicating via screens so it’s often more comfortable for them to communicate with health care providers this way.

Dr. Cheng said adopting such a model may be difficult for providers reluctant to switch from the practice model with which they are most comfortable.

“We prefer to do things we have the most confidence in,” he said. “It does take an investment to train staff and build your own clinical comfort. If that experience wasn’t good over the past 3 years, you may be anxious to get back to your normal way of doing business.”

The authors and Dr. Cheng have no relevant financial relationships to disclose.

More than 3 decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Dr. Sarno, a rehabilitation medicine specialist in New York, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Dr. Sarno attributed the pain to what he called tension myoneural syndrome (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Dr. Sarno believed, would lead to an improvement in pain.
 

Dr. Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefited from his strategies fill the Internet. Dr. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation coauthored by Ira Rashbaum, MD.

This news organization spoke recently with Dr. Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York, about TMS and how he manages patients with chronic pain. The interview has been edited for length and clarity.

What is your theory of back pain?

Dr. Rashbaum: My null hypothesis is that back pain is not due to psychological issues, so as to not be a biased doctor, I try to accept the null hypothesis or reject the null hypothesis. In most cases chronic back pain is not due to structural etiology. My sense is it’s a mind-body issue – the avoidance of feeling strong emotions like anger, rage, sadness, fear, shame, and guilt. Patients can embrace psychoeducational programs and if they don’t get better, we work with a psychotherapist or a licensed mental health counselor to help work through the patient’s feelings. That’s my experience over a number of years.

How do you determine if a patient has back pain from a mind-body issue or another cause?

Dr. Rashbaum: I do a very careful medical history, including a physical examination and review of any diagnostic studies they’ve undergone. In most situations, there’s not really a medical cause of the back pain. For instance, a lot of asymptomatic individuals have all sorts of horrible findings on medical imaging like CTs and MRIs, and the reverse is also true – many people with negative findings on imaging tests experience significant pain. My job as a diagnostician is to see how much of this is really a mind-body problem or something that stems from structural pathology.

How well do your patients react to being told that their back pain is, in a way, “in their head?”

Dr. Rashbaum: I have a skewed population. I’m sort of like a guru in mind-body back pain, so the people who come to me are already thinking along those lines. I ask: “What’s going on in your life?” Maybe there are job issues, marital issues, health issues, and I’d say that it’s certainly possible that stress can be causing this back pain.

Sometimes when I see a patient referred from another physician, I’m a bit hesitant to ask about what’s going on in their life. Even earlier today, I’d seen a patient with back pain and I had a sense that they were not really going to be open to a mind-body approach. So I said, do physical therapy.

What do you recommend primary care clinicians do with patients with back pain?

Dr. Rashbaum: You have to do a proper neurologic examination and musculoskeletal examination. It’s a tough situation because doctors in primary care have limited time to take care of patients. It’s difficult to have a deeper dive just to kind of see what’s going on in their life. But you can recommend useful agents like acetaminophen and muscle relaxants, which are sometimes okay.

What sorts of things do you tell patients to say to themselves when they’re experiencing pain? 

Dr. Rashbaum: If the pain is severe, I recommend they take medication – over-the-counter analgesics or a muscle relaxant, if they have them – and take a warm shower or bath. I prefer acetaminophen up to three times per day, if that’s okay with the patient’s primary care physician, over NSAIDs because most pain is noninflammatory in nature. Once the pain is more manageable, patients should journal about what’s going on in their lives and/or meditate, and try to feel any strong emotions, such as anger, sadness, or fear.

What do you say to clinicians who are dismissive of the notion that chronic pain may stem from emotional repression, and that addressing the latter can resolve the former – particularly those who point to a lack of peer-reviewed data for such a link?

Dr. Rashbaum: I would tell them they could be looking harder for that evidence. For example, in a patient page from JAMA from April 24, 2013, on low back pain, often the cause of back pain is unknown. There are data in spine surgical journals that patients with psychological issues do worse with spine surgery. And in 2016 JAMA published a study from Cherkin and colleagues, which found that, among adults with chronic low back pain, treatment with mindfulness-based stress reduction or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations at 26 weeks, compared with usual care.

My feeling is that these psychosocial interventions are easy to try, relatively inexpensive, noninvasive, and, in my experience, often can lead to marked improvements. I believe that, for the vast majority of people with chronic pain, it makes much more sense to start by addressing mind-body issues than turning to that approach as a last resort.

Dr. Rashbaum reported no relevant financial relationships.

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

More than 3 decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Dr. Sarno, a rehabilitation medicine specialist in New York, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Dr. Sarno attributed the pain to what he called tension myoneural syndrome (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Dr. Sarno believed, would lead to an improvement in pain.
 

Dr. Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefited from his strategies fill the Internet. Dr. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation coauthored by Ira Rashbaum, MD.

This news organization spoke recently with Dr. Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York, about TMS and how he manages patients with chronic pain. The interview has been edited for length and clarity.

What is your theory of back pain?

Dr. Rashbaum: My null hypothesis is that back pain is not due to psychological issues, so as to not be a biased doctor, I try to accept the null hypothesis or reject the null hypothesis. In most cases chronic back pain is not due to structural etiology. My sense is it’s a mind-body issue – the avoidance of feeling strong emotions like anger, rage, sadness, fear, shame, and guilt. Patients can embrace psychoeducational programs and if they don’t get better, we work with a psychotherapist or a licensed mental health counselor to help work through the patient’s feelings. That’s my experience over a number of years.

How do you determine if a patient has back pain from a mind-body issue or another cause?

Dr. Rashbaum: I do a very careful medical history, including a physical examination and review of any diagnostic studies they’ve undergone. In most situations, there’s not really a medical cause of the back pain. For instance, a lot of asymptomatic individuals have all sorts of horrible findings on medical imaging like CTs and MRIs, and the reverse is also true – many people with negative findings on imaging tests experience significant pain. My job as a diagnostician is to see how much of this is really a mind-body problem or something that stems from structural pathology.

How well do your patients react to being told that their back pain is, in a way, “in their head?”

Dr. Rashbaum: I have a skewed population. I’m sort of like a guru in mind-body back pain, so the people who come to me are already thinking along those lines. I ask: “What’s going on in your life?” Maybe there are job issues, marital issues, health issues, and I’d say that it’s certainly possible that stress can be causing this back pain.

Sometimes when I see a patient referred from another physician, I’m a bit hesitant to ask about what’s going on in their life. Even earlier today, I’d seen a patient with back pain and I had a sense that they were not really going to be open to a mind-body approach. So I said, do physical therapy.

What do you recommend primary care clinicians do with patients with back pain?

Dr. Rashbaum: You have to do a proper neurologic examination and musculoskeletal examination. It’s a tough situation because doctors in primary care have limited time to take care of patients. It’s difficult to have a deeper dive just to kind of see what’s going on in their life. But you can recommend useful agents like acetaminophen and muscle relaxants, which are sometimes okay.

What sorts of things do you tell patients to say to themselves when they’re experiencing pain? 

Dr. Rashbaum: If the pain is severe, I recommend they take medication – over-the-counter analgesics or a muscle relaxant, if they have them – and take a warm shower or bath. I prefer acetaminophen up to three times per day, if that’s okay with the patient’s primary care physician, over NSAIDs because most pain is noninflammatory in nature. Once the pain is more manageable, patients should journal about what’s going on in their lives and/or meditate, and try to feel any strong emotions, such as anger, sadness, or fear.

What do you say to clinicians who are dismissive of the notion that chronic pain may stem from emotional repression, and that addressing the latter can resolve the former – particularly those who point to a lack of peer-reviewed data for such a link?

Dr. Rashbaum: I would tell them they could be looking harder for that evidence. For example, in a patient page from JAMA from April 24, 2013, on low back pain, often the cause of back pain is unknown. There are data in spine surgical journals that patients with psychological issues do worse with spine surgery. And in 2016 JAMA published a study from Cherkin and colleagues, which found that, among adults with chronic low back pain, treatment with mindfulness-based stress reduction or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations at 26 weeks, compared with usual care.

My feeling is that these psychosocial interventions are easy to try, relatively inexpensive, noninvasive, and, in my experience, often can lead to marked improvements. I believe that, for the vast majority of people with chronic pain, it makes much more sense to start by addressing mind-body issues than turning to that approach as a last resort.

Dr. Rashbaum reported no relevant financial relationships.

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

More than 3 decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Dr. Sarno, a rehabilitation medicine specialist in New York, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Dr. Sarno attributed the pain to what he called tension myoneural syndrome (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Dr. Sarno believed, would lead to an improvement in pain.
 

Dr. Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefited from his strategies fill the Internet. Dr. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation coauthored by Ira Rashbaum, MD.

This news organization spoke recently with Dr. Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York, about TMS and how he manages patients with chronic pain. The interview has been edited for length and clarity.

What is your theory of back pain?

Dr. Rashbaum: My null hypothesis is that back pain is not due to psychological issues, so as to not be a biased doctor, I try to accept the null hypothesis or reject the null hypothesis. In most cases chronic back pain is not due to structural etiology. My sense is it’s a mind-body issue – the avoidance of feeling strong emotions like anger, rage, sadness, fear, shame, and guilt. Patients can embrace psychoeducational programs and if they don’t get better, we work with a psychotherapist or a licensed mental health counselor to help work through the patient’s feelings. That’s my experience over a number of years.

How do you determine if a patient has back pain from a mind-body issue or another cause?

Dr. Rashbaum: I do a very careful medical history, including a physical examination and review of any diagnostic studies they’ve undergone. In most situations, there’s not really a medical cause of the back pain. For instance, a lot of asymptomatic individuals have all sorts of horrible findings on medical imaging like CTs and MRIs, and the reverse is also true – many people with negative findings on imaging tests experience significant pain. My job as a diagnostician is to see how much of this is really a mind-body problem or something that stems from structural pathology.

How well do your patients react to being told that their back pain is, in a way, “in their head?”

Dr. Rashbaum: I have a skewed population. I’m sort of like a guru in mind-body back pain, so the people who come to me are already thinking along those lines. I ask: “What’s going on in your life?” Maybe there are job issues, marital issues, health issues, and I’d say that it’s certainly possible that stress can be causing this back pain.

Sometimes when I see a patient referred from another physician, I’m a bit hesitant to ask about what’s going on in their life. Even earlier today, I’d seen a patient with back pain and I had a sense that they were not really going to be open to a mind-body approach. So I said, do physical therapy.

What do you recommend primary care clinicians do with patients with back pain?

Dr. Rashbaum: You have to do a proper neurologic examination and musculoskeletal examination. It’s a tough situation because doctors in primary care have limited time to take care of patients. It’s difficult to have a deeper dive just to kind of see what’s going on in their life. But you can recommend useful agents like acetaminophen and muscle relaxants, which are sometimes okay.

What sorts of things do you tell patients to say to themselves when they’re experiencing pain? 

Dr. Rashbaum: If the pain is severe, I recommend they take medication – over-the-counter analgesics or a muscle relaxant, if they have them – and take a warm shower or bath. I prefer acetaminophen up to three times per day, if that’s okay with the patient’s primary care physician, over NSAIDs because most pain is noninflammatory in nature. Once the pain is more manageable, patients should journal about what’s going on in their lives and/or meditate, and try to feel any strong emotions, such as anger, sadness, or fear.

What do you say to clinicians who are dismissive of the notion that chronic pain may stem from emotional repression, and that addressing the latter can resolve the former – particularly those who point to a lack of peer-reviewed data for such a link?

Dr. Rashbaum: I would tell them they could be looking harder for that evidence. For example, in a patient page from JAMA from April 24, 2013, on low back pain, often the cause of back pain is unknown. There are data in spine surgical journals that patients with psychological issues do worse with spine surgery. And in 2016 JAMA published a study from Cherkin and colleagues, which found that, among adults with chronic low back pain, treatment with mindfulness-based stress reduction or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations at 26 weeks, compared with usual care.

My feeling is that these psychosocial interventions are easy to try, relatively inexpensive, noninvasive, and, in my experience, often can lead to marked improvements. I believe that, for the vast majority of people with chronic pain, it makes much more sense to start by addressing mind-body issues than turning to that approach as a last resort.

Dr. Rashbaum reported no relevant financial relationships.

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

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Postpartum depression (PPD) remains the most common complication in modern obstetrics, and a leading cause of postpartum mortality in the first year of life. The last 15 years have brought considerable progress with respect to adoption of systematic screening for PPD across America. Screening for PPD, most often using the Edinburgh Postnatal Depression Scale (EPDS), has become part of routine obstetrical care, and is also widely used in pediatric settings.

That is the good news. But the flip side of the identification of those women whose scores on the EPDS suggest significant depressive symptoms is that the number of these patients who, following identification, receive referrals for adequate treatment that gets them well is unfortunately low. This “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression (Cox E. et al. J Clin Psychiatry. 2016 Sep;77[9]:1189-1200). This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well with the available treatments at hand?

Recently, a widely read and circulated article was published in The Wall Street Journal about the challenges associated with navigating care resources for women suffering from PPD. In that article, it was made clear, based on clinical vignette after clinical vignette from postpartum women across America, that neither obstetricians, mental health professionals, nor pediatricians are the “clinical home” for women suffering from postpartum mood and anxiety disorders. The article painfully highlights the system-wide failure to coordinate mental health care for women suffering from postpartum psychiatric illness.

Within a day of the publication of The Wall Street Journal article, the Food and Drug Administration approved zuranolone (Zurzuvae; Sage Therapeutics; Cambridge, Mass.) for the treatment of PPD following the review of two studies demonstrating the superiority of the new medicine over placebo. Women who were enrolled met criteria for major depressive disorder based on Diagnostic and Statistical Manual of Mental Disorders criteria beginning in no earlier than the third trimester of pregnancy or later than 4 weeks of delivery. The two studies included a combined sample size of approximately 350 patients suffering from severe PPD. In the studies, women received either 50 mg or 40 mg of zuranolone, or placebo for 14 days. Treatment was associated with a significant change in the Hamilton Depression Rating Scale at day 15, and treatment response was maintained at day 42, which was 4 weeks after the last dose of study medication.

Zuranolone is a neuroactive steroid, which is taken orally, unlike brexanolone (Zulresso; Sage Therapeutics; Cambridge, Mass.), which requires intravenous administration. Zuranolone will be commercially available based on estimates around the fourth quarter of 2023. The most common side effects are drowsiness, dizziness, and sedation, and the FDA label will have a boxed warning about zuranolone’s potential to impact a person’s driving ability, and performance of potentially hazardous activities.

It is noteworthy that while this new medication received FDA approval for the PPD indication, it did not receive FDA approval for the treatment of major depressive disorder (MDD), and the agency issued a Complete Response Letter to the manufacturers noting their application did not provide substantial evidence of effectiveness in MDD. The FDA said in the Complete Response Letter that an additional study or studies will be needed; the manufacturers are currently evaluating next steps.
 

Where zuranolone fits into the treatment algorithm for severe PPD

Many clinicians who support women with PPD will wonder, upon hearing this news, where zuranolone fits into the treatment algorithm for severe postpartum major depression. Some relevant issues that may determine the answer are the following:

Cost. The cost of brexanolone was substantial, at $34,000 per year, and was viewed by some as a limiting factor in terms of its very limited uptake. As of this column’s publication, zuranolone’s manufacturer has not stated how much the medication will cost.

Breastfeeding. Unlike selective serotonin reuptake inhibitors, which have been demonstrated to be effective for the treatment of PPD and safe during pregnancy and lactation, we have sparse data on the safety of zuranolone for women who wish to breastfeed. It is also unclear whether women eligible for zuranolone would, based on the limited data on safety in lactation, choose deferral of breastfeeding for 14 days in exchange for treatment.

Duration of treatment. While zuranolone was studied in the context of 14 days of acute treatment, then out to day 42, we have no published data on what happens on the other side of this brief interval. As a simple example, in a patient with a history of recurrent major depression previously treated with antidepressants, but where antidepressants were perhaps deferred during pregnancy, is PPD to be treated with zuranolone for 14 days? Or, hypothetically, should it be followed by empiric antidepressant treatment at day 14? Alternatively, are patient and clinician supposed to wait until recurrence occurs before pursuing adjunctive antidepressant therapy whether it is pharmacologic, nonpharmacologic, or both?

Treatment in patients with bipolar disorder. It is also unclear whether treatment with zuranolone applies to other populations of postpartum women. Certainly, for women with bipolar depression, which is common in postpartum women given the vulnerability of bipolar women to new onset of depression or postpartum depressive relapse of underlying disorder, we simply have no data regarding where zuranolone might fit in with respect to this group of patients.

The answers to these questions may help to determine whether zuranolone, a new antidepressant with efficacy, quick time to onset, and a novel mechanism of action is a “game changer.” The article in The Wall Street Journal provided me with some optimism, as it gave PPD and the issues surrounding PPD the attention it deserves in a major periodical. As a new treatment, it may help alleviate suffering at a critical time for patients and their families. We are inching closer to mitigation of stigma associated with this common illness.

Thinking back across the last 3 decades of my treating women suffering from PPD, I have reflected on what has gotten these patients well. I concluded that successful treatment of PPD is not a “one-stop shop,” but rather typically includes a combination of pharmacologic and nonpharmacologic interventions, along with family and community-based support groups, as well as a culture that reduces stigma and by so doing lessens the toll of this important and too frequently incompletely-treated illness.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. The Center for Women’s Mental Health at MGH was a non-enrolling site for the pivotal phase 3 SKYLARK trial evaluating zuranolone. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

Postpartum depression (PPD) remains the most common complication in modern obstetrics, and a leading cause of postpartum mortality in the first year of life. The last 15 years have brought considerable progress with respect to adoption of systematic screening for PPD across America. Screening for PPD, most often using the Edinburgh Postnatal Depression Scale (EPDS), has become part of routine obstetrical care, and is also widely used in pediatric settings.

That is the good news. But the flip side of the identification of those women whose scores on the EPDS suggest significant depressive symptoms is that the number of these patients who, following identification, receive referrals for adequate treatment that gets them well is unfortunately low. This “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression (Cox E. et al. J Clin Psychiatry. 2016 Sep;77[9]:1189-1200). This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well with the available treatments at hand?

Recently, a widely read and circulated article was published in The Wall Street Journal about the challenges associated with navigating care resources for women suffering from PPD. In that article, it was made clear, based on clinical vignette after clinical vignette from postpartum women across America, that neither obstetricians, mental health professionals, nor pediatricians are the “clinical home” for women suffering from postpartum mood and anxiety disorders. The article painfully highlights the system-wide failure to coordinate mental health care for women suffering from postpartum psychiatric illness.

Within a day of the publication of The Wall Street Journal article, the Food and Drug Administration approved zuranolone (Zurzuvae; Sage Therapeutics; Cambridge, Mass.) for the treatment of PPD following the review of two studies demonstrating the superiority of the new medicine over placebo. Women who were enrolled met criteria for major depressive disorder based on Diagnostic and Statistical Manual of Mental Disorders criteria beginning in no earlier than the third trimester of pregnancy or later than 4 weeks of delivery. The two studies included a combined sample size of approximately 350 patients suffering from severe PPD. In the studies, women received either 50 mg or 40 mg of zuranolone, or placebo for 14 days. Treatment was associated with a significant change in the Hamilton Depression Rating Scale at day 15, and treatment response was maintained at day 42, which was 4 weeks after the last dose of study medication.

Zuranolone is a neuroactive steroid, which is taken orally, unlike brexanolone (Zulresso; Sage Therapeutics; Cambridge, Mass.), which requires intravenous administration. Zuranolone will be commercially available based on estimates around the fourth quarter of 2023. The most common side effects are drowsiness, dizziness, and sedation, and the FDA label will have a boxed warning about zuranolone’s potential to impact a person’s driving ability, and performance of potentially hazardous activities.

It is noteworthy that while this new medication received FDA approval for the PPD indication, it did not receive FDA approval for the treatment of major depressive disorder (MDD), and the agency issued a Complete Response Letter to the manufacturers noting their application did not provide substantial evidence of effectiveness in MDD. The FDA said in the Complete Response Letter that an additional study or studies will be needed; the manufacturers are currently evaluating next steps.
 

Where zuranolone fits into the treatment algorithm for severe PPD

Many clinicians who support women with PPD will wonder, upon hearing this news, where zuranolone fits into the treatment algorithm for severe postpartum major depression. Some relevant issues that may determine the answer are the following:

Cost. The cost of brexanolone was substantial, at $34,000 per year, and was viewed by some as a limiting factor in terms of its very limited uptake. As of this column’s publication, zuranolone’s manufacturer has not stated how much the medication will cost.

Breastfeeding. Unlike selective serotonin reuptake inhibitors, which have been demonstrated to be effective for the treatment of PPD and safe during pregnancy and lactation, we have sparse data on the safety of zuranolone for women who wish to breastfeed. It is also unclear whether women eligible for zuranolone would, based on the limited data on safety in lactation, choose deferral of breastfeeding for 14 days in exchange for treatment.

Duration of treatment. While zuranolone was studied in the context of 14 days of acute treatment, then out to day 42, we have no published data on what happens on the other side of this brief interval. As a simple example, in a patient with a history of recurrent major depression previously treated with antidepressants, but where antidepressants were perhaps deferred during pregnancy, is PPD to be treated with zuranolone for 14 days? Or, hypothetically, should it be followed by empiric antidepressant treatment at day 14? Alternatively, are patient and clinician supposed to wait until recurrence occurs before pursuing adjunctive antidepressant therapy whether it is pharmacologic, nonpharmacologic, or both?

Treatment in patients with bipolar disorder. It is also unclear whether treatment with zuranolone applies to other populations of postpartum women. Certainly, for women with bipolar depression, which is common in postpartum women given the vulnerability of bipolar women to new onset of depression or postpartum depressive relapse of underlying disorder, we simply have no data regarding where zuranolone might fit in with respect to this group of patients.

The answers to these questions may help to determine whether zuranolone, a new antidepressant with efficacy, quick time to onset, and a novel mechanism of action is a “game changer.” The article in The Wall Street Journal provided me with some optimism, as it gave PPD and the issues surrounding PPD the attention it deserves in a major periodical. As a new treatment, it may help alleviate suffering at a critical time for patients and their families. We are inching closer to mitigation of stigma associated with this common illness.

Thinking back across the last 3 decades of my treating women suffering from PPD, I have reflected on what has gotten these patients well. I concluded that successful treatment of PPD is not a “one-stop shop,” but rather typically includes a combination of pharmacologic and nonpharmacologic interventions, along with family and community-based support groups, as well as a culture that reduces stigma and by so doing lessens the toll of this important and too frequently incompletely-treated illness.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. The Center for Women’s Mental Health at MGH was a non-enrolling site for the pivotal phase 3 SKYLARK trial evaluating zuranolone. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

Postpartum depression (PPD) remains the most common complication in modern obstetrics, and a leading cause of postpartum mortality in the first year of life. The last 15 years have brought considerable progress with respect to adoption of systematic screening for PPD across America. Screening for PPD, most often using the Edinburgh Postnatal Depression Scale (EPDS), has become part of routine obstetrical care, and is also widely used in pediatric settings.

That is the good news. But the flip side of the identification of those women whose scores on the EPDS suggest significant depressive symptoms is that the number of these patients who, following identification, receive referrals for adequate treatment that gets them well is unfortunately low. This “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression (Cox E. et al. J Clin Psychiatry. 2016 Sep;77[9]:1189-1200). This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well with the available treatments at hand?

Recently, a widely read and circulated article was published in The Wall Street Journal about the challenges associated with navigating care resources for women suffering from PPD. In that article, it was made clear, based on clinical vignette after clinical vignette from postpartum women across America, that neither obstetricians, mental health professionals, nor pediatricians are the “clinical home” for women suffering from postpartum mood and anxiety disorders. The article painfully highlights the system-wide failure to coordinate mental health care for women suffering from postpartum psychiatric illness.

Within a day of the publication of The Wall Street Journal article, the Food and Drug Administration approved zuranolone (Zurzuvae; Sage Therapeutics; Cambridge, Mass.) for the treatment of PPD following the review of two studies demonstrating the superiority of the new medicine over placebo. Women who were enrolled met criteria for major depressive disorder based on Diagnostic and Statistical Manual of Mental Disorders criteria beginning in no earlier than the third trimester of pregnancy or later than 4 weeks of delivery. The two studies included a combined sample size of approximately 350 patients suffering from severe PPD. In the studies, women received either 50 mg or 40 mg of zuranolone, or placebo for 14 days. Treatment was associated with a significant change in the Hamilton Depression Rating Scale at day 15, and treatment response was maintained at day 42, which was 4 weeks after the last dose of study medication.

Zuranolone is a neuroactive steroid, which is taken orally, unlike brexanolone (Zulresso; Sage Therapeutics; Cambridge, Mass.), which requires intravenous administration. Zuranolone will be commercially available based on estimates around the fourth quarter of 2023. The most common side effects are drowsiness, dizziness, and sedation, and the FDA label will have a boxed warning about zuranolone’s potential to impact a person’s driving ability, and performance of potentially hazardous activities.

It is noteworthy that while this new medication received FDA approval for the PPD indication, it did not receive FDA approval for the treatment of major depressive disorder (MDD), and the agency issued a Complete Response Letter to the manufacturers noting their application did not provide substantial evidence of effectiveness in MDD. The FDA said in the Complete Response Letter that an additional study or studies will be needed; the manufacturers are currently evaluating next steps.
 

Where zuranolone fits into the treatment algorithm for severe PPD

Many clinicians who support women with PPD will wonder, upon hearing this news, where zuranolone fits into the treatment algorithm for severe postpartum major depression. Some relevant issues that may determine the answer are the following:

Cost. The cost of brexanolone was substantial, at $34,000 per year, and was viewed by some as a limiting factor in terms of its very limited uptake. As of this column’s publication, zuranolone’s manufacturer has not stated how much the medication will cost.

Breastfeeding. Unlike selective serotonin reuptake inhibitors, which have been demonstrated to be effective for the treatment of PPD and safe during pregnancy and lactation, we have sparse data on the safety of zuranolone for women who wish to breastfeed. It is also unclear whether women eligible for zuranolone would, based on the limited data on safety in lactation, choose deferral of breastfeeding for 14 days in exchange for treatment.

Duration of treatment. While zuranolone was studied in the context of 14 days of acute treatment, then out to day 42, we have no published data on what happens on the other side of this brief interval. As a simple example, in a patient with a history of recurrent major depression previously treated with antidepressants, but where antidepressants were perhaps deferred during pregnancy, is PPD to be treated with zuranolone for 14 days? Or, hypothetically, should it be followed by empiric antidepressant treatment at day 14? Alternatively, are patient and clinician supposed to wait until recurrence occurs before pursuing adjunctive antidepressant therapy whether it is pharmacologic, nonpharmacologic, or both?

Treatment in patients with bipolar disorder. It is also unclear whether treatment with zuranolone applies to other populations of postpartum women. Certainly, for women with bipolar depression, which is common in postpartum women given the vulnerability of bipolar women to new onset of depression or postpartum depressive relapse of underlying disorder, we simply have no data regarding where zuranolone might fit in with respect to this group of patients.

The answers to these questions may help to determine whether zuranolone, a new antidepressant with efficacy, quick time to onset, and a novel mechanism of action is a “game changer.” The article in The Wall Street Journal provided me with some optimism, as it gave PPD and the issues surrounding PPD the attention it deserves in a major periodical. As a new treatment, it may help alleviate suffering at a critical time for patients and their families. We are inching closer to mitigation of stigma associated with this common illness.

Thinking back across the last 3 decades of my treating women suffering from PPD, I have reflected on what has gotten these patients well. I concluded that successful treatment of PPD is not a “one-stop shop,” but rather typically includes a combination of pharmacologic and nonpharmacologic interventions, along with family and community-based support groups, as well as a culture that reduces stigma and by so doing lessens the toll of this important and too frequently incompletely-treated illness.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. The Center for Women’s Mental Health at MGH was a non-enrolling site for the pivotal phase 3 SKYLARK trial evaluating zuranolone. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at [email protected].

Cisgender women who identify as sexual minorities may have an increased risk of postpartum depression compared with heterosexual women, new research shows. However, with sexual orientation highly underdocumented among women giving birth, understanding of the prevalence is lacking.

“To our knowledge, this cohort study was the first to examine perinatal depression screening and symptom endorsement among sexual minority women in a major medical center in the U.S.,” reported the authors of the study published in JAMA Psychiatry.

The results “highlight the need for investigations that include strategies for measuring sexual orientation because reliance on medical record review has substantial limitations with regard to the research questions and the validity of the data,” they noted.

Clinical guidelines recommend universal perinatal depression screening at obstetric and pediatric well-infant visits; however, there are significant gaps in data on the issue when it comes to sexual minority women.

To assess the prevalence of sexual minority people giving birth and compare perinatal depression screening rates and scores with those of heterosexual cisgender women, the authors conducted a review of medical records of 18,243 female patients who gave birth at a large, diverse, university-based medical center in Chicago between January and December of 2019.

Of the patients, 57.3% of whom were non-Hispanic White, 1.5% (280) had documentation of their sexual orientation, or sexual minority status.

The results show that those identified as being in sexual minorities, including lesbian, bisexual, queer, pansexual or asexual, were more likely than were heterosexual women to be more engaged in their care – they were more likely to have attended at least one prenatal visit (20.0% vs. 13.7%; P = .002) and at least one postpartum care visit (18.6% vs. 12.8%; P = .004), and more likely to be screened for depression during postpartum care (odds ratio, 1.77; P = .002).

Sexual minority women were also significantly more likely to screen positive for depression during the postpartum period than were heterosexual women (odds ratio, 2.38; P = .03); however, all other comparisons were not significantly different.

The finding regarding postpartum depression was consistent with recent literature, including a systematic review indicating that the stress of being in a sexual minority may be heightened during the postpartum period, the authors noted.

Reasons for the heightened stress may include “being perceived as inadequate parents, heteronormativity in perinatal care, such as intake forms asking for information about the child’s father, and lack of familial social support due to nonacceptance of the parents’ sexual orientation,” the researchers explained.

The rate of only 1.5% of people giving birth who identified as a sexual minority was significantly lower than expected, and much lower that the 17% reported in a recent nationally representative sample of women, first author Leiszle Lapping-Carr, PhD, director of the sexual and relationship health program, department of psychiatry and behavioral sciences, Northwestern University, Chicago, said in an interview.

“I did not expect a rate as low at 1.5%,” she said. “I anticipated it would not be as high as the 17%, but this was quite low. I think one primary reason is that women are not interested in disclosing their sexual orientation to their ob.gyns. if they don’t have to.”

Furthermore, Dr. Lapping-Carr said, “most medical systems do not have an easy way to document sexual orientation or gender identity, and even if it exists many physicians are unaware of the process.”

On a broader level, the lower rates may be indicative of a lack of acknowledgment of sexual minorities in the ob.gyn. setting, Dr. Lapping-Carr added.

Dr. Lapping-Carr

Develop more supportive systems

To address postpartum depression among sexual minority women, Dr. Lapping-Carr suggested that clinicians generally start by avoiding language and behaviors that could suggest the potential bias that sexual minority patients can face.

“The main change [in treatment] that would likely be helpful for postpartum depression treatment is removing heteronormative language, e.g., not referring to partners as ‘fathers,’ ” she said.

Also, patients may benefit from “discussion of issues of relevance to people with sexual minority identities, such as the process of adoption for female non-birthing partners,” Dr. Lapping-Carr added.

“Starting to create spaces that are inclusive and welcoming for people of all identities will go a long way in increasing your patient’s trust in you,” she said.

While there is a lack of published data regarding increases in rates of sexual minority patients who are giving birth, societal trends suggest the rates may likely be on the rise, Dr. Lapping-Carr said.

“We do know that among adolescents, endorsement of sexual and gender minority identities is much higher than in previous generations, so it would follow that the proportion of birthing people with sexual and gender minority identities would also increase,” she said.

Commenting on the study, K. Ashley Brandt, DO, obstetrics section chief and medical director of Gender Affirming Surgery at Reading Hospital, in West Reading, Pa., noted that limitations include a lack of information about the bigger picture of patients’ risk factors.

“There is no documentation of other risks factors, including rates of depression in the antenatal period, which is higher in LGBTQ individuals and also a risk factor for postpartum depression,” Dr. Brandt told this news organization.

She agreed, however, that patients may be reluctant to report their sexual minority status on the record – but such issues are often addressed.

“I believe that obstetricians do ask this question far more than other providers, but it may not be easily captured in medical records, and patients may also hesitate to disclose sexual practices and sexual orientation due to fear of medical discrimination, which is still extremely prevalent,” Dr. Brandt said. 

The study underscores, however, that “same-sex parents are a reality that providers will face,” she said. “They have unique social determinants for health that often go undocumented and unaddressed, which could contribute to higher rates of depression in the postpartum period.”

Factors that may be ignored or undocumented, such as sexual minorities’ religious beliefs or social and familial support, can play significant roles in health care outcomes, Dr. Brandt added.

“Providers need to find ways to better educate themselves about LGBTQ individuals and develop more supportive systems to ensure patients feel safe in disclosing their identities.”  

The authors and Dr. Brandt had no disclosures to report.

Cisgender women who identify as sexual minorities may have an increased risk of postpartum depression compared with heterosexual women, new research shows. However, with sexual orientation highly underdocumented among women giving birth, understanding of the prevalence is lacking.

“To our knowledge, this cohort study was the first to examine perinatal depression screening and symptom endorsement among sexual minority women in a major medical center in the U.S.,” reported the authors of the study published in JAMA Psychiatry.

The results “highlight the need for investigations that include strategies for measuring sexual orientation because reliance on medical record review has substantial limitations with regard to the research questions and the validity of the data,” they noted.

Clinical guidelines recommend universal perinatal depression screening at obstetric and pediatric well-infant visits; however, there are significant gaps in data on the issue when it comes to sexual minority women.

To assess the prevalence of sexual minority people giving birth and compare perinatal depression screening rates and scores with those of heterosexual cisgender women, the authors conducted a review of medical records of 18,243 female patients who gave birth at a large, diverse, university-based medical center in Chicago between January and December of 2019.

Of the patients, 57.3% of whom were non-Hispanic White, 1.5% (280) had documentation of their sexual orientation, or sexual minority status.

The results show that those identified as being in sexual minorities, including lesbian, bisexual, queer, pansexual or asexual, were more likely than were heterosexual women to be more engaged in their care – they were more likely to have attended at least one prenatal visit (20.0% vs. 13.7%; P = .002) and at least one postpartum care visit (18.6% vs. 12.8%; P = .004), and more likely to be screened for depression during postpartum care (odds ratio, 1.77; P = .002).

Sexual minority women were also significantly more likely to screen positive for depression during the postpartum period than were heterosexual women (odds ratio, 2.38; P = .03); however, all other comparisons were not significantly different.

The finding regarding postpartum depression was consistent with recent literature, including a systematic review indicating that the stress of being in a sexual minority may be heightened during the postpartum period, the authors noted.

Reasons for the heightened stress may include “being perceived as inadequate parents, heteronormativity in perinatal care, such as intake forms asking for information about the child’s father, and lack of familial social support due to nonacceptance of the parents’ sexual orientation,” the researchers explained.

The rate of only 1.5% of people giving birth who identified as a sexual minority was significantly lower than expected, and much lower that the 17% reported in a recent nationally representative sample of women, first author Leiszle Lapping-Carr, PhD, director of the sexual and relationship health program, department of psychiatry and behavioral sciences, Northwestern University, Chicago, said in an interview.

“I did not expect a rate as low at 1.5%,” she said. “I anticipated it would not be as high as the 17%, but this was quite low. I think one primary reason is that women are not interested in disclosing their sexual orientation to their ob.gyns. if they don’t have to.”

Furthermore, Dr. Lapping-Carr said, “most medical systems do not have an easy way to document sexual orientation or gender identity, and even if it exists many physicians are unaware of the process.”

On a broader level, the lower rates may be indicative of a lack of acknowledgment of sexual minorities in the ob.gyn. setting, Dr. Lapping-Carr added.

Dr. Lapping-Carr

Develop more supportive systems

To address postpartum depression among sexual minority women, Dr. Lapping-Carr suggested that clinicians generally start by avoiding language and behaviors that could suggest the potential bias that sexual minority patients can face.

“The main change [in treatment] that would likely be helpful for postpartum depression treatment is removing heteronormative language, e.g., not referring to partners as ‘fathers,’ ” she said.

Also, patients may benefit from “discussion of issues of relevance to people with sexual minority identities, such as the process of adoption for female non-birthing partners,” Dr. Lapping-Carr added.

“Starting to create spaces that are inclusive and welcoming for people of all identities will go a long way in increasing your patient’s trust in you,” she said.

While there is a lack of published data regarding increases in rates of sexual minority patients who are giving birth, societal trends suggest the rates may likely be on the rise, Dr. Lapping-Carr said.

“We do know that among adolescents, endorsement of sexual and gender minority identities is much higher than in previous generations, so it would follow that the proportion of birthing people with sexual and gender minority identities would also increase,” she said.

Commenting on the study, K. Ashley Brandt, DO, obstetrics section chief and medical director of Gender Affirming Surgery at Reading Hospital, in West Reading, Pa., noted that limitations include a lack of information about the bigger picture of patients’ risk factors.

“There is no documentation of other risks factors, including rates of depression in the antenatal period, which is higher in LGBTQ individuals and also a risk factor for postpartum depression,” Dr. Brandt told this news organization.

She agreed, however, that patients may be reluctant to report their sexual minority status on the record – but such issues are often addressed.

“I believe that obstetricians do ask this question far more than other providers, but it may not be easily captured in medical records, and patients may also hesitate to disclose sexual practices and sexual orientation due to fear of medical discrimination, which is still extremely prevalent,” Dr. Brandt said. 

The study underscores, however, that “same-sex parents are a reality that providers will face,” she said. “They have unique social determinants for health that often go undocumented and unaddressed, which could contribute to higher rates of depression in the postpartum period.”

Factors that may be ignored or undocumented, such as sexual minorities’ religious beliefs or social and familial support, can play significant roles in health care outcomes, Dr. Brandt added.

“Providers need to find ways to better educate themselves about LGBTQ individuals and develop more supportive systems to ensure patients feel safe in disclosing their identities.”  

The authors and Dr. Brandt had no disclosures to report.

Cisgender women who identify as sexual minorities may have an increased risk of postpartum depression compared with heterosexual women, new research shows. However, with sexual orientation highly underdocumented among women giving birth, understanding of the prevalence is lacking.

“To our knowledge, this cohort study was the first to examine perinatal depression screening and symptom endorsement among sexual minority women in a major medical center in the U.S.,” reported the authors of the study published in JAMA Psychiatry.

The results “highlight the need for investigations that include strategies for measuring sexual orientation because reliance on medical record review has substantial limitations with regard to the research questions and the validity of the data,” they noted.

Clinical guidelines recommend universal perinatal depression screening at obstetric and pediatric well-infant visits; however, there are significant gaps in data on the issue when it comes to sexual minority women.

To assess the prevalence of sexual minority people giving birth and compare perinatal depression screening rates and scores with those of heterosexual cisgender women, the authors conducted a review of medical records of 18,243 female patients who gave birth at a large, diverse, university-based medical center in Chicago between January and December of 2019.

Of the patients, 57.3% of whom were non-Hispanic White, 1.5% (280) had documentation of their sexual orientation, or sexual minority status.

The results show that those identified as being in sexual minorities, including lesbian, bisexual, queer, pansexual or asexual, were more likely than were heterosexual women to be more engaged in their care – they were more likely to have attended at least one prenatal visit (20.0% vs. 13.7%; P = .002) and at least one postpartum care visit (18.6% vs. 12.8%; P = .004), and more likely to be screened for depression during postpartum care (odds ratio, 1.77; P = .002).

Sexual minority women were also significantly more likely to screen positive for depression during the postpartum period than were heterosexual women (odds ratio, 2.38; P = .03); however, all other comparisons were not significantly different.

The finding regarding postpartum depression was consistent with recent literature, including a systematic review indicating that the stress of being in a sexual minority may be heightened during the postpartum period, the authors noted.

Reasons for the heightened stress may include “being perceived as inadequate parents, heteronormativity in perinatal care, such as intake forms asking for information about the child’s father, and lack of familial social support due to nonacceptance of the parents’ sexual orientation,” the researchers explained.

The rate of only 1.5% of people giving birth who identified as a sexual minority was significantly lower than expected, and much lower that the 17% reported in a recent nationally representative sample of women, first author Leiszle Lapping-Carr, PhD, director of the sexual and relationship health program, department of psychiatry and behavioral sciences, Northwestern University, Chicago, said in an interview.

“I did not expect a rate as low at 1.5%,” she said. “I anticipated it would not be as high as the 17%, but this was quite low. I think one primary reason is that women are not interested in disclosing their sexual orientation to their ob.gyns. if they don’t have to.”

Furthermore, Dr. Lapping-Carr said, “most medical systems do not have an easy way to document sexual orientation or gender identity, and even if it exists many physicians are unaware of the process.”

On a broader level, the lower rates may be indicative of a lack of acknowledgment of sexual minorities in the ob.gyn. setting, Dr. Lapping-Carr added.

Dr. Lapping-Carr

Develop more supportive systems

To address postpartum depression among sexual minority women, Dr. Lapping-Carr suggested that clinicians generally start by avoiding language and behaviors that could suggest the potential bias that sexual minority patients can face.

“The main change [in treatment] that would likely be helpful for postpartum depression treatment is removing heteronormative language, e.g., not referring to partners as ‘fathers,’ ” she said.

Also, patients may benefit from “discussion of issues of relevance to people with sexual minority identities, such as the process of adoption for female non-birthing partners,” Dr. Lapping-Carr added.

“Starting to create spaces that are inclusive and welcoming for people of all identities will go a long way in increasing your patient’s trust in you,” she said.

While there is a lack of published data regarding increases in rates of sexual minority patients who are giving birth, societal trends suggest the rates may likely be on the rise, Dr. Lapping-Carr said.

“We do know that among adolescents, endorsement of sexual and gender minority identities is much higher than in previous generations, so it would follow that the proportion of birthing people with sexual and gender minority identities would also increase,” she said.

Commenting on the study, K. Ashley Brandt, DO, obstetrics section chief and medical director of Gender Affirming Surgery at Reading Hospital, in West Reading, Pa., noted that limitations include a lack of information about the bigger picture of patients’ risk factors.

“There is no documentation of other risks factors, including rates of depression in the antenatal period, which is higher in LGBTQ individuals and also a risk factor for postpartum depression,” Dr. Brandt told this news organization.

She agreed, however, that patients may be reluctant to report their sexual minority status on the record – but such issues are often addressed.

“I believe that obstetricians do ask this question far more than other providers, but it may not be easily captured in medical records, and patients may also hesitate to disclose sexual practices and sexual orientation due to fear of medical discrimination, which is still extremely prevalent,” Dr. Brandt said. 

The study underscores, however, that “same-sex parents are a reality that providers will face,” she said. “They have unique social determinants for health that often go undocumented and unaddressed, which could contribute to higher rates of depression in the postpartum period.”

Factors that may be ignored or undocumented, such as sexual minorities’ religious beliefs or social and familial support, can play significant roles in health care outcomes, Dr. Brandt added.

“Providers need to find ways to better educate themselves about LGBTQ individuals and develop more supportive systems to ensure patients feel safe in disclosing their identities.”  

The authors and Dr. Brandt had no disclosures to report.

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

Veterans speak of losing their innocence and longing to regain it. They ask: “Why can’t I just go back to the way I was?”

Jonathan Shay, Achilles in Vietnam ¹

On July 17, 2023, several media outlets covering military and federal news carried a story about the US Department of Veterans Affairs (VA) plan to conduct a major survey of moral injury in veterans.² This is not the first such survey: There have been numerous previous studies conducted by both VA and non-VA investigators.³ Moral injury has been increasingly recognized as the signature wound of service members, especially those who fought in Operation Enduring Freedom and Operation Iraqi Freedom.⁴ This new VA survey can provide crucial information because we know so little about moral injury or how to help those with the condition.

At the time of this writing, there has been no official VA public statement about the study. At face value, this seemed to be strange, given that the groundbreaking research could improve the diagnosis and therapy of moral injury. According to a June 2023 VA Office of Research and Development internal announcement, the primary goal of the study is to determine the prevalence of moral injury among US veterans. The secondary goals of the study are to (1) compare those who develop moral injury and those who do not after exposure to similar traumas; and (2) conduct interviews about thoughts and experiences from 20 veterans who identify as having moral injury and 20 who do not but who have similar exposure to morally injurious events.

Data for the study will be collected through an extensive online survey from a nationally representative sample of 3000 post-9/11 war veterans. The sample will include at least 950 who served in a war zone and at least 400 who are aged 18 to 54 years. The respondents will be paid $20 for the 30 to 45 minutes survey. The collection and analysis of data are expected to take 3 or more years.

The modern version of moral injury is often associated with Jonathan Shay, MD, a VA psychiatrist.⁵ Shay wrote about the origin of moral injury found in Homer’s The Iliad and The Odyssey and how the poems offer ancient echoes of his therapy with modern-day combat veterans.¹

There is no universal agreement on the definition of moral injury. A working definition of moral injury used in the VA suggests that it describes the difficulties that people face after doing high-stakes actions that violate a sense of what is right and just or after being forced to experience others’ immoral actions.⁶

Two conditions are necessary for moral injury to occur. First, an individual acts or witnesses an action that contravenes their core ethical principles. Secondly, that occurrence is experienced as a breach of the person’s moral barrier. Military personnel killing civilians to protect their lives and those of their fellow troops is a tragic example of moral injury. The translation of this for health care professionals may be the inability to save severely wounded service members in the combat theater due to the exigencies of war.⁷

Experts in moral injury emphasize the importance of distinguishing the phenomenon from posttraumatic stress disorder (PTSD). Unlike many psychiatric disorders, both moral injury and PTSD have known etiologies: traumatic events. An individual may have 1 or both conditions, and each can manifest anger, guilt, shame, and loss of trust in others. One way that moral injury can be distinguished from PTSD is that it goes beyond the psychological to compromise the moral and often spiritual beliefs and values of the individual. One of the characteristics that makes us human is that we have a conscience to guide us in navigating the moral field of human life, but moral injury scrambles the internal compass that discerns right and wrong, good and bad. When an individual commits an action or witnesses the perpetration of an action that crosses their personal moral boundary, their integrity is shattered, and they may lose faith in their intrinsic worth. These beliefs prevent many service members from disclosing their distress, leading some commentators to refer to moral injury as a silent or invisible wound.⁸

The timing of the VA’s launching of a study of moral injury of this size and scope may reflect 3 recent developments: Not unexpected in VA matters, one is political, another is benefits, and the last pertains to health care.

First, August marks the second anniversary of the withdrawal of American troops from Afghanistan. Many Afghans who assisted US forces during the war were not evacuated. For some of the troops who served in the country, these events as well as the chaotic end to the long war were experienced as a contravening of an ethical code, resulting in moral injury.⁹

Second, many of those service members are now calling on the federal government to recognize and respond to the detrimental impact of the withdrawal, including the high prevalence of moral injury in troops who served in Afghanistan.¹⁰ Moral injury at this time is not considered a psychiatric diagnosis; hence, not eligible for VA benefits. However, many of the psychological manifestations of moral injury, such as depression and anxiety, are established service-connected disorders.

Third, several VA studies have demonstrated that moral injury either alone or combined with PTSD substantially elevates the risk of suicide.¹¹ Since preventing suicide is a major strategic priority for the VA, the importance of learning more about the epidemiology of moral injury is the necessary first step to developing therapeutic approaches. At a time when organized medicine is becoming increasingly technological and fragmented, launching this unprecedented survey demonstrates the VA’s commitment to delivering holistic and humanistic care of the service member: body, mind, and spirit.

This project also sends a strong message to those who lobby for shifting funding from the VA to community care or call for privatization. Veterans are different: They experience unique disorders borne of the battles they fought for our freedom. The VA has the specialized knowledge and skills in research and health care to develop the knowledge to ground innovative treatments for conditions like moral injury, PTSD, and traumatic brain injuries. VA chaplains and mental health professionals have pioneered assessment instruments and promising therapies for moral injury. Their distinctive expertise unrivaled in the civilian sector benefits not only veterans but also the wider community where there is a growing awareness of the devastating impact of moral injury, particularly on health care professionals.¹² And there may have been no other time in history when this broken, violent world was more in need of moral healing and peace.

Veterans speak of losing their innocence and longing to regain it. They ask: “Why can’t I just go back to the way I was?”

Jonathan Shay, Achilles in Vietnam ¹

On July 17, 2023, several media outlets covering military and federal news carried a story about the US Department of Veterans Affairs (VA) plan to conduct a major survey of moral injury in veterans.² This is not the first such survey: There have been numerous previous studies conducted by both VA and non-VA investigators.³ Moral injury has been increasingly recognized as the signature wound of service members, especially those who fought in Operation Enduring Freedom and Operation Iraqi Freedom.⁴ This new VA survey can provide crucial information because we know so little about moral injury or how to help those with the condition.

At the time of this writing, there has been no official VA public statement about the study. At face value, this seemed to be strange, given that the groundbreaking research could improve the diagnosis and therapy of moral injury. According to a June 2023 VA Office of Research and Development internal announcement, the primary goal of the study is to determine the prevalence of moral injury among US veterans. The secondary goals of the study are to (1) compare those who develop moral injury and those who do not after exposure to similar traumas; and (2) conduct interviews about thoughts and experiences from 20 veterans who identify as having moral injury and 20 who do not but who have similar exposure to morally injurious events.

Data for the study will be collected through an extensive online survey from a nationally representative sample of 3000 post-9/11 war veterans. The sample will include at least 950 who served in a war zone and at least 400 who are aged 18 to 54 years. The respondents will be paid $20 for the 30 to 45 minutes survey. The collection and analysis of data are expected to take 3 or more years.

The modern version of moral injury is often associated with Jonathan Shay, MD, a VA psychiatrist.⁵ Shay wrote about the origin of moral injury found in Homer’s The Iliad and The Odyssey and how the poems offer ancient echoes of his therapy with modern-day combat veterans.¹

There is no universal agreement on the definition of moral injury. A working definition of moral injury used in the VA suggests that it describes the difficulties that people face after doing high-stakes actions that violate a sense of what is right and just or after being forced to experience others’ immoral actions.⁶

Two conditions are necessary for moral injury to occur. First, an individual acts or witnesses an action that contravenes their core ethical principles. Secondly, that occurrence is experienced as a breach of the person’s moral barrier. Military personnel killing civilians to protect their lives and those of their fellow troops is a tragic example of moral injury. The translation of this for health care professionals may be the inability to save severely wounded service members in the combat theater due to the exigencies of war.⁷

Experts in moral injury emphasize the importance of distinguishing the phenomenon from posttraumatic stress disorder (PTSD). Unlike many psychiatric disorders, both moral injury and PTSD have known etiologies: traumatic events. An individual may have 1 or both conditions, and each can manifest anger, guilt, shame, and loss of trust in others. One way that moral injury can be distinguished from PTSD is that it goes beyond the psychological to compromise the moral and often spiritual beliefs and values of the individual. One of the characteristics that makes us human is that we have a conscience to guide us in navigating the moral field of human life, but moral injury scrambles the internal compass that discerns right and wrong, good and bad. When an individual commits an action or witnesses the perpetration of an action that crosses their personal moral boundary, their integrity is shattered, and they may lose faith in their intrinsic worth. These beliefs prevent many service members from disclosing their distress, leading some commentators to refer to moral injury as a silent or invisible wound.⁸

The timing of the VA’s launching of a study of moral injury of this size and scope may reflect 3 recent developments: Not unexpected in VA matters, one is political, another is benefits, and the last pertains to health care.

First, August marks the second anniversary of the withdrawal of American troops from Afghanistan. Many Afghans who assisted US forces during the war were not evacuated. For some of the troops who served in the country, these events as well as the chaotic end to the long war were experienced as a contravening of an ethical code, resulting in moral injury.⁹

Second, many of those service members are now calling on the federal government to recognize and respond to the detrimental impact of the withdrawal, including the high prevalence of moral injury in troops who served in Afghanistan.¹⁰ Moral injury at this time is not considered a psychiatric diagnosis; hence, not eligible for VA benefits. However, many of the psychological manifestations of moral injury, such as depression and anxiety, are established service-connected disorders.

Third, several VA studies have demonstrated that moral injury either alone or combined with PTSD substantially elevates the risk of suicide.¹¹ Since preventing suicide is a major strategic priority for the VA, the importance of learning more about the epidemiology of moral injury is the necessary first step to developing therapeutic approaches. At a time when organized medicine is becoming increasingly technological and fragmented, launching this unprecedented survey demonstrates the VA’s commitment to delivering holistic and humanistic care of the service member: body, mind, and spirit.

This project also sends a strong message to those who lobby for shifting funding from the VA to community care or call for privatization. Veterans are different: They experience unique disorders borne of the battles they fought for our freedom. The VA has the specialized knowledge and skills in research and health care to develop the knowledge to ground innovative treatments for conditions like moral injury, PTSD, and traumatic brain injuries. VA chaplains and mental health professionals have pioneered assessment instruments and promising therapies for moral injury. Their distinctive expertise unrivaled in the civilian sector benefits not only veterans but also the wider community where there is a growing awareness of the devastating impact of moral injury, particularly on health care professionals.¹² And there may have been no other time in history when this broken, violent world was more in need of moral healing and peace.

Veterans speak of losing their innocence and longing to regain it. They ask: “Why can’t I just go back to the way I was?”

Jonathan Shay, Achilles in Vietnam ¹

On July 17, 2023, several media outlets covering military and federal news carried a story about the US Department of Veterans Affairs (VA) plan to conduct a major survey of moral injury in veterans.² This is not the first such survey: There have been numerous previous studies conducted by both VA and non-VA investigators.³ Moral injury has been increasingly recognized as the signature wound of service members, especially those who fought in Operation Enduring Freedom and Operation Iraqi Freedom.⁴ This new VA survey can provide crucial information because we know so little about moral injury or how to help those with the condition.

At the time of this writing, there has been no official VA public statement about the study. At face value, this seemed to be strange, given that the groundbreaking research could improve the diagnosis and therapy of moral injury. According to a June 2023 VA Office of Research and Development internal announcement, the primary goal of the study is to determine the prevalence of moral injury among US veterans. The secondary goals of the study are to (1) compare those who develop moral injury and those who do not after exposure to similar traumas; and (2) conduct interviews about thoughts and experiences from 20 veterans who identify as having moral injury and 20 who do not but who have similar exposure to morally injurious events.

Data for the study will be collected through an extensive online survey from a nationally representative sample of 3000 post-9/11 war veterans. The sample will include at least 950 who served in a war zone and at least 400 who are aged 18 to 54 years. The respondents will be paid $20 for the 30 to 45 minutes survey. The collection and analysis of data are expected to take 3 or more years.

The modern version of moral injury is often associated with Jonathan Shay, MD, a VA psychiatrist.⁵ Shay wrote about the origin of moral injury found in Homer’s The Iliad and The Odyssey and how the poems offer ancient echoes of his therapy with modern-day combat veterans.¹

There is no universal agreement on the definition of moral injury. A working definition of moral injury used in the VA suggests that it describes the difficulties that people face after doing high-stakes actions that violate a sense of what is right and just or after being forced to experience others’ immoral actions.⁶

Two conditions are necessary for moral injury to occur. First, an individual acts or witnesses an action that contravenes their core ethical principles. Secondly, that occurrence is experienced as a breach of the person’s moral barrier. Military personnel killing civilians to protect their lives and those of their fellow troops is a tragic example of moral injury. The translation of this for health care professionals may be the inability to save severely wounded service members in the combat theater due to the exigencies of war.⁷

Experts in moral injury emphasize the importance of distinguishing the phenomenon from posttraumatic stress disorder (PTSD). Unlike many psychiatric disorders, both moral injury and PTSD have known etiologies: traumatic events. An individual may have 1 or both conditions, and each can manifest anger, guilt, shame, and loss of trust in others. One way that moral injury can be distinguished from PTSD is that it goes beyond the psychological to compromise the moral and often spiritual beliefs and values of the individual. One of the characteristics that makes us human is that we have a conscience to guide us in navigating the moral field of human life, but moral injury scrambles the internal compass that discerns right and wrong, good and bad. When an individual commits an action or witnesses the perpetration of an action that crosses their personal moral boundary, their integrity is shattered, and they may lose faith in their intrinsic worth. These beliefs prevent many service members from disclosing their distress, leading some commentators to refer to moral injury as a silent or invisible wound.⁸

The timing of the VA’s launching of a study of moral injury of this size and scope may reflect 3 recent developments: Not unexpected in VA matters, one is political, another is benefits, and the last pertains to health care.

First, August marks the second anniversary of the withdrawal of American troops from Afghanistan. Many Afghans who assisted US forces during the war were not evacuated. For some of the troops who served in the country, these events as well as the chaotic end to the long war were experienced as a contravening of an ethical code, resulting in moral injury.⁹

Second, many of those service members are now calling on the federal government to recognize and respond to the detrimental impact of the withdrawal, including the high prevalence of moral injury in troops who served in Afghanistan.¹⁰ Moral injury at this time is not considered a psychiatric diagnosis; hence, not eligible for VA benefits. However, many of the psychological manifestations of moral injury, such as depression and anxiety, are established service-connected disorders.

Third, several VA studies have demonstrated that moral injury either alone or combined with PTSD substantially elevates the risk of suicide.¹¹ Since preventing suicide is a major strategic priority for the VA, the importance of learning more about the epidemiology of moral injury is the necessary first step to developing therapeutic approaches. At a time when organized medicine is becoming increasingly technological and fragmented, launching this unprecedented survey demonstrates the VA’s commitment to delivering holistic and humanistic care of the service member: body, mind, and spirit.

This project also sends a strong message to those who lobby for shifting funding from the VA to community care or call for privatization. Veterans are different: They experience unique disorders borne of the battles they fought for our freedom. The VA has the specialized knowledge and skills in research and health care to develop the knowledge to ground innovative treatments for conditions like moral injury, PTSD, and traumatic brain injuries. VA chaplains and mental health professionals have pioneered assessment instruments and promising therapies for moral injury. Their distinctive expertise unrivaled in the civilian sector benefits not only veterans but also the wider community where there is a growing awareness of the devastating impact of moral injury, particularly on health care professionals.¹² And there may have been no other time in history when this broken, violent world was more in need of moral healing and peace.

New research calls into question the established method of assessing patient response to antidepressant treatment and expands the concepts of “responder” and “nonresponder.” 

Investigators assessed more than 800 patients with major depressive disorder (MDD) attending a partial hospital program. The patients completed questionnaires about depressive symptoms as well as functioning and broader measures of quality of life (QoL).

Brown University

Although fewer than 40% were classified as treatment responders on the basis of depressive symptoms, as measured by the Remission from Depression Questionnaire (RDQ), two-thirds met criteria as responders on the Patient Global Rating of Improvement (PGI) scale, which takes into consideration broader domains of life satisfaction.

“The treatments we’re offering patients may be doing a better job than we think in treating depression, because many patients say they feel significantly better, even if their depression symptoms haven’t been diminished by the arbitrary threshold of 50% or greater improvement,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., told this news organization.

“Many of these patients – even if they have ongoing depressive symptoms – nevertheless say treatment has been very or extremely helpful, which is picked by other emphasizes in outcome, such as functioning, quality of life, coping abilities, and positive mental health,” added Dr. Zimmerman, director of the outpatient division at the Partial Hospital Program, Rhode Island Hospital.

The study was published online in the Annals of Clinical Psychiatry.

What’s the best tool?

“Almost all studies of depression treatment rely on measures of symptom severity to evaluate outcome – which is understandable, because a diagnosis of MDD requires a minimum number of symptoms for a sustained period of time,” said Dr. Zimmerman.

However, while important, symptom reduction is only one component of depression treatment. Improving overall function, QoL, and ability to deal with life’s stressors are equally important, he said.

Dr. Zimmerman emphasized he’s an “advocate, supporter, and practitioner of measurement-based care.” This approach, he said, “increases efficiency of the visit and directs me to the areas I should be inquiring about and the areas that need less time for inquiry.”

Measurement tools also enable numerical documentation of how a patient is doing and helps them understand and recognize their improvement.

The question is which tool captures improvements most effectively. Several surveys show that patients value improved functioning and QoL as primary treatment goals, which “is different from the emphasis of symptom improvement found in research,” said Dr. Zimmerman.

A multidimensional questionnaire that assesses functioning, QoL, and coping ability as well as symptoms is more likely to reflect patients’ treatment goals than simply measuring symptoms, he said.

Dr. Zimmerman and his coauthor reported on findings from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, which “examined the concordance between patients’ global rating of improvement from treatment and responder status, based on a depression symptoms severity scale.”
 

Doing better than we think

The study was conducted in Rhode Island Hospital’s department of psychiatry partial hospital program, where 844 patients with MDD (65.2% women; mean [SD] age, 36.8 [13.9] years) completed the RDQ – a self-report measure that “assesses constructs that patients consider to be relevant for assessing treatment outcome.” This questionnaire assesses symptom and nonsymptom domains that people consider important when evaluating treatment effectiveness.

To the original 41-item questionnaire, the researchers added 19 items. The final 60-item questionnaire included the following:

• 14 depressive symptoms.
• 11 nondepressive symptoms.
• 5 coping ability/stress tolerance items (for instance, “I had trouble handling pressure”).
• 12 positive mental health items (for instance, “I saw myself as a person of value”).
• 10 functioning items (for instance, “I was socially withdrawn”).
• 8 general well-being/life satisfaction items (for instance, “I was engaging in life rather than hiding from it”).

Patients were divided into three groups:

• Symptom responders (whose scores on the RDQ depressive symptom subscale improved by ≥ 50% from admission to discharge).
• PGI responders, who weren’t symptom responders – that is, who reported global improvement but didn’t improve ≥ 50% on the depression symptom subscale.
• Nonresponders (that is, patients who didn’t respond on the PGI and the depressive symptom subscale).

The researchers compared the three groups on the four symptom domains of the RDQ. Patients also completed the PGI on discharge, and the researchers compared these responses to responses to the RDQ.

Only 38.7% were responders on the depressive symptoms subscale, while 67.4% were PGI responders.

Most patients (91.4%) who were responders on the depressive symptom subscale were also PGI responders, while 32% were PGI responders but not responders on the depressive symptom subscale.

Although 29.2% were nonresponders on both measures, 70.8% were responders on one scale or the other.

As far as the nonsymptom domains, response rates varied between 30% (life satisfaction) to 33.1% (positive mental health).

“If you’re using a measurement tool in practice, I’d recommend one that goes beyond symptom improvement and also captures broader domains,” Dr. Zimmerman said.
 

‘Better enough’

Commenting on the study, Philip Muskin, MD, professor of psychiatry, Columbia University Medical Center, New York, said the use of symptom-driven rating scales to measure depression response originated in mandates of the U.S. Food and Drug Administration to determine whether a drug being tested in a clinical trial is superior to placebo.

Columbia University Medical Center

“But there has been, for a long time, the question of whether these people are really better,” said Dr. Muskin, who was not involved with the current study. “Symptomatically, they may show improvement, but do they actually perceive themselves as better?”

Some patients might report, “I’m about 75% myself, but not back to 100%.” Dr. Muskin doesn’t “take these to be hard-and-fast numbers, but patients can tell you how they perceive themselves. This study suggests that if you’re wedded to [symptom measurement] scales, you may not realize that patients are actually getting better. And who decides if a patient is better, or better enough? The patient decides that.”

He added that some patients won’t achieve complete remission. “Even if I can’t get the person to be 100% better, I’m glad if I can help them become ‘better enough’ to function in life, do things, go to work, and improve in quality-of-life domains.”

The study received no outside funding. Dr. Zimmerman and his coauthor and Dr. Muskin report no relevant financial relationships.

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

New research calls into question the established method of assessing patient response to antidepressant treatment and expands the concepts of “responder” and “nonresponder.” 

Investigators assessed more than 800 patients with major depressive disorder (MDD) attending a partial hospital program. The patients completed questionnaires about depressive symptoms as well as functioning and broader measures of quality of life (QoL).

Brown University

Although fewer than 40% were classified as treatment responders on the basis of depressive symptoms, as measured by the Remission from Depression Questionnaire (RDQ), two-thirds met criteria as responders on the Patient Global Rating of Improvement (PGI) scale, which takes into consideration broader domains of life satisfaction.

“The treatments we’re offering patients may be doing a better job than we think in treating depression, because many patients say they feel significantly better, even if their depression symptoms haven’t been diminished by the arbitrary threshold of 50% or greater improvement,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., told this news organization.

“Many of these patients – even if they have ongoing depressive symptoms – nevertheless say treatment has been very or extremely helpful, which is picked by other emphasizes in outcome, such as functioning, quality of life, coping abilities, and positive mental health,” added Dr. Zimmerman, director of the outpatient division at the Partial Hospital Program, Rhode Island Hospital.

The study was published online in the Annals of Clinical Psychiatry.

What’s the best tool?

“Almost all studies of depression treatment rely on measures of symptom severity to evaluate outcome – which is understandable, because a diagnosis of MDD requires a minimum number of symptoms for a sustained period of time,” said Dr. Zimmerman.

However, while important, symptom reduction is only one component of depression treatment. Improving overall function, QoL, and ability to deal with life’s stressors are equally important, he said.

Dr. Zimmerman emphasized he’s an “advocate, supporter, and practitioner of measurement-based care.” This approach, he said, “increases efficiency of the visit and directs me to the areas I should be inquiring about and the areas that need less time for inquiry.”

Measurement tools also enable numerical documentation of how a patient is doing and helps them understand and recognize their improvement.

The question is which tool captures improvements most effectively. Several surveys show that patients value improved functioning and QoL as primary treatment goals, which “is different from the emphasis of symptom improvement found in research,” said Dr. Zimmerman.

A multidimensional questionnaire that assesses functioning, QoL, and coping ability as well as symptoms is more likely to reflect patients’ treatment goals than simply measuring symptoms, he said.

Dr. Zimmerman and his coauthor reported on findings from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, which “examined the concordance between patients’ global rating of improvement from treatment and responder status, based on a depression symptoms severity scale.”
 

Doing better than we think

The study was conducted in Rhode Island Hospital’s department of psychiatry partial hospital program, where 844 patients with MDD (65.2% women; mean [SD] age, 36.8 [13.9] years) completed the RDQ – a self-report measure that “assesses constructs that patients consider to be relevant for assessing treatment outcome.” This questionnaire assesses symptom and nonsymptom domains that people consider important when evaluating treatment effectiveness.

To the original 41-item questionnaire, the researchers added 19 items. The final 60-item questionnaire included the following:

• 14 depressive symptoms.
• 11 nondepressive symptoms.
• 5 coping ability/stress tolerance items (for instance, “I had trouble handling pressure”).
• 12 positive mental health items (for instance, “I saw myself as a person of value”).
• 10 functioning items (for instance, “I was socially withdrawn”).
• 8 general well-being/life satisfaction items (for instance, “I was engaging in life rather than hiding from it”).

Patients were divided into three groups:

• Symptom responders (whose scores on the RDQ depressive symptom subscale improved by ≥ 50% from admission to discharge).
• PGI responders, who weren’t symptom responders – that is, who reported global improvement but didn’t improve ≥ 50% on the depression symptom subscale.
• Nonresponders (that is, patients who didn’t respond on the PGI and the depressive symptom subscale).

The researchers compared the three groups on the four symptom domains of the RDQ. Patients also completed the PGI on discharge, and the researchers compared these responses to responses to the RDQ.

Only 38.7% were responders on the depressive symptoms subscale, while 67.4% were PGI responders.

Most patients (91.4%) who were responders on the depressive symptom subscale were also PGI responders, while 32% were PGI responders but not responders on the depressive symptom subscale.

Although 29.2% were nonresponders on both measures, 70.8% were responders on one scale or the other.

As far as the nonsymptom domains, response rates varied between 30% (life satisfaction) to 33.1% (positive mental health).

“If you’re using a measurement tool in practice, I’d recommend one that goes beyond symptom improvement and also captures broader domains,” Dr. Zimmerman said.
 

‘Better enough’

Commenting on the study, Philip Muskin, MD, professor of psychiatry, Columbia University Medical Center, New York, said the use of symptom-driven rating scales to measure depression response originated in mandates of the U.S. Food and Drug Administration to determine whether a drug being tested in a clinical trial is superior to placebo.

Columbia University Medical Center

“But there has been, for a long time, the question of whether these people are really better,” said Dr. Muskin, who was not involved with the current study. “Symptomatically, they may show improvement, but do they actually perceive themselves as better?”

Some patients might report, “I’m about 75% myself, but not back to 100%.” Dr. Muskin doesn’t “take these to be hard-and-fast numbers, but patients can tell you how they perceive themselves. This study suggests that if you’re wedded to [symptom measurement] scales, you may not realize that patients are actually getting better. And who decides if a patient is better, or better enough? The patient decides that.”

He added that some patients won’t achieve complete remission. “Even if I can’t get the person to be 100% better, I’m glad if I can help them become ‘better enough’ to function in life, do things, go to work, and improve in quality-of-life domains.”

The study received no outside funding. Dr. Zimmerman and his coauthor and Dr. Muskin report no relevant financial relationships.

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

New research calls into question the established method of assessing patient response to antidepressant treatment and expands the concepts of “responder” and “nonresponder.” 

Investigators assessed more than 800 patients with major depressive disorder (MDD) attending a partial hospital program. The patients completed questionnaires about depressive symptoms as well as functioning and broader measures of quality of life (QoL).

Brown University

Although fewer than 40% were classified as treatment responders on the basis of depressive symptoms, as measured by the Remission from Depression Questionnaire (RDQ), two-thirds met criteria as responders on the Patient Global Rating of Improvement (PGI) scale, which takes into consideration broader domains of life satisfaction.

“The treatments we’re offering patients may be doing a better job than we think in treating depression, because many patients say they feel significantly better, even if their depression symptoms haven’t been diminished by the arbitrary threshold of 50% or greater improvement,” study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, R.I., told this news organization.

“Many of these patients – even if they have ongoing depressive symptoms – nevertheless say treatment has been very or extremely helpful, which is picked by other emphasizes in outcome, such as functioning, quality of life, coping abilities, and positive mental health,” added Dr. Zimmerman, director of the outpatient division at the Partial Hospital Program, Rhode Island Hospital.

The study was published online in the Annals of Clinical Psychiatry.

What’s the best tool?

“Almost all studies of depression treatment rely on measures of symptom severity to evaluate outcome – which is understandable, because a diagnosis of MDD requires a minimum number of symptoms for a sustained period of time,” said Dr. Zimmerman.

However, while important, symptom reduction is only one component of depression treatment. Improving overall function, QoL, and ability to deal with life’s stressors are equally important, he said.

Dr. Zimmerman emphasized he’s an “advocate, supporter, and practitioner of measurement-based care.” This approach, he said, “increases efficiency of the visit and directs me to the areas I should be inquiring about and the areas that need less time for inquiry.”

Measurement tools also enable numerical documentation of how a patient is doing and helps them understand and recognize their improvement.

The question is which tool captures improvements most effectively. Several surveys show that patients value improved functioning and QoL as primary treatment goals, which “is different from the emphasis of symptom improvement found in research,” said Dr. Zimmerman.

A multidimensional questionnaire that assesses functioning, QoL, and coping ability as well as symptoms is more likely to reflect patients’ treatment goals than simply measuring symptoms, he said.

Dr. Zimmerman and his coauthor reported on findings from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, which “examined the concordance between patients’ global rating of improvement from treatment and responder status, based on a depression symptoms severity scale.”
 

Doing better than we think

The study was conducted in Rhode Island Hospital’s department of psychiatry partial hospital program, where 844 patients with MDD (65.2% women; mean [SD] age, 36.8 [13.9] years) completed the RDQ – a self-report measure that “assesses constructs that patients consider to be relevant for assessing treatment outcome.” This questionnaire assesses symptom and nonsymptom domains that people consider important when evaluating treatment effectiveness.

To the original 41-item questionnaire, the researchers added 19 items. The final 60-item questionnaire included the following:

• 14 depressive symptoms.
• 11 nondepressive symptoms.
• 5 coping ability/stress tolerance items (for instance, “I had trouble handling pressure”).
• 12 positive mental health items (for instance, “I saw myself as a person of value”).
• 10 functioning items (for instance, “I was socially withdrawn”).
• 8 general well-being/life satisfaction items (for instance, “I was engaging in life rather than hiding from it”).

Patients were divided into three groups:

• Symptom responders (whose scores on the RDQ depressive symptom subscale improved by ≥ 50% from admission to discharge).
• PGI responders, who weren’t symptom responders – that is, who reported global improvement but didn’t improve ≥ 50% on the depression symptom subscale.
• Nonresponders (that is, patients who didn’t respond on the PGI and the depressive symptom subscale).

The researchers compared the three groups on the four symptom domains of the RDQ. Patients also completed the PGI on discharge, and the researchers compared these responses to responses to the RDQ.

Only 38.7% were responders on the depressive symptoms subscale, while 67.4% were PGI responders.

Most patients (91.4%) who were responders on the depressive symptom subscale were also PGI responders, while 32% were PGI responders but not responders on the depressive symptom subscale.

Although 29.2% were nonresponders on both measures, 70.8% were responders on one scale or the other.

As far as the nonsymptom domains, response rates varied between 30% (life satisfaction) to 33.1% (positive mental health).

“If you’re using a measurement tool in practice, I’d recommend one that goes beyond symptom improvement and also captures broader domains,” Dr. Zimmerman said.
 

‘Better enough’

Commenting on the study, Philip Muskin, MD, professor of psychiatry, Columbia University Medical Center, New York, said the use of symptom-driven rating scales to measure depression response originated in mandates of the U.S. Food and Drug Administration to determine whether a drug being tested in a clinical trial is superior to placebo.

Columbia University Medical Center

“But there has been, for a long time, the question of whether these people are really better,” said Dr. Muskin, who was not involved with the current study. “Symptomatically, they may show improvement, but do they actually perceive themselves as better?”

Some patients might report, “I’m about 75% myself, but not back to 100%.” Dr. Muskin doesn’t “take these to be hard-and-fast numbers, but patients can tell you how they perceive themselves. This study suggests that if you’re wedded to [symptom measurement] scales, you may not realize that patients are actually getting better. And who decides if a patient is better, or better enough? The patient decides that.”

He added that some patients won’t achieve complete remission. “Even if I can’t get the person to be 100% better, I’m glad if I can help them become ‘better enough’ to function in life, do things, go to work, and improve in quality-of-life domains.”

The study received no outside funding. Dr. Zimmerman and his coauthor and Dr. Muskin report no relevant financial relationships.

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

TOPLINE:

Even after accounting for sociodemographic factors, intellectual disabilities, and psychiatric diagnoses, autism is associated with an 83% increased risk of self-harm among females and a 47% increased risk among males.

METHODOLOGY:

Evidence shows those with autism have over threefold greater odds than their counterparts without the disorder of self-injurious behavior, suicidal ideation, suicide attempt, or suicide death, but reasons for these elevated risks are unclear.

Using various linked databases in the province of Ontario, researchers identified all individuals with an autism diagnosis from April 1, 1988, to March 31, 2018, and matched each on age and sex to four nonautistic individuals for the comparison group.

Investigators created two cohorts to separately evaluate outcomes of self-harm events leading to emergency health care and suicide death with the accrual period for both cohorts beginning at a person’s 10th birthday.

The self-harm cohort included 379,630 individuals while the suicide cohort included 334,690 individuals.

TAKEAWAY:

Over 15 years, autistic females showed the highest cumulative self-harm events, followed by autistic males, nonautistic females, and nonautistic males; over 25 years, autistic males had the highest cumulative incidence of suicide death, followed by autistic females, nonautistic males, and nonautistic females.

Autism had independent associations with self-harm events (females: relative rate, 1.83 [95% confidence interval, 1.61-2.08]; males: RR, 1.47 [95% CI, 1.28-1.69]) even after accounting for sociodemographic factors (varied directions of associations), intellectual disabilities (associated with increased risks), and psychiatric diagnoses including mood and anxiety, psychotic, addiction, and personality disorders (associated with increased risks).

For both females and males, final models showed autism per se was not significantly associated with suicide death, but certain correlates were linked to risk. Among both sexes, intellectual disabilities were associated with reduced risks and psychiatric diagnoses were associated with increased risks.

As a substantial proportion (28.4%) of the suicide cohort did not have data on self-harm, researchers were unable to examine the association of self-harm with suicide death.

IN PRACTICE:

That psychiatric diagnoses increased suicide risks among people with autism suggests supports to reduce such risks “should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses,” write the authors.

SOURCE:

The study was conducted by Meng-Chuan Lai, MD, PhD, Centre for Addiction and Mental Health, Toronto, and colleagues. It was published online in JAMA Network Open.

LIMITATIONS:

The autism cohort didn’t capture those diagnosed in private practices or with subtle presentations not yet diagnosed. Misclassification of autistic people in the nonautistic cohort may have resulted in underestimation of suicide-related outcomes. The administrative data don’t reliably identify diagnoses associated with suicide risks such as attention-deficit/hyperactivity disorder or subcategories of mood disorders, and don’t contain information about risk and protective mechanisms of suicide behaviors such as family history.

DISCLOSURES:

The study received support from ICES, an independent nonprofit research institute; the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario; the Academic Scholars Award from the Department of Psychiatry, University of Toronto; and the Canadian Institutes of Health Research Sex and Gender Science Chair. Dr. Lai reported receiving personal fees from SAGE Publications as an editorial honorarium outside the submitted work. One coauthor reported receiving honoraria from the BMJ Group, Archives of Diseases in Childhood.

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

TOPLINE:

Even after accounting for sociodemographic factors, intellectual disabilities, and psychiatric diagnoses, autism is associated with an 83% increased risk of self-harm among females and a 47% increased risk among males.

METHODOLOGY:

Evidence shows those with autism have over threefold greater odds than their counterparts without the disorder of self-injurious behavior, suicidal ideation, suicide attempt, or suicide death, but reasons for these elevated risks are unclear.

Using various linked databases in the province of Ontario, researchers identified all individuals with an autism diagnosis from April 1, 1988, to March 31, 2018, and matched each on age and sex to four nonautistic individuals for the comparison group.

Investigators created two cohorts to separately evaluate outcomes of self-harm events leading to emergency health care and suicide death with the accrual period for both cohorts beginning at a person’s 10th birthday.

The self-harm cohort included 379,630 individuals while the suicide cohort included 334,690 individuals.

TAKEAWAY:

Over 15 years, autistic females showed the highest cumulative self-harm events, followed by autistic males, nonautistic females, and nonautistic males; over 25 years, autistic males had the highest cumulative incidence of suicide death, followed by autistic females, nonautistic males, and nonautistic females.

Autism had independent associations with self-harm events (females: relative rate, 1.83 [95% confidence interval, 1.61-2.08]; males: RR, 1.47 [95% CI, 1.28-1.69]) even after accounting for sociodemographic factors (varied directions of associations), intellectual disabilities (associated with increased risks), and psychiatric diagnoses including mood and anxiety, psychotic, addiction, and personality disorders (associated with increased risks).

For both females and males, final models showed autism per se was not significantly associated with suicide death, but certain correlates were linked to risk. Among both sexes, intellectual disabilities were associated with reduced risks and psychiatric diagnoses were associated with increased risks.

As a substantial proportion (28.4%) of the suicide cohort did not have data on self-harm, researchers were unable to examine the association of self-harm with suicide death.

IN PRACTICE:

That psychiatric diagnoses increased suicide risks among people with autism suggests supports to reduce such risks “should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses,” write the authors.

SOURCE:

The study was conducted by Meng-Chuan Lai, MD, PhD, Centre for Addiction and Mental Health, Toronto, and colleagues. It was published online in JAMA Network Open.

LIMITATIONS:

The autism cohort didn’t capture those diagnosed in private practices or with subtle presentations not yet diagnosed. Misclassification of autistic people in the nonautistic cohort may have resulted in underestimation of suicide-related outcomes. The administrative data don’t reliably identify diagnoses associated with suicide risks such as attention-deficit/hyperactivity disorder or subcategories of mood disorders, and don’t contain information about risk and protective mechanisms of suicide behaviors such as family history.

DISCLOSURES:

The study received support from ICES, an independent nonprofit research institute; the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario; the Academic Scholars Award from the Department of Psychiatry, University of Toronto; and the Canadian Institutes of Health Research Sex and Gender Science Chair. Dr. Lai reported receiving personal fees from SAGE Publications as an editorial honorarium outside the submitted work. One coauthor reported receiving honoraria from the BMJ Group, Archives of Diseases in Childhood.

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

TOPLINE:

Even after accounting for sociodemographic factors, intellectual disabilities, and psychiatric diagnoses, autism is associated with an 83% increased risk of self-harm among females and a 47% increased risk among males.

METHODOLOGY:

Evidence shows those with autism have over threefold greater odds than their counterparts without the disorder of self-injurious behavior, suicidal ideation, suicide attempt, or suicide death, but reasons for these elevated risks are unclear.

Using various linked databases in the province of Ontario, researchers identified all individuals with an autism diagnosis from April 1, 1988, to March 31, 2018, and matched each on age and sex to four nonautistic individuals for the comparison group.

Investigators created two cohorts to separately evaluate outcomes of self-harm events leading to emergency health care and suicide death with the accrual period for both cohorts beginning at a person’s 10th birthday.

The self-harm cohort included 379,630 individuals while the suicide cohort included 334,690 individuals.

TAKEAWAY:

Over 15 years, autistic females showed the highest cumulative self-harm events, followed by autistic males, nonautistic females, and nonautistic males; over 25 years, autistic males had the highest cumulative incidence of suicide death, followed by autistic females, nonautistic males, and nonautistic females.

Autism had independent associations with self-harm events (females: relative rate, 1.83 [95% confidence interval, 1.61-2.08]; males: RR, 1.47 [95% CI, 1.28-1.69]) even after accounting for sociodemographic factors (varied directions of associations), intellectual disabilities (associated with increased risks), and psychiatric diagnoses including mood and anxiety, psychotic, addiction, and personality disorders (associated with increased risks).

For both females and males, final models showed autism per se was not significantly associated with suicide death, but certain correlates were linked to risk. Among both sexes, intellectual disabilities were associated with reduced risks and psychiatric diagnoses were associated with increased risks.

As a substantial proportion (28.4%) of the suicide cohort did not have data on self-harm, researchers were unable to examine the association of self-harm with suicide death.

IN PRACTICE:

That psychiatric diagnoses increased suicide risks among people with autism suggests supports to reduce such risks “should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses,” write the authors.

SOURCE:

The study was conducted by Meng-Chuan Lai, MD, PhD, Centre for Addiction and Mental Health, Toronto, and colleagues. It was published online in JAMA Network Open.

LIMITATIONS:

The autism cohort didn’t capture those diagnosed in private practices or with subtle presentations not yet diagnosed. Misclassification of autistic people in the nonautistic cohort may have resulted in underestimation of suicide-related outcomes. The administrative data don’t reliably identify diagnoses associated with suicide risks such as attention-deficit/hyperactivity disorder or subcategories of mood disorders, and don’t contain information about risk and protective mechanisms of suicide behaviors such as family history.

DISCLOSURES:

The study received support from ICES, an independent nonprofit research institute; the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario; the Academic Scholars Award from the Department of Psychiatry, University of Toronto; and the Canadian Institutes of Health Research Sex and Gender Science Chair. Dr. Lai reported receiving personal fees from SAGE Publications as an editorial honorarium outside the submitted work. One coauthor reported receiving honoraria from the BMJ Group, Archives of Diseases in Childhood.

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

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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

One of the most controversial issues today is whether a physician should be permitted, or even obligated, to assist patients with a terminal or incurable illness to end their life – a process known as medical assistance in dying (MAID) or physician-assisted suicide (PAS.)

Until recently, this contentious issue applied only to patients with physical illnesses who want to end their suffering and who seek out a physician willing to assist with that objective. In the United States and other countries, this is the patient population who may be able to avail themselves of this option.

However, newly proposed legislation in Canada – which has the largest number of physician-assisted deaths worldwide – would expand the indication for MAID to include serious mental illness. Originally set to be passed in March 2023, the law has been deferred for final decision until March 2024.

A recent commentary by psychiatrist Dinah Miller, MD, explored the ethics of this proposed legislation for mental health professionals. “To offer the option of death facilitated by the very person who is trying to get [patients with serious mental illness] better seems so counter to everything I have learned and contradicts our role as psychiatrists who work so hard to prevent suicide,” Dr. Miller wrote. “As psychiatrists, do we offer hope to our most vulnerable patients, or do we offer death? Do we rail against suicide, or do we facilitate it?”

Dr. Miller’s piece garnered a huge amount of reader response that included many laudatory comments: a “nuanced and open-ended inquiry here,” “timely and honest,” and “beautifully written.” One reader thanked the author for “this thoughtful, questioning, and open reflection on what it means to be a psychiatrist facing a thorny and deeply personal practice and philosophical question.”
 

Cognitive distortion or objective reality?

Many readers were opposed to any type of physician involvement in hastening a patient’s death, regardless of whether the condition is medical or psychiatric. “Let others who wish to die make their own arrangement without the aid of the medical profession,” one reader wrote.

But others felt that for those with terminal physical illnesses or intractable pain, it is justified for medical professionals to either facilitate death or, at the very least, withhold life-prolonging treatments.

A critical-care physician described responding to families’ accusations that withdrawal of life-sustaining measures means “playing God.” On the contrary, the physician wrote, “there is a limit to our abilities; and withdrawing those life-prolonging interventions allows nature or God or whatever to play a role and take its course.”

Another U.S. reader pointed out that “multiple polls in this country have shown that the majority of the general public, physicians in general and psychiatrists in particular, support the option of MAID for the terminally ill. They do not find it at variance with their calling as physicians.”

“I and many of my elderly friends don’t fear death but fear prolonged dementia with its dependency and lack of quality of life,” one reader wrote. “We would be much more at peace if we could put in our advanced directive that we request MAID once some point of dependency has been reached.”

Another wrote that in the event of entering a state of “degrading dependency and hardship on the family, please let me go peacefully, without burdening others, into that good night [of death].”

Many felt that not only physical illness but also the prospect of cognitive degeneration – specifically dementia – also justifies assisting patient death.
 

“Enormous suffering”

One Canadian reader noted that provisions for advance consent are now in place in Canada for those facing the prospect of neurodegenerative disease and who are still mentally competent to make such decisions.

But therein lies the rub – the concept of an advanced directive goes to the question of decisional capacity. Dr. Miller noted that “depression distorts cognition and leads many patients to believe that they would be better off dead and that their loves ones would be better off without them.”

The concept of “cognitive distortion” implies that the illness itself may impede the decisional capacity required for an advanced directive or a decision made in the moment, in the absence of such a directive. Dr. Miller asked, “How do we determine whether patients with serious mental illness are competent to make such a decision or whether it is mental illness that is driving their perception of a future without hope?”

One reader attested to this from personal experience. “As both a physician and a sufferer of severe, often profound depression for 50 years, I can confidently say that ... the pursuit of death is the result of an impaired mental state, which simultaneously prevents a rational decision.”

Another agreed. “As a psychiatrist, I treated suicidal patients almost every day of my 27-year career. I believe in making every effort to prevent the suicide of a healthy depressed person and I do not support MAID for psychiatric conditions. But I do support MAID for the terminally ill.”

Other readers disagreed. In the words of one commentator, “I think that if we are going to help mentally ill people, we have to consider their choices. The stress imposed by a severe/intractable mental illness is as bad as any other devastating medical illness. If no one is going to hold their hand in life (as support services are limited and psychiatric treatments often fail), allow a medical professional to hold their hand through their final moments.”

A psychiatrist described very ill patients with treatment-resistant bipolar disorder who had not only received medications, including ketamine, but had also received electroconvulsive therapy and still did not respond.

“Their suffering is enormous and the truth is that there is no improvement for more than a few days or weeks and later they return to their hell. Appreciating that they would be better off dead for themselves and their families is not always a cognitive distortion but an objective evaluation of their reality.”

However, as another reader pointed out, an issue with the argument presented here is that it presupposes that MAID requires “clinical justification.” But in Canada, “MAID ... is understood as an expression of personal autonomy. Rooted in liberal political philosophy of individualism ... approval for death need not be based on a clinical assessment.” Instead, “death is seen as a ‘right’ that the state must therefore provide.”
 

Another form of eugenics?

Dr. Miller raised the ethical implications of racial and socioeconomic factors playing a role in the consideration of MAID for those with psychiatric illness.

“Might those who are poor, who have less access to expensive treatment options and social support, be more likely to request facilitated death?” she asks. “Do we risk facilitating a patient’s demise when other options are unavailable because of a lack of access to treatment or when social and financial struggles exacerbate a person’s hopelessness? Should we worry that psychiatric euthanasia will turn into a form of eugenics where those who can’t contribute are made to feel that they should bow out?”

Several readers agreed. “Looking at the disproportionate burden of illness, rates of imprisonment, and application of the death penalty indicates to me that race and socioeconomic status will be an immediate factor in how, where, and with whom MAID for mental illness would be practice in much, if not all, of the U.S.,” wrote one physician.

A Canadian reader expressed similar concerns. “I’ve seen a handful of people, including someone I considered a good friend, opt for MAID because it was easier than living as a disabled person in poverty without adequate mental health care.”

Another Canadian clinician noted that offering people good care can make all the difference. “As a Canadian mental health clinician who served youth with severe mental illness for over 20 years through our socialized medical network, I can attest to the difference good care usually makes in shifting clients from despair and a commitment to death to embracing life once again. Let’s not, as clinicians, embrace easing a government/state-sanctioned pathway to death.”

Some readers believe that these types of issues can’t be solved with a blanket approach, noting that each case is different. “Real life is always more complicated than academic discussions. Having served on a hospital ethics committee, I know that each case is unique,” one reader noted.

Another reader added, “I think all we can do as physicians is to let people decide for themselves and participate only if our conscience allows.”
 

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