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More than 30 experts question validity of serotonin/depression study
The authors of the article, however, stand by their conclusion.
“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.
In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
‘No convincing evidence’
Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.
Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.
The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.
The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.
Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
‘Unconventional, odd’ methodology
However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”
Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.
Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.
For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.
He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”
With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.
For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.
“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.
Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
No new data
An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.
And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.
In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.
Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.
“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.
“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”
If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
Dr. Moncrieff pushes back
Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.
“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”
These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”
In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.
In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”
It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.
Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.
A version of this article originally appeared on Medscape.com.
The authors of the article, however, stand by their conclusion.
“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.
In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
‘No convincing evidence’
Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.
Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.
The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.
The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.
Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
‘Unconventional, odd’ methodology
However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”
Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.
Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.
For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.
He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”
With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.
For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.
“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.
Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
No new data
An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.
And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.
In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.
Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.
“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.
“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”
If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
Dr. Moncrieff pushes back
Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.
“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”
These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”
In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.
In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”
It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.
Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.
A version of this article originally appeared on Medscape.com.
The authors of the article, however, stand by their conclusion.
“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.
In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
‘No convincing evidence’
Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.
Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.
The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.
The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.
Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
‘Unconventional, odd’ methodology
However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”
Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.
Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.
For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.
He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”
With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.
For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.
“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.
Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
No new data
An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.
And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.
In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.
Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.
“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.
“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”
If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
Dr. Moncrieff pushes back
Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.
“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”
These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”
In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.
In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”
It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.
Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.
A version of this article originally appeared on Medscape.com.
Limiting social media use in youths brings challenges, benefits
Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.
How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.
Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.
A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.
Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.
And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.
As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.
After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.
While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that
Goal: 30 minutes a day
In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.
At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.
“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”
Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”
Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
‘Youth are aware’
Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”
In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.
From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.
“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.
In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
Less FOMO, less anxiety
In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.
At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.
And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.
While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”
She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.
“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
Be ‘more mindful’
These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.
But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.
As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
Real-world strategies
Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.
But for many other teens and young adults, the struggle to stay off social media is real.
Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.
Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”
She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”
During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.
“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.
Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.
“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.
These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”
A version of this article first appeared on WebMD.com.
Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.
How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.
Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.
A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.
Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.
And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.
As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.
After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.
While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that
Goal: 30 minutes a day
In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.
At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.
“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”
Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”
Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
‘Youth are aware’
Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”
In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.
From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.
“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.
In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
Less FOMO, less anxiety
In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.
At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.
And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.
While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”
She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.
“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
Be ‘more mindful’
These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.
But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.
As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
Real-world strategies
Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.
But for many other teens and young adults, the struggle to stay off social media is real.
Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.
Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”
She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”
During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.
“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.
Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.
“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.
These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”
A version of this article first appeared on WebMD.com.
Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.
How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.
Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.
A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.
Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.
And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.
As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.
After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.
While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that
Goal: 30 minutes a day
In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.
At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.
“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”
Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”
Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
‘Youth are aware’
Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”
In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.
From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.
“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.
In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
Less FOMO, less anxiety
In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.
At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.
And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.
While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”
She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.
“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
Be ‘more mindful’
These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.
But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.
As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
Real-world strategies
Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.
But for many other teens and young adults, the struggle to stay off social media is real.
Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.
Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”
She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”
During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.
“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.
Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.
“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.
These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”
A version of this article first appeared on WebMD.com.
Agency issues advisory on mental health symptoms of long COVID
The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.
The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.
“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”
The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements.
“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”
A version of this article first appeared on WebMD.com.
The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.
The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.
“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”
The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements.
“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”
A version of this article first appeared on WebMD.com.
The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.
The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.
“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”
The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements.
“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”
A version of this article first appeared on WebMD.com.
CBSM phone app eases anxiety, depression in cancer patients
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
CHICAGO – One-third of patients with cancer also experience anxiety or depression, and an estimated 70% of the 18 million patients with cancer and cancer survivors in the US experience emotional symptoms, including fear of recurrence.
Despite many having these symptoms, few patients with cancer have access to psycho-oncologic support.
A digital cognitive-behavioral stress management (CBSM) application may help to ease some of the burden, reported Allison Ramiller, MPH, of Blue Note Therapeutics in San Francisco, which developed the app version of the program.
In addition, patients assigned to the CBSM app were twice as likely as control persons to report that their symptoms were “much” or “very much” improved after using the app for 12 weeks, Ms. Ramiller reported at an oral abstract session at the annual meeting of the American Society of Clinical Oncology (ASCO).
However, the investigators did not report baseline characteristics of patients in each of the study arms, which might have helped to clarify the depth of the effects they saw.
The CBSM program was developed by Michael H. Antoni, PhD, and colleagues in the University of Miami Health System. It is based on cognitive-behavioral therapy but also includes stress management and relaxation techniques to help patients cope with cancer-specific stress.
“”It has been clinically validated and shown to benefit patients with cancer,” Ms. Ramiller said. “However, access is a problem,” she said.
“There aren’t enough qualified, trained providers for the need, and patients with cancer encounter barriers to in-person participation, including things like transportation or financial barriers. So to overcome this, we developed a digitized version of CBSM,” she explained.
Impressive and elegant
“Everything about [the study] I thought was very impressive, very elegant, very nicely done,” said invited discussant Raymond U. Osarogiagbon, MBBS, FACP, chief scientist at Baptist Memorial Health Care Corp in Memphis, Tenn.
“They showed efficacy, they showed safety – very nice – user friendliness – very good. Certainly they look like they’re trying to address a highly important, unmet need in a very elegant way. Certainly, they pointed out it needs longer follow-up to see sustainability. We need to see will this work in other settings. Will this be cost-effective? You’ve gotta believe it probably will be,” he said.
CBSM has previously been shown to help patients with cancer reduce stress, improve general and cancer-specific quality of life at various stages of treatment, reduce symptom burden, and improve coping skills, Ms. Ramiller said.
To see whether these benefits could be conveyed digitally rather than in face-to-face encounters, Ms. Ramiller and colleagues worked with Dr. Antoni to develop the CBSM app.
Patients using the app received therapeutic content over 10 sessions with audio, video, and interactive tools that mimicked the sessions they would have received during in-person interventions.
They then compared the app against the control educational app in the randomized, decentralized RESTORE study.
High-quality control
Ms. Ramiller said that the control app set “a high bar.”
“The control also offered 10 interactive self-guided sessions. Both treatment apps were professionally designed and visually similar in styling, and they were presented as digital therapeutic-specific for cancer patients. And they were also in a match condition, meaning they received the same attention from study staff and cadence of reminders, but importantly, only the intervention app was based on CBSM,” she explained.
A total of 449 patients with cancers of stage I–III who were undergoing active systemic treatment or were planning to undergo such treatment within 6 months were randomly assigned to the CBSM app or the control app.
The CBSM app was superior to the control app for the primary outcome of anxiety reduction over baseline, as measured at 4, 8 and 12 weeks by the Patient-Reported Outcomes Measurement Information System Anxiety Scale (PROMIS-A) (beta = -.03; P = .019).
CBSM was also significantly better than the control app for the secondary endpoints of reducing symptoms of depression, as measured by the PROMIS-D scale (beta = -.02, P = .042), and also at increasing the percentage of patients who reported improvement in anxiety and depression symptoms on the Patient Global Impression of Change instrument (P < .001)
An extension study of the durability of the effects at 3 and 6 months is underway.
The investigators noted that the incremental cost of management of anxiety or depression is greater than $17,000 per patient per year.
“One of the big promises of a digital therapeutic like this is that it could potentially reduce costs,” Ms. Ramiller told the audience, but she acknowledged, “More work is really needed, however, to directly test the potential savings.”
The RESTORE study is funded by Blue Note Therapeutics. Dr. Osarogiagbon owns stock in Gilead, Lilly, and Pfizer, has received honoraria from Biodesix and Medscape, and has a consulting or advisory role for the American Cancer Society AstraZeneca, Genentech/Roche, LUNGevity, National Cancer Institute, and Triptych Health Partners.
A version of this article originally appeared on Medscape.com.
AT ASCO 2023
New cannabis laws, higher binge drinking rates linked
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
Among adolescents, binge drinking, defined as having five or more drinks for men and four or more drinks for women at one time, is associated with poor academic performance, sexual risk, and injury in the short term, as well as the development of alcohol use disorder and academic disengagement in the long term.
Current evidence regarding the association between recreational cannabis laws (RCLs) and binge drinking is limited.
States in which RCLs have been implemented include Colorado, Washington, Alaska, Oregon, Nevada, California, Massachusetts, and Vermont, as well as the District of Columbia.
The study included 817,359 people aged 12 and older who participated in the 2008-2019 National Survey on Drug Use and Health (NSDUH), a nationally representative survey of the U.S. population.
TAKEAWAY:
Overall, states that have not enacted cannabis laws showed consistently lower rates of binge drinking over time among all age groups.
In all states, there were substantial declines in reporting of past-month binge drinking in some age groups – from 17.5% (95% confidence interval, 16.9-18.2) in 2008 to 11.1% (10.4-11.8) in 2019 among those aged 12-20 and a drop from 43.7% (42.4-44.9) to 40.2% (39.1-41.1) among those aged 21-30.
There were overall increases in binge drinking in all states regardless of cannabis laws among individuals aged 31 and older. The most extensive increases were among people aged 31-40 (from 28.1% [95% CI, 26.6-29.6] to 33.3% [32.1-34.6]), followed by participants aged 51 and over (from 13.3% [95% CI, 12.2-14.4] to 16.8% [15.8-17.7]).
IN PRACTICE:
“Our findings support calls to reinforce health care providers’ discussions about alcohol use with older adults,” particularly in RCL states, the researchers write.
STUDY DETAILS:
The study was conducted out by Priscila Dib Gonçalves, PhD, department of epidemiology, Columbia University School of Public Health, New York, and colleagues. It was published in the International Journal of Drug Policy.
LIMITATIONS:
Alcohol-related measures, including binge drinking, were self-reported, which may introduce recall bias and underreporting. NSDUH binge drinking measures were not adjusted for sex differences from 2008 to 2014, which may result in underreporting of binge drinking in females before 2015. The researchers did not examine cannabis policy provisions, such as cultivation restrictions, pricing control, the tax imposed, and consumption restrictions.
DISCLOSURES:
The study received support from the National Institutes of Health, the National Institute on Drug Abuse, the National Center for Injury Prevention and Control, and the Centers for Disease Control and Prevention. The authors report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
SSRI improves cognition, major depression in early dementia
TOPLINE:
METHODOLOGY:
- The multicenter MEMORY study included 82 subjects with MDD and early-stage dementia, mean age 70.3 years, mostly female (66%) and White (95%).
- Vortioxetine, a modulator of 5-hydroxytryptamine receptor activity and an inhibitor of the 5-HT transporter, initiated at 5 mg/day (recommended starting dose in older adults) with the dose up-titrated to 10 mg/day after a week and flexible dosing thereafter.
- Depression was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), and cognition with the Digit Symbol Substitution Test (DSST) and Rey Auditory Verbal Learning Test.
TAKEAWAY:
- There was significant and clinically meaningful improvement in the severity of depressive symptoms, as measured by MADRS total score (the primary outcome), at all assessment time points (P < .0001).
- Improvements in depressive symptoms were irrespective of dementia type.
- There were also significant improvements in DSST total score (P < .0001) and in daily functioning and health-related quality of life (HRQoL).
- Vortioxetine was well tolerated; side effects, including nausea and abdominal pain, were mostly mild to moderate.
IN PRACTICE:
“Vortioxetine demonstrated effectiveness in clinically significantly improving depressive symptoms, cognitive performance, daily and global functioning, and HRQoL in patients with MDD and comorbid early-stage dementia treated for 12 weeks” the researchers noted.
STUDY DETAILS:
The study was conducted by Michael Cronquist Christensen from pharmaceutical company H. Lundbeck, Valby, Denmark, and colleagues. It was published online in the Journal of Affective Disorders.
LIMITATIONS:
The study is open label and lacked a control group. Learning effects were possible, which could contribute to improved cognitive performance, although significant improvement on the RAVLT was not observed until week 4, suggesting earning effects were minimal.
DISCLOSURES:
The study was funded by H. Lundbeck. Mr. Christensen is an employee of H. Lundbeck.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The multicenter MEMORY study included 82 subjects with MDD and early-stage dementia, mean age 70.3 years, mostly female (66%) and White (95%).
- Vortioxetine, a modulator of 5-hydroxytryptamine receptor activity and an inhibitor of the 5-HT transporter, initiated at 5 mg/day (recommended starting dose in older adults) with the dose up-titrated to 10 mg/day after a week and flexible dosing thereafter.
- Depression was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), and cognition with the Digit Symbol Substitution Test (DSST) and Rey Auditory Verbal Learning Test.
TAKEAWAY:
- There was significant and clinically meaningful improvement in the severity of depressive symptoms, as measured by MADRS total score (the primary outcome), at all assessment time points (P < .0001).
- Improvements in depressive symptoms were irrespective of dementia type.
- There were also significant improvements in DSST total score (P < .0001) and in daily functioning and health-related quality of life (HRQoL).
- Vortioxetine was well tolerated; side effects, including nausea and abdominal pain, were mostly mild to moderate.
IN PRACTICE:
“Vortioxetine demonstrated effectiveness in clinically significantly improving depressive symptoms, cognitive performance, daily and global functioning, and HRQoL in patients with MDD and comorbid early-stage dementia treated for 12 weeks” the researchers noted.
STUDY DETAILS:
The study was conducted by Michael Cronquist Christensen from pharmaceutical company H. Lundbeck, Valby, Denmark, and colleagues. It was published online in the Journal of Affective Disorders.
LIMITATIONS:
The study is open label and lacked a control group. Learning effects were possible, which could contribute to improved cognitive performance, although significant improvement on the RAVLT was not observed until week 4, suggesting earning effects were minimal.
DISCLOSURES:
The study was funded by H. Lundbeck. Mr. Christensen is an employee of H. Lundbeck.
A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- The multicenter MEMORY study included 82 subjects with MDD and early-stage dementia, mean age 70.3 years, mostly female (66%) and White (95%).
- Vortioxetine, a modulator of 5-hydroxytryptamine receptor activity and an inhibitor of the 5-HT transporter, initiated at 5 mg/day (recommended starting dose in older adults) with the dose up-titrated to 10 mg/day after a week and flexible dosing thereafter.
- Depression was assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS), and cognition with the Digit Symbol Substitution Test (DSST) and Rey Auditory Verbal Learning Test.
TAKEAWAY:
- There was significant and clinically meaningful improvement in the severity of depressive symptoms, as measured by MADRS total score (the primary outcome), at all assessment time points (P < .0001).
- Improvements in depressive symptoms were irrespective of dementia type.
- There were also significant improvements in DSST total score (P < .0001) and in daily functioning and health-related quality of life (HRQoL).
- Vortioxetine was well tolerated; side effects, including nausea and abdominal pain, were mostly mild to moderate.
IN PRACTICE:
“Vortioxetine demonstrated effectiveness in clinically significantly improving depressive symptoms, cognitive performance, daily and global functioning, and HRQoL in patients with MDD and comorbid early-stage dementia treated for 12 weeks” the researchers noted.
STUDY DETAILS:
The study was conducted by Michael Cronquist Christensen from pharmaceutical company H. Lundbeck, Valby, Denmark, and colleagues. It was published online in the Journal of Affective Disorders.
LIMITATIONS:
The study is open label and lacked a control group. Learning effects were possible, which could contribute to improved cognitive performance, although significant improvement on the RAVLT was not observed until week 4, suggesting earning effects were minimal.
DISCLOSURES:
The study was funded by H. Lundbeck. Mr. Christensen is an employee of H. Lundbeck.
A version of this article first appeared on Medscape.com.
Final USPSTF recommendations on anxiety, depression, suicide risk
In line with draft recommendations, the task force for the first time has endorsed screening for anxiety disorders in all adults younger than age 65 without recognized signs or symptoms of anxiety.
This “B” recommendation reflects “moderate certainty” evidence that screening for anxiety in this population has a moderate net benefit. There currently is not enough evidence to recommend for or against screening for anxiety disorders in adults 65 and older, the task force said.
The USPSTF final recommendation statements and corresponding evidence summaries were published online in the Journal of the American Medical Association, as well as on the task force website.
Jury out on screening for suicide risk
The task force continues to recommend screening all adults for depression. This “B” recommendation reflects moderate-certainty evidence that screening for major depression in adults has a moderate net benefit.
However, there is not enough evidence to recommend for or against screening for suicide risk in all adults. Therefore, the task issued an “I” statement, indicating that the balance of benefits and harms cannot be determined at present.
“We are urgently calling for more research to determine the effectiveness of screening all adults for suicide risk and screening adults 65 and older for anxiety disorders,” task force member Gbenga Ogedegbe, MD, MPH, founding director of the Institute for Excellence in Health Equity at NYU Langone Health, New York, said in a statement.
The authors of an accompanying editorial noted that a positive screen result for anxiety “should be immediately followed with clinical evaluation for suicidality”.
Murray Stein, MD, MPH, and Linda Hill, MD, MPH, both with University of California, San Diego, also noted that a positive screen for anxiety could be indicative of posttraumatic stress disorder (PTSD) and clinicians should “be prepared to follow up with requisite questions about traumatic experiences that will be needed to home in on a diagnosis of PTSD that may require additional follow-up, referral, or both.
“Anxiety disorders can be distressing and disabling, and appropriate recognition and treatment can be life-altering and, in some cases, lifesaving, for patients,” Dr. Stein and Dr. Hill pointed out.
Effective, evidence-based psychological and pharmacologic treatments for anxiety disorders are available, they added. But the recommendation to routinely screen for anxiety disorder “must be accompanied by the recognition that there are too few mental health specialists available to manage the care of all patients with anxiety disorders, and even fewer who provide services for low-income and non-English-speaking populations,” they wrote.
This research report received no commercial funding. Disclosures for task force members and editorial writers are listed with the original articles.
A version of this article originally appeared on Medscape.com.
In line with draft recommendations, the task force for the first time has endorsed screening for anxiety disorders in all adults younger than age 65 without recognized signs or symptoms of anxiety.
This “B” recommendation reflects “moderate certainty” evidence that screening for anxiety in this population has a moderate net benefit. There currently is not enough evidence to recommend for or against screening for anxiety disorders in adults 65 and older, the task force said.
The USPSTF final recommendation statements and corresponding evidence summaries were published online in the Journal of the American Medical Association, as well as on the task force website.
Jury out on screening for suicide risk
The task force continues to recommend screening all adults for depression. This “B” recommendation reflects moderate-certainty evidence that screening for major depression in adults has a moderate net benefit.
However, there is not enough evidence to recommend for or against screening for suicide risk in all adults. Therefore, the task issued an “I” statement, indicating that the balance of benefits and harms cannot be determined at present.
“We are urgently calling for more research to determine the effectiveness of screening all adults for suicide risk and screening adults 65 and older for anxiety disorders,” task force member Gbenga Ogedegbe, MD, MPH, founding director of the Institute for Excellence in Health Equity at NYU Langone Health, New York, said in a statement.
The authors of an accompanying editorial noted that a positive screen result for anxiety “should be immediately followed with clinical evaluation for suicidality”.
Murray Stein, MD, MPH, and Linda Hill, MD, MPH, both with University of California, San Diego, also noted that a positive screen for anxiety could be indicative of posttraumatic stress disorder (PTSD) and clinicians should “be prepared to follow up with requisite questions about traumatic experiences that will be needed to home in on a diagnosis of PTSD that may require additional follow-up, referral, or both.
“Anxiety disorders can be distressing and disabling, and appropriate recognition and treatment can be life-altering and, in some cases, lifesaving, for patients,” Dr. Stein and Dr. Hill pointed out.
Effective, evidence-based psychological and pharmacologic treatments for anxiety disorders are available, they added. But the recommendation to routinely screen for anxiety disorder “must be accompanied by the recognition that there are too few mental health specialists available to manage the care of all patients with anxiety disorders, and even fewer who provide services for low-income and non-English-speaking populations,” they wrote.
This research report received no commercial funding. Disclosures for task force members and editorial writers are listed with the original articles.
A version of this article originally appeared on Medscape.com.
In line with draft recommendations, the task force for the first time has endorsed screening for anxiety disorders in all adults younger than age 65 without recognized signs or symptoms of anxiety.
This “B” recommendation reflects “moderate certainty” evidence that screening for anxiety in this population has a moderate net benefit. There currently is not enough evidence to recommend for or against screening for anxiety disorders in adults 65 and older, the task force said.
The USPSTF final recommendation statements and corresponding evidence summaries were published online in the Journal of the American Medical Association, as well as on the task force website.
Jury out on screening for suicide risk
The task force continues to recommend screening all adults for depression. This “B” recommendation reflects moderate-certainty evidence that screening for major depression in adults has a moderate net benefit.
However, there is not enough evidence to recommend for or against screening for suicide risk in all adults. Therefore, the task issued an “I” statement, indicating that the balance of benefits and harms cannot be determined at present.
“We are urgently calling for more research to determine the effectiveness of screening all adults for suicide risk and screening adults 65 and older for anxiety disorders,” task force member Gbenga Ogedegbe, MD, MPH, founding director of the Institute for Excellence in Health Equity at NYU Langone Health, New York, said in a statement.
The authors of an accompanying editorial noted that a positive screen result for anxiety “should be immediately followed with clinical evaluation for suicidality”.
Murray Stein, MD, MPH, and Linda Hill, MD, MPH, both with University of California, San Diego, also noted that a positive screen for anxiety could be indicative of posttraumatic stress disorder (PTSD) and clinicians should “be prepared to follow up with requisite questions about traumatic experiences that will be needed to home in on a diagnosis of PTSD that may require additional follow-up, referral, or both.
“Anxiety disorders can be distressing and disabling, and appropriate recognition and treatment can be life-altering and, in some cases, lifesaving, for patients,” Dr. Stein and Dr. Hill pointed out.
Effective, evidence-based psychological and pharmacologic treatments for anxiety disorders are available, they added. But the recommendation to routinely screen for anxiety disorder “must be accompanied by the recognition that there are too few mental health specialists available to manage the care of all patients with anxiety disorders, and even fewer who provide services for low-income and non-English-speaking populations,” they wrote.
This research report received no commercial funding. Disclosures for task force members and editorial writers are listed with the original articles.
A version of this article originally appeared on Medscape.com.
Tips for addressing uptick in mental health visits: Primary care providers collaborate, innovate
This growth in the number of patients needing behavioral health–related care is likely driven by multiple factors, including a shortage of mental health care providers, an increasing incidence of psychiatric illness, and destigmatization of mental health in general, suggested Swetha P. Iruku, MD, MPH, associate professor of family medicine and community health at the University of Pennsylvania and Penn Medicine family physician in Philadelphia.
The Centers for Disease Control and Prevention noted that “the COVID-19 pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders,” in a Morbidity and Mortality Weekly Report.
From June 24 to 30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19, and symptoms of anxiety disorder and depressive disorder climbed during the months of April through June of the same year, compared with the same period in 2019, they wrote.
Even before the pandemic got underway, multiple studies of national data published this year suggested mental issues were on the rise in the United States. For example, the proportion of adult patient visits to primary care providers that addressed mental health concerns rose from 10.7% to 15.9% from 2006 to 2018, according to research published in Health Affairs. Plus, the number and proportion of pediatric acute care hospitalizations because of mental health diagnoses increased significantly between 2009 and 2019, according to a paper published in JAMA.
“I truly believe that we can’t, as primary care physicians, take care of someone’s physical health without also taking care of their mental health,” Dr. Iruku said in an interview. “It’s all intertwined.”
To rise to this challenge, PCPs first need a collaborative mindset, she suggested, as well as familiarity with available resources, both locally and virtually.
This article examines strategies for managing mental illness in primary care, outlines clinical resources, and reviews related educational opportunities.
In addition, clinical pearls are shared by Dr. Iruku and five other clinicians who provide or have provided mental health care to primary care patients or work in close collaboration with a primary care practice, including a clinical psychologist, a nurse practitioner licensed in psychiatric health, a pediatrician, and a licensed clinical social worker.
Build a network
Most of the providers interviewed cited the importance of collaboration in mental health care, particularly for complex cases.
“I would recommend [that primary care providers get] to know the psychiatric providers [in their area],” said Jessica Viton, DNP, FNP, PMHNP, who delivers mental health care through a community-based primary care practice in Colorado which she requested remain anonymous.
Dr. Iruku suggested making an in-person connection first, if possible.
“So much of what we do is ‘see one, do one, teach one,’ so learn a little bit, then go off and trial,” she said. “[It can be valuable] having someone in your back pocket that you can contact in the case of an emergency, or in a situation where you just don’t know how to tackle it.”
Screen for depression and anxiety
William J. Sieber, PhD, a clinical psychologist, director of integrated behavioral health, and professor in the department of family medicine and public health and the department of psychiatry at the University of California, San Diego, said primary care providers should screen all adult patients for depression and anxiety with the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder Assessment (GAD-7), respectively.
To save time, he suggested a cascading approach.
“In primary care, everybody’s in a hurry,” Dr. Sieber said. “[With the cascading approach,] the first two items [from each questionnaire] are given, and if a person endorses either of those items … then they are asked to complete the other items.”
Jennifer Mullally, MD, a pediatrician at Sanford Health in Fargo, N.D., uses this cascading approach to depression and anxiety screening with all her patients aged 13-18. For younger kids, she screens only those who present with signs or symptoms of mental health issues, or if the parent shares a concern.
This approach differs slightly from U.S. Preventive Services Task Force recommendations, which suggest screening for anxiety in patients aged 8-18 years and depression in patients aged 12-18 years.
Use other screening tools only as needed
Dr. Sieber, the research director for the division of family medicine at UC San Diego, collaborates regularly with primary care providers via hallway consultations, by sharing cases, and through providing oversight of psychiatric care at 13 primary care practices within the UC San Diego network. He recommended against routine screening beyond depression and anxiety in the primary care setting.
“There are a lot of screening tools,” Dr. Sieber said. “It depends on what you’re presented with. The challenge in primary care is you’re going to see all kinds of things. It’s not like running a depression clinic.”
Other than the PHQ-9 and GAD-7, he suggested primary care providers establish familiarity with screening tools for posttraumatic stress disorder and attention-deficit/hyperactivity disorder, noting again that these should be used only when one of the conditions is already suspected.
Dr. Mullally follows a similar approach with her pediatric population. In addition to the GAD-7, she investigates whether a patient has anxiety with the Screen for Child Anxiety Related Disorders (SCARED). For depression, she couples the PHQ-9 with the Columbia Suicide Severity Rating Scale.
While additional screening tools like these are readily available online, Dr. Viton suggested that they should be employed only if the provider is trained to interpret and respond to those findings, and only if they know which tool to use, and when.
For example, she has recently observed PCPs diagnosing adults with ADHD using a three-question test, when in fact a full-length, standardized instrument should be administered by a provider with necessary training.
She also pointed out that bipolar disorder continues to be underdiagnosed, possibly because of providers detecting depression using a questionnaire like the PHQ-9, while failing to inquire about manic episodes.
Leverage online resources
If depression is confirmed, Dr. Iruku often directs the patient to the Mayo Clinic Depression Medication Choice Decision Aid. This website steers patients through medication options based on their answers to a questionnaire. Choices are listed alongside possible adverse effects.
For clinician use, Dr. Iruku recommended The Waco Guide to Psychopharmacology in Primary Care, which aids clinical decision-making for mental illness and substance abuse. The app processes case details to suggest first-, second-, and third-line pharmacotherapies, as well as modifications based on patient needs.
Even with tools like these, however, a referral may be needed.
“[Primary care providers] may not be the best fit for what the patient is looking for, from a mental health or behavioral standpoint,” Dr. Sieber said.
In this case, he encourages patients to visit Psychology Today, a “quite popular portal” that helps patients locate a suitable provider based on location, insurance, driving radius, and mental health concern. This usually generates 10-20 options, Dr. Sieber said, although results can vary.
“It may be discouraging, because maybe only three [providers] pop up based on your criteria, and the closest one is miles away,” he said.
Consider virtual support
If no local psychiatric help is available, Dr. Sieber suggested virtual support, highlighting that “it’s much easier now than it was 3 or 4 years ago” to connect patients with external mental health care.
But this strategy should be reserved for cases of actual need instead of pure convenience, cautioned Dr. Viton, who noted that virtual visits may fail to capture the nuance of an in-person meeting, as body language, mode of dress, and other clues can provide insights into mental health status.
“Occasionally, I think you do have to have an in-person visit, especially when you’re developing a rapport with someone,” Dr. Viton said.
Claire McArdle, a licensed clinical social worker in Fort Collins, Colo., noted that virtual care from an outside provider may also impede the collaboration needed to effectively address mental illness.
In her 11 years in primary care at Associates in Family Medicine, Ms. McArdle had countless interactions with colleagues seeking support when managing a complex case. “I’m coaching providers, front desk staff, and nursing staff on how to interact with patients [with] behavioral health needs,” she said, citing the multitude of nonmedical factors that need to be considered, such as family relationships and patient preferences.
These unscheduled conversations with colleagues throughout the day are impossible to have when sharing a case with an unknown, remote peer.
Ms. McArdle speaks from experience. She recently resigned from Associates in Family Medicine to start her own private therapy practice after her former employer was acquired by VillageMD, a national provider that terminated employment of most other social workers in the practice and began outsourcing mental health care to Mindoula Health, a virtual provider.
Dr. Sieber offered a similar perspective on in-person collaboration as the psychiatric specialist at his center. He routinely offers on-site support for both providers and patients, serving as “another set of eyes and ears” when there is a concern about patient safety or directly managing care when a patient is hospitalized for mental illness.
While virtual solutions may fall short of in-person management, they can offer care at a scale and cost impossible through traditional practice.
This could even be free. Zero-cost, automated software now allows individuals who are uninsured or unable to afford care at least one avenue to manage their mental health concerns.
For example, Bliss is a free, 8-session, interactive online therapy program for depression that was created by the Centre for Interactive Mental Health Solutions. The program offers a tool for monitoring mood and quizzes to test understanding of personal mental health management, among other features.
More advanced programs are emerging as artificial intelligence (AI) enables dialogues between humans and machines. This is the case with Woebot, an app that asks the user about their mood throughout the day, and responds with evidence-based strategies for managing concerns, all for free at press time.
Keep learning
A range of educational options and professional resources are available for primary care providers who would like to improve their knowledge of mental health care. These include formal fellowships in primary care psychiatry/behavioral health integration, free mental health webinars, and various other opportunities.
Eric Eschweiler, DNP, APRN, FNP-C, PHN, completed the University of California, Irvine, Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship in 2016, when he was working as a solo nurse practitioner.
“I was drowning in practice,” said Dr. Eschweiler, director of nursing and public health outreach services at Riverside-San Bernardino County Indian Health, Grand Terrace, Calif., in an interview. “I was a solo NP. There was no physician on site. We were seeing a lot of [individuals with] schizoaffective [disorder] in downtown San Bernardino, the homeless, unhoused – a lot of substance use. I felt I needed to have the skills to be able to treat them effectively. That’s what the fellowship did.”
The skills Dr. Eschweiler learned from participating in his fellowship allowed him to manage more cases of mental illness without need for referral. When a referral was needed for a complex or severe case, he had the confidence to bridge care and collaborate more effectively with psychiatric specialists.
“It was awesome, because we were able to communicate using the same language,” Dr. Eschweiler said of these collaborations. “It’s [about] talking that same language, starting those initial treatments, and then moving forward with specialty care, and vice versa. [Psychiatric specialists] would send me patients that needed medical care because of the types of medications they were taking. And I was then very well aware of those side effects and other issues that might come up from those treatments. So it’s a two-way street.”
Dr. Eschweiler was so impressed by his fellowship that he has since ushered multiple providers through the program since transitioning to an administrative role as director of nursing.
In Fargo, where psychiatric care is sparse and wait times for referral can be months long, Dr. Mullally, like Dr. Eschweiler, knew that she needed more training in mental health.
“I don’t feel like we get enough training in residency,” Dr. Mullally said. “So you do need to look at your options for further CME.”
Out of several CME courses she has taken to further her understanding of pediatric psychiatry, Dr. Mullally recommended The Reach Institute above all others, as their courses involve in-depth discussions and valuable handouts, particularly for medication selection.
“I think that a lot of the other CMEs tend to involve a lot more PowerPoint presentations,” Dr. Mullally said. “And you don’t necessarily leave with a lot of good documents. I still use my Reach handouts. I have them sitting right next to me. I use them every single day.”
Providers interested in The Reach Institute, however, should be prepared to invest both time and money, she added, citing a 2-3 day commitment, and calling it “not cheap.” To overcome these barriers, she suggested that providers get their institution to support their attendance.
For a lighter commitment, Dr. Iruku recommended the American Academy of Family Physicians CME portal, as this offers 13 online, accredited courses covering a range of topics, from adolescent health to substance abuse disorders.
Dr. Sieber suggested that primary care providers join the Collaborative Family Healthcare Association, which aims to integrate physical and behavioral health in routine practice. CFHA, of which he is a member, offers a “bevy of different resources” for interested providers, including a conference in Phoenix this October.
The interviewees disclosed no conflicts of interest.
This growth in the number of patients needing behavioral health–related care is likely driven by multiple factors, including a shortage of mental health care providers, an increasing incidence of psychiatric illness, and destigmatization of mental health in general, suggested Swetha P. Iruku, MD, MPH, associate professor of family medicine and community health at the University of Pennsylvania and Penn Medicine family physician in Philadelphia.
The Centers for Disease Control and Prevention noted that “the COVID-19 pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders,” in a Morbidity and Mortality Weekly Report.
From June 24 to 30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19, and symptoms of anxiety disorder and depressive disorder climbed during the months of April through June of the same year, compared with the same period in 2019, they wrote.
Even before the pandemic got underway, multiple studies of national data published this year suggested mental issues were on the rise in the United States. For example, the proportion of adult patient visits to primary care providers that addressed mental health concerns rose from 10.7% to 15.9% from 2006 to 2018, according to research published in Health Affairs. Plus, the number and proportion of pediatric acute care hospitalizations because of mental health diagnoses increased significantly between 2009 and 2019, according to a paper published in JAMA.
“I truly believe that we can’t, as primary care physicians, take care of someone’s physical health without also taking care of their mental health,” Dr. Iruku said in an interview. “It’s all intertwined.”
To rise to this challenge, PCPs first need a collaborative mindset, she suggested, as well as familiarity with available resources, both locally and virtually.
This article examines strategies for managing mental illness in primary care, outlines clinical resources, and reviews related educational opportunities.
In addition, clinical pearls are shared by Dr. Iruku and five other clinicians who provide or have provided mental health care to primary care patients or work in close collaboration with a primary care practice, including a clinical psychologist, a nurse practitioner licensed in psychiatric health, a pediatrician, and a licensed clinical social worker.
Build a network
Most of the providers interviewed cited the importance of collaboration in mental health care, particularly for complex cases.
“I would recommend [that primary care providers get] to know the psychiatric providers [in their area],” said Jessica Viton, DNP, FNP, PMHNP, who delivers mental health care through a community-based primary care practice in Colorado which she requested remain anonymous.
Dr. Iruku suggested making an in-person connection first, if possible.
“So much of what we do is ‘see one, do one, teach one,’ so learn a little bit, then go off and trial,” she said. “[It can be valuable] having someone in your back pocket that you can contact in the case of an emergency, or in a situation where you just don’t know how to tackle it.”
Screen for depression and anxiety
William J. Sieber, PhD, a clinical psychologist, director of integrated behavioral health, and professor in the department of family medicine and public health and the department of psychiatry at the University of California, San Diego, said primary care providers should screen all adult patients for depression and anxiety with the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder Assessment (GAD-7), respectively.
To save time, he suggested a cascading approach.
“In primary care, everybody’s in a hurry,” Dr. Sieber said. “[With the cascading approach,] the first two items [from each questionnaire] are given, and if a person endorses either of those items … then they are asked to complete the other items.”
Jennifer Mullally, MD, a pediatrician at Sanford Health in Fargo, N.D., uses this cascading approach to depression and anxiety screening with all her patients aged 13-18. For younger kids, she screens only those who present with signs or symptoms of mental health issues, or if the parent shares a concern.
This approach differs slightly from U.S. Preventive Services Task Force recommendations, which suggest screening for anxiety in patients aged 8-18 years and depression in patients aged 12-18 years.
Use other screening tools only as needed
Dr. Sieber, the research director for the division of family medicine at UC San Diego, collaborates regularly with primary care providers via hallway consultations, by sharing cases, and through providing oversight of psychiatric care at 13 primary care practices within the UC San Diego network. He recommended against routine screening beyond depression and anxiety in the primary care setting.
“There are a lot of screening tools,” Dr. Sieber said. “It depends on what you’re presented with. The challenge in primary care is you’re going to see all kinds of things. It’s not like running a depression clinic.”
Other than the PHQ-9 and GAD-7, he suggested primary care providers establish familiarity with screening tools for posttraumatic stress disorder and attention-deficit/hyperactivity disorder, noting again that these should be used only when one of the conditions is already suspected.
Dr. Mullally follows a similar approach with her pediatric population. In addition to the GAD-7, she investigates whether a patient has anxiety with the Screen for Child Anxiety Related Disorders (SCARED). For depression, she couples the PHQ-9 with the Columbia Suicide Severity Rating Scale.
While additional screening tools like these are readily available online, Dr. Viton suggested that they should be employed only if the provider is trained to interpret and respond to those findings, and only if they know which tool to use, and when.
For example, she has recently observed PCPs diagnosing adults with ADHD using a three-question test, when in fact a full-length, standardized instrument should be administered by a provider with necessary training.
She also pointed out that bipolar disorder continues to be underdiagnosed, possibly because of providers detecting depression using a questionnaire like the PHQ-9, while failing to inquire about manic episodes.
Leverage online resources
If depression is confirmed, Dr. Iruku often directs the patient to the Mayo Clinic Depression Medication Choice Decision Aid. This website steers patients through medication options based on their answers to a questionnaire. Choices are listed alongside possible adverse effects.
For clinician use, Dr. Iruku recommended The Waco Guide to Psychopharmacology in Primary Care, which aids clinical decision-making for mental illness and substance abuse. The app processes case details to suggest first-, second-, and third-line pharmacotherapies, as well as modifications based on patient needs.
Even with tools like these, however, a referral may be needed.
“[Primary care providers] may not be the best fit for what the patient is looking for, from a mental health or behavioral standpoint,” Dr. Sieber said.
In this case, he encourages patients to visit Psychology Today, a “quite popular portal” that helps patients locate a suitable provider based on location, insurance, driving radius, and mental health concern. This usually generates 10-20 options, Dr. Sieber said, although results can vary.
“It may be discouraging, because maybe only three [providers] pop up based on your criteria, and the closest one is miles away,” he said.
Consider virtual support
If no local psychiatric help is available, Dr. Sieber suggested virtual support, highlighting that “it’s much easier now than it was 3 or 4 years ago” to connect patients with external mental health care.
But this strategy should be reserved for cases of actual need instead of pure convenience, cautioned Dr. Viton, who noted that virtual visits may fail to capture the nuance of an in-person meeting, as body language, mode of dress, and other clues can provide insights into mental health status.
“Occasionally, I think you do have to have an in-person visit, especially when you’re developing a rapport with someone,” Dr. Viton said.
Claire McArdle, a licensed clinical social worker in Fort Collins, Colo., noted that virtual care from an outside provider may also impede the collaboration needed to effectively address mental illness.
In her 11 years in primary care at Associates in Family Medicine, Ms. McArdle had countless interactions with colleagues seeking support when managing a complex case. “I’m coaching providers, front desk staff, and nursing staff on how to interact with patients [with] behavioral health needs,” she said, citing the multitude of nonmedical factors that need to be considered, such as family relationships and patient preferences.
These unscheduled conversations with colleagues throughout the day are impossible to have when sharing a case with an unknown, remote peer.
Ms. McArdle speaks from experience. She recently resigned from Associates in Family Medicine to start her own private therapy practice after her former employer was acquired by VillageMD, a national provider that terminated employment of most other social workers in the practice and began outsourcing mental health care to Mindoula Health, a virtual provider.
Dr. Sieber offered a similar perspective on in-person collaboration as the psychiatric specialist at his center. He routinely offers on-site support for both providers and patients, serving as “another set of eyes and ears” when there is a concern about patient safety or directly managing care when a patient is hospitalized for mental illness.
While virtual solutions may fall short of in-person management, they can offer care at a scale and cost impossible through traditional practice.
This could even be free. Zero-cost, automated software now allows individuals who are uninsured or unable to afford care at least one avenue to manage their mental health concerns.
For example, Bliss is a free, 8-session, interactive online therapy program for depression that was created by the Centre for Interactive Mental Health Solutions. The program offers a tool for monitoring mood and quizzes to test understanding of personal mental health management, among other features.
More advanced programs are emerging as artificial intelligence (AI) enables dialogues between humans and machines. This is the case with Woebot, an app that asks the user about their mood throughout the day, and responds with evidence-based strategies for managing concerns, all for free at press time.
Keep learning
A range of educational options and professional resources are available for primary care providers who would like to improve their knowledge of mental health care. These include formal fellowships in primary care psychiatry/behavioral health integration, free mental health webinars, and various other opportunities.
Eric Eschweiler, DNP, APRN, FNP-C, PHN, completed the University of California, Irvine, Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship in 2016, when he was working as a solo nurse practitioner.
“I was drowning in practice,” said Dr. Eschweiler, director of nursing and public health outreach services at Riverside-San Bernardino County Indian Health, Grand Terrace, Calif., in an interview. “I was a solo NP. There was no physician on site. We were seeing a lot of [individuals with] schizoaffective [disorder] in downtown San Bernardino, the homeless, unhoused – a lot of substance use. I felt I needed to have the skills to be able to treat them effectively. That’s what the fellowship did.”
The skills Dr. Eschweiler learned from participating in his fellowship allowed him to manage more cases of mental illness without need for referral. When a referral was needed for a complex or severe case, he had the confidence to bridge care and collaborate more effectively with psychiatric specialists.
“It was awesome, because we were able to communicate using the same language,” Dr. Eschweiler said of these collaborations. “It’s [about] talking that same language, starting those initial treatments, and then moving forward with specialty care, and vice versa. [Psychiatric specialists] would send me patients that needed medical care because of the types of medications they were taking. And I was then very well aware of those side effects and other issues that might come up from those treatments. So it’s a two-way street.”
Dr. Eschweiler was so impressed by his fellowship that he has since ushered multiple providers through the program since transitioning to an administrative role as director of nursing.
In Fargo, where psychiatric care is sparse and wait times for referral can be months long, Dr. Mullally, like Dr. Eschweiler, knew that she needed more training in mental health.
“I don’t feel like we get enough training in residency,” Dr. Mullally said. “So you do need to look at your options for further CME.”
Out of several CME courses she has taken to further her understanding of pediatric psychiatry, Dr. Mullally recommended The Reach Institute above all others, as their courses involve in-depth discussions and valuable handouts, particularly for medication selection.
“I think that a lot of the other CMEs tend to involve a lot more PowerPoint presentations,” Dr. Mullally said. “And you don’t necessarily leave with a lot of good documents. I still use my Reach handouts. I have them sitting right next to me. I use them every single day.”
Providers interested in The Reach Institute, however, should be prepared to invest both time and money, she added, citing a 2-3 day commitment, and calling it “not cheap.” To overcome these barriers, she suggested that providers get their institution to support their attendance.
For a lighter commitment, Dr. Iruku recommended the American Academy of Family Physicians CME portal, as this offers 13 online, accredited courses covering a range of topics, from adolescent health to substance abuse disorders.
Dr. Sieber suggested that primary care providers join the Collaborative Family Healthcare Association, which aims to integrate physical and behavioral health in routine practice. CFHA, of which he is a member, offers a “bevy of different resources” for interested providers, including a conference in Phoenix this October.
The interviewees disclosed no conflicts of interest.
This growth in the number of patients needing behavioral health–related care is likely driven by multiple factors, including a shortage of mental health care providers, an increasing incidence of psychiatric illness, and destigmatization of mental health in general, suggested Swetha P. Iruku, MD, MPH, associate professor of family medicine and community health at the University of Pennsylvania and Penn Medicine family physician in Philadelphia.
The Centers for Disease Control and Prevention noted that “the COVID-19 pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders,” in a Morbidity and Mortality Weekly Report.
From June 24 to 30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19, and symptoms of anxiety disorder and depressive disorder climbed during the months of April through June of the same year, compared with the same period in 2019, they wrote.
Even before the pandemic got underway, multiple studies of national data published this year suggested mental issues were on the rise in the United States. For example, the proportion of adult patient visits to primary care providers that addressed mental health concerns rose from 10.7% to 15.9% from 2006 to 2018, according to research published in Health Affairs. Plus, the number and proportion of pediatric acute care hospitalizations because of mental health diagnoses increased significantly between 2009 and 2019, according to a paper published in JAMA.
“I truly believe that we can’t, as primary care physicians, take care of someone’s physical health without also taking care of their mental health,” Dr. Iruku said in an interview. “It’s all intertwined.”
To rise to this challenge, PCPs first need a collaborative mindset, she suggested, as well as familiarity with available resources, both locally and virtually.
This article examines strategies for managing mental illness in primary care, outlines clinical resources, and reviews related educational opportunities.
In addition, clinical pearls are shared by Dr. Iruku and five other clinicians who provide or have provided mental health care to primary care patients or work in close collaboration with a primary care practice, including a clinical psychologist, a nurse practitioner licensed in psychiatric health, a pediatrician, and a licensed clinical social worker.
Build a network
Most of the providers interviewed cited the importance of collaboration in mental health care, particularly for complex cases.
“I would recommend [that primary care providers get] to know the psychiatric providers [in their area],” said Jessica Viton, DNP, FNP, PMHNP, who delivers mental health care through a community-based primary care practice in Colorado which she requested remain anonymous.
Dr. Iruku suggested making an in-person connection first, if possible.
“So much of what we do is ‘see one, do one, teach one,’ so learn a little bit, then go off and trial,” she said. “[It can be valuable] having someone in your back pocket that you can contact in the case of an emergency, or in a situation where you just don’t know how to tackle it.”
Screen for depression and anxiety
William J. Sieber, PhD, a clinical psychologist, director of integrated behavioral health, and professor in the department of family medicine and public health and the department of psychiatry at the University of California, San Diego, said primary care providers should screen all adult patients for depression and anxiety with the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder Assessment (GAD-7), respectively.
To save time, he suggested a cascading approach.
“In primary care, everybody’s in a hurry,” Dr. Sieber said. “[With the cascading approach,] the first two items [from each questionnaire] are given, and if a person endorses either of those items … then they are asked to complete the other items.”
Jennifer Mullally, MD, a pediatrician at Sanford Health in Fargo, N.D., uses this cascading approach to depression and anxiety screening with all her patients aged 13-18. For younger kids, she screens only those who present with signs or symptoms of mental health issues, or if the parent shares a concern.
This approach differs slightly from U.S. Preventive Services Task Force recommendations, which suggest screening for anxiety in patients aged 8-18 years and depression in patients aged 12-18 years.
Use other screening tools only as needed
Dr. Sieber, the research director for the division of family medicine at UC San Diego, collaborates regularly with primary care providers via hallway consultations, by sharing cases, and through providing oversight of psychiatric care at 13 primary care practices within the UC San Diego network. He recommended against routine screening beyond depression and anxiety in the primary care setting.
“There are a lot of screening tools,” Dr. Sieber said. “It depends on what you’re presented with. The challenge in primary care is you’re going to see all kinds of things. It’s not like running a depression clinic.”
Other than the PHQ-9 and GAD-7, he suggested primary care providers establish familiarity with screening tools for posttraumatic stress disorder and attention-deficit/hyperactivity disorder, noting again that these should be used only when one of the conditions is already suspected.
Dr. Mullally follows a similar approach with her pediatric population. In addition to the GAD-7, she investigates whether a patient has anxiety with the Screen for Child Anxiety Related Disorders (SCARED). For depression, she couples the PHQ-9 with the Columbia Suicide Severity Rating Scale.
While additional screening tools like these are readily available online, Dr. Viton suggested that they should be employed only if the provider is trained to interpret and respond to those findings, and only if they know which tool to use, and when.
For example, she has recently observed PCPs diagnosing adults with ADHD using a three-question test, when in fact a full-length, standardized instrument should be administered by a provider with necessary training.
She also pointed out that bipolar disorder continues to be underdiagnosed, possibly because of providers detecting depression using a questionnaire like the PHQ-9, while failing to inquire about manic episodes.
Leverage online resources
If depression is confirmed, Dr. Iruku often directs the patient to the Mayo Clinic Depression Medication Choice Decision Aid. This website steers patients through medication options based on their answers to a questionnaire. Choices are listed alongside possible adverse effects.
For clinician use, Dr. Iruku recommended The Waco Guide to Psychopharmacology in Primary Care, which aids clinical decision-making for mental illness and substance abuse. The app processes case details to suggest first-, second-, and third-line pharmacotherapies, as well as modifications based on patient needs.
Even with tools like these, however, a referral may be needed.
“[Primary care providers] may not be the best fit for what the patient is looking for, from a mental health or behavioral standpoint,” Dr. Sieber said.
In this case, he encourages patients to visit Psychology Today, a “quite popular portal” that helps patients locate a suitable provider based on location, insurance, driving radius, and mental health concern. This usually generates 10-20 options, Dr. Sieber said, although results can vary.
“It may be discouraging, because maybe only three [providers] pop up based on your criteria, and the closest one is miles away,” he said.
Consider virtual support
If no local psychiatric help is available, Dr. Sieber suggested virtual support, highlighting that “it’s much easier now than it was 3 or 4 years ago” to connect patients with external mental health care.
But this strategy should be reserved for cases of actual need instead of pure convenience, cautioned Dr. Viton, who noted that virtual visits may fail to capture the nuance of an in-person meeting, as body language, mode of dress, and other clues can provide insights into mental health status.
“Occasionally, I think you do have to have an in-person visit, especially when you’re developing a rapport with someone,” Dr. Viton said.
Claire McArdle, a licensed clinical social worker in Fort Collins, Colo., noted that virtual care from an outside provider may also impede the collaboration needed to effectively address mental illness.
In her 11 years in primary care at Associates in Family Medicine, Ms. McArdle had countless interactions with colleagues seeking support when managing a complex case. “I’m coaching providers, front desk staff, and nursing staff on how to interact with patients [with] behavioral health needs,” she said, citing the multitude of nonmedical factors that need to be considered, such as family relationships and patient preferences.
These unscheduled conversations with colleagues throughout the day are impossible to have when sharing a case with an unknown, remote peer.
Ms. McArdle speaks from experience. She recently resigned from Associates in Family Medicine to start her own private therapy practice after her former employer was acquired by VillageMD, a national provider that terminated employment of most other social workers in the practice and began outsourcing mental health care to Mindoula Health, a virtual provider.
Dr. Sieber offered a similar perspective on in-person collaboration as the psychiatric specialist at his center. He routinely offers on-site support for both providers and patients, serving as “another set of eyes and ears” when there is a concern about patient safety or directly managing care when a patient is hospitalized for mental illness.
While virtual solutions may fall short of in-person management, they can offer care at a scale and cost impossible through traditional practice.
This could even be free. Zero-cost, automated software now allows individuals who are uninsured or unable to afford care at least one avenue to manage their mental health concerns.
For example, Bliss is a free, 8-session, interactive online therapy program for depression that was created by the Centre for Interactive Mental Health Solutions. The program offers a tool for monitoring mood and quizzes to test understanding of personal mental health management, among other features.
More advanced programs are emerging as artificial intelligence (AI) enables dialogues between humans and machines. This is the case with Woebot, an app that asks the user about their mood throughout the day, and responds with evidence-based strategies for managing concerns, all for free at press time.
Keep learning
A range of educational options and professional resources are available for primary care providers who would like to improve their knowledge of mental health care. These include formal fellowships in primary care psychiatry/behavioral health integration, free mental health webinars, and various other opportunities.
Eric Eschweiler, DNP, APRN, FNP-C, PHN, completed the University of California, Irvine, Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship in 2016, when he was working as a solo nurse practitioner.
“I was drowning in practice,” said Dr. Eschweiler, director of nursing and public health outreach services at Riverside-San Bernardino County Indian Health, Grand Terrace, Calif., in an interview. “I was a solo NP. There was no physician on site. We were seeing a lot of [individuals with] schizoaffective [disorder] in downtown San Bernardino, the homeless, unhoused – a lot of substance use. I felt I needed to have the skills to be able to treat them effectively. That’s what the fellowship did.”
The skills Dr. Eschweiler learned from participating in his fellowship allowed him to manage more cases of mental illness without need for referral. When a referral was needed for a complex or severe case, he had the confidence to bridge care and collaborate more effectively with psychiatric specialists.
“It was awesome, because we were able to communicate using the same language,” Dr. Eschweiler said of these collaborations. “It’s [about] talking that same language, starting those initial treatments, and then moving forward with specialty care, and vice versa. [Psychiatric specialists] would send me patients that needed medical care because of the types of medications they were taking. And I was then very well aware of those side effects and other issues that might come up from those treatments. So it’s a two-way street.”
Dr. Eschweiler was so impressed by his fellowship that he has since ushered multiple providers through the program since transitioning to an administrative role as director of nursing.
In Fargo, where psychiatric care is sparse and wait times for referral can be months long, Dr. Mullally, like Dr. Eschweiler, knew that she needed more training in mental health.
“I don’t feel like we get enough training in residency,” Dr. Mullally said. “So you do need to look at your options for further CME.”
Out of several CME courses she has taken to further her understanding of pediatric psychiatry, Dr. Mullally recommended The Reach Institute above all others, as their courses involve in-depth discussions and valuable handouts, particularly for medication selection.
“I think that a lot of the other CMEs tend to involve a lot more PowerPoint presentations,” Dr. Mullally said. “And you don’t necessarily leave with a lot of good documents. I still use my Reach handouts. I have them sitting right next to me. I use them every single day.”
Providers interested in The Reach Institute, however, should be prepared to invest both time and money, she added, citing a 2-3 day commitment, and calling it “not cheap.” To overcome these barriers, she suggested that providers get their institution to support their attendance.
For a lighter commitment, Dr. Iruku recommended the American Academy of Family Physicians CME portal, as this offers 13 online, accredited courses covering a range of topics, from adolescent health to substance abuse disorders.
Dr. Sieber suggested that primary care providers join the Collaborative Family Healthcare Association, which aims to integrate physical and behavioral health in routine practice. CFHA, of which he is a member, offers a “bevy of different resources” for interested providers, including a conference in Phoenix this October.
The interviewees disclosed no conflicts of interest.
Probiotics an effective adjunct to antidepressants for major depression
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY
Are you a physician ... or a vending machine?
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.