Mental Health

TOPLINE

Mean lipid levels are similar among adolescents with and without major depressive disorder (MDD), as is the proportion of adolescents with borderline-high lipid levels.

METHODOLOGY

Teen depression is associated with an increased likelihood of experiencing cardiovascular (CV) events, with dyslipidemia being a potentially modifiable risk factor.

Only a few studies have examined the association between depression and lipids during adolescence, when confounding comorbidities such as obesity and diabetes are less common.

The study included 243 adolescents (186 with MDD and 57 healthy controls [HCs]) who were mostly female and had a mean age of 15 years.

Researchers assessed CV risk factors including body mass index (BMI), blood pressure, smoking status, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride (TG), which were classified as acceptable or borderline high.

Dyslipidemia was defined as having concentration of at least one lipid outside the acceptable range.
 

TAKEAWAY

Most participants in both groups had lipid concentrations within the acceptable range.

There were no differences between study groups in mean lipid levels after adjusting for age, sex, and standardized BMI.

There were also no differences in the proportion of adolescents with borderline-high lipid concentrations.

Among youth with MDD, greater depressive symptoms were associated with higher HDL levels and a lower TG:HDL ratio after adjusting for sex, age, and standardized BMI.
 

IN PRACTICE

“Taken together, results of the current study support the need for further examination of the relationship between gender, depression, and cholesterol,” the authors write.

STUDY DETAILS

The study was conducted by Anisa F. Khalfan, Neurosciences and Mental Health research program, SickKids Research Institute, Toronto, Canada, and colleagues. It was published online in the Journal of Affective Disorders.

LIMITATIONS

The HC group was relatively small, which might have contributed to the null findings. The mean Center for Epidemiologic Studies Depression Scale for Children (CES-DC) score was 8.3 among healthy youth, compared with 37.5 among MDD youth, limiting detection of an association related to depression severity.

DISCLOSURES

The study was supported by the Lunenfeld Summer Studentship. The authors report no relevant financial relationships.

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

TOPLINE

Mean lipid levels are similar among adolescents with and without major depressive disorder (MDD), as is the proportion of adolescents with borderline-high lipid levels.

METHODOLOGY

Teen depression is associated with an increased likelihood of experiencing cardiovascular (CV) events, with dyslipidemia being a potentially modifiable risk factor.

Only a few studies have examined the association between depression and lipids during adolescence, when confounding comorbidities such as obesity and diabetes are less common.

The study included 243 adolescents (186 with MDD and 57 healthy controls [HCs]) who were mostly female and had a mean age of 15 years.

Researchers assessed CV risk factors including body mass index (BMI), blood pressure, smoking status, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride (TG), which were classified as acceptable or borderline high.

Dyslipidemia was defined as having concentration of at least one lipid outside the acceptable range.
 

TAKEAWAY

Most participants in both groups had lipid concentrations within the acceptable range.

There were no differences between study groups in mean lipid levels after adjusting for age, sex, and standardized BMI.

There were also no differences in the proportion of adolescents with borderline-high lipid concentrations.

Among youth with MDD, greater depressive symptoms were associated with higher HDL levels and a lower TG:HDL ratio after adjusting for sex, age, and standardized BMI.
 

IN PRACTICE

“Taken together, results of the current study support the need for further examination of the relationship between gender, depression, and cholesterol,” the authors write.

STUDY DETAILS

The study was conducted by Anisa F. Khalfan, Neurosciences and Mental Health research program, SickKids Research Institute, Toronto, Canada, and colleagues. It was published online in the Journal of Affective Disorders.

LIMITATIONS

The HC group was relatively small, which might have contributed to the null findings. The mean Center for Epidemiologic Studies Depression Scale for Children (CES-DC) score was 8.3 among healthy youth, compared with 37.5 among MDD youth, limiting detection of an association related to depression severity.

DISCLOSURES

The study was supported by the Lunenfeld Summer Studentship. The authors report no relevant financial relationships.

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

TOPLINE

Mean lipid levels are similar among adolescents with and without major depressive disorder (MDD), as is the proportion of adolescents with borderline-high lipid levels.

METHODOLOGY

Teen depression is associated with an increased likelihood of experiencing cardiovascular (CV) events, with dyslipidemia being a potentially modifiable risk factor.

Only a few studies have examined the association between depression and lipids during adolescence, when confounding comorbidities such as obesity and diabetes are less common.

The study included 243 adolescents (186 with MDD and 57 healthy controls [HCs]) who were mostly female and had a mean age of 15 years.

Researchers assessed CV risk factors including body mass index (BMI), blood pressure, smoking status, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride (TG), which were classified as acceptable or borderline high.

Dyslipidemia was defined as having concentration of at least one lipid outside the acceptable range.
 

TAKEAWAY

Most participants in both groups had lipid concentrations within the acceptable range.

There were no differences between study groups in mean lipid levels after adjusting for age, sex, and standardized BMI.

There were also no differences in the proportion of adolescents with borderline-high lipid concentrations.

Among youth with MDD, greater depressive symptoms were associated with higher HDL levels and a lower TG:HDL ratio after adjusting for sex, age, and standardized BMI.
 

IN PRACTICE

“Taken together, results of the current study support the need for further examination of the relationship between gender, depression, and cholesterol,” the authors write.

STUDY DETAILS

The study was conducted by Anisa F. Khalfan, Neurosciences and Mental Health research program, SickKids Research Institute, Toronto, Canada, and colleagues. It was published online in the Journal of Affective Disorders.

LIMITATIONS

The HC group was relatively small, which might have contributed to the null findings. The mean Center for Epidemiologic Studies Depression Scale for Children (CES-DC) score was 8.3 among healthy youth, compared with 37.5 among MDD youth, limiting detection of an association related to depression severity.

DISCLOSURES

The study was supported by the Lunenfeld Summer Studentship. The authors report no relevant financial relationships.

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

Baseline depression was significantly associated with recovered, incident, and persistent metabolic syndrome, based on data from more than 13,000 individuals.

Previous research has established a connection between metabolic syndrome and depression, but data on the increased risk for depressed individuals to develop metabolic syndrome (MetS) are lacking, wrote Lara Onofre Ferriani, PhD, of Federal University of Espírito Santo, Vitoria, Brazil, and colleagues.

“Individuals with MetS and depression have increased levels of inflammatory markers, and it is speculated that inflammation could mediate this comorbidity,” they said.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 13,883 participants in the Brazilian Longitudinal Study of Adult Health; all were civil servants at universities in Brazil. The participants ranged from 35 to 74 years of age, with a mean age of 51.9 years; 54.3% were women; and 52.4% were white; the mean follow-up period was 3.8 years.

The primary outcome was the association between depression diagnosis and severity on components of MetS at baseline and over a 4-year period. Participants were classified by MetS trajectory as recovered, incident, or persistent, and classified by depression status as without depression or with a mild, moderate, or severe current depressive episode. Depression status was based on the Clinical Interview Schedule Revised. MetS components and diagnosis were based on the National Cholesterol Education Program Adult Treatment Panel III.

In a logistic regression analysis, baseline depression was positively associated with recovered, incident, and persistent MetS (odds ratios, 1.59, 1.45, and 1.70, respectively).

Depression at baseline also was significantly associated with separate components of MetS: large waist circumference, high triglycerides, low high-density lipoprotein cholesterol, and hyperglycemia, with odds ratios of 1.47, 1.23, 1.30, and 1.38, respectively.

Although not seen at baseline, a significant positive association between baseline depression and the presence of three or more MetS components was noted at follow-up, with a positive dose-response effect, the researchers wrote in their discussion.

Not all associations were statistically significant, but this was mainly because of the small number of cases of moderate and severe depression, they said. However, the magnitude of associations was greater in severe depression, when compared with moderate and mild, which suggests that the risk of MetS may be higher in this population, they added.

The study findings were limited by several factors including the possible misclassification of depression, inability to differentiate among depressive subtypes, and the potential lack of generalizability to other populations beyond Brazilian civil servants, the researchers noted.

However, the results were strengthened by the large sample size and support the role of depression as a risk factor for MetS, they said. More research is needed to determine a bidirectional relationship and to assess the trajectory of depression after MetS develops, but the findings “highlight the need to investigate and manage metabolic and cardiovascular alterations in the presence of depression in clinical settings,” they concluded.

The study was supported by the Brazilian Ministry of Health (Science and Technology Department) and the Brazilian Ministry of Science, Technology and Innovation FINEP and CNPq, and by the Coordenaçaõ de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES). The researchers had no financial conflicts to disclose.
 

Baseline depression was significantly associated with recovered, incident, and persistent metabolic syndrome, based on data from more than 13,000 individuals.

Previous research has established a connection between metabolic syndrome and depression, but data on the increased risk for depressed individuals to develop metabolic syndrome (MetS) are lacking, wrote Lara Onofre Ferriani, PhD, of Federal University of Espírito Santo, Vitoria, Brazil, and colleagues.

“Individuals with MetS and depression have increased levels of inflammatory markers, and it is speculated that inflammation could mediate this comorbidity,” they said.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 13,883 participants in the Brazilian Longitudinal Study of Adult Health; all were civil servants at universities in Brazil. The participants ranged from 35 to 74 years of age, with a mean age of 51.9 years; 54.3% were women; and 52.4% were white; the mean follow-up period was 3.8 years.

The primary outcome was the association between depression diagnosis and severity on components of MetS at baseline and over a 4-year period. Participants were classified by MetS trajectory as recovered, incident, or persistent, and classified by depression status as without depression or with a mild, moderate, or severe current depressive episode. Depression status was based on the Clinical Interview Schedule Revised. MetS components and diagnosis were based on the National Cholesterol Education Program Adult Treatment Panel III.

In a logistic regression analysis, baseline depression was positively associated with recovered, incident, and persistent MetS (odds ratios, 1.59, 1.45, and 1.70, respectively).

Depression at baseline also was significantly associated with separate components of MetS: large waist circumference, high triglycerides, low high-density lipoprotein cholesterol, and hyperglycemia, with odds ratios of 1.47, 1.23, 1.30, and 1.38, respectively.

Although not seen at baseline, a significant positive association between baseline depression and the presence of three or more MetS components was noted at follow-up, with a positive dose-response effect, the researchers wrote in their discussion.

Not all associations were statistically significant, but this was mainly because of the small number of cases of moderate and severe depression, they said. However, the magnitude of associations was greater in severe depression, when compared with moderate and mild, which suggests that the risk of MetS may be higher in this population, they added.

The study findings were limited by several factors including the possible misclassification of depression, inability to differentiate among depressive subtypes, and the potential lack of generalizability to other populations beyond Brazilian civil servants, the researchers noted.

However, the results were strengthened by the large sample size and support the role of depression as a risk factor for MetS, they said. More research is needed to determine a bidirectional relationship and to assess the trajectory of depression after MetS develops, but the findings “highlight the need to investigate and manage metabolic and cardiovascular alterations in the presence of depression in clinical settings,” they concluded.

The study was supported by the Brazilian Ministry of Health (Science and Technology Department) and the Brazilian Ministry of Science, Technology and Innovation FINEP and CNPq, and by the Coordenaçaõ de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES). The researchers had no financial conflicts to disclose.
 

Baseline depression was significantly associated with recovered, incident, and persistent metabolic syndrome, based on data from more than 13,000 individuals.

Previous research has established a connection between metabolic syndrome and depression, but data on the increased risk for depressed individuals to develop metabolic syndrome (MetS) are lacking, wrote Lara Onofre Ferriani, PhD, of Federal University of Espírito Santo, Vitoria, Brazil, and colleagues.

“Individuals with MetS and depression have increased levels of inflammatory markers, and it is speculated that inflammation could mediate this comorbidity,” they said.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 13,883 participants in the Brazilian Longitudinal Study of Adult Health; all were civil servants at universities in Brazil. The participants ranged from 35 to 74 years of age, with a mean age of 51.9 years; 54.3% were women; and 52.4% were white; the mean follow-up period was 3.8 years.

The primary outcome was the association between depression diagnosis and severity on components of MetS at baseline and over a 4-year period. Participants were classified by MetS trajectory as recovered, incident, or persistent, and classified by depression status as without depression or with a mild, moderate, or severe current depressive episode. Depression status was based on the Clinical Interview Schedule Revised. MetS components and diagnosis were based on the National Cholesterol Education Program Adult Treatment Panel III.

In a logistic regression analysis, baseline depression was positively associated with recovered, incident, and persistent MetS (odds ratios, 1.59, 1.45, and 1.70, respectively).

Depression at baseline also was significantly associated with separate components of MetS: large waist circumference, high triglycerides, low high-density lipoprotein cholesterol, and hyperglycemia, with odds ratios of 1.47, 1.23, 1.30, and 1.38, respectively.

Although not seen at baseline, a significant positive association between baseline depression and the presence of three or more MetS components was noted at follow-up, with a positive dose-response effect, the researchers wrote in their discussion.

Not all associations were statistically significant, but this was mainly because of the small number of cases of moderate and severe depression, they said. However, the magnitude of associations was greater in severe depression, when compared with moderate and mild, which suggests that the risk of MetS may be higher in this population, they added.

The study findings were limited by several factors including the possible misclassification of depression, inability to differentiate among depressive subtypes, and the potential lack of generalizability to other populations beyond Brazilian civil servants, the researchers noted.

However, the results were strengthened by the large sample size and support the role of depression as a risk factor for MetS, they said. More research is needed to determine a bidirectional relationship and to assess the trajectory of depression after MetS develops, but the findings “highlight the need to investigate and manage metabolic and cardiovascular alterations in the presence of depression in clinical settings,” they concluded.

The study was supported by the Brazilian Ministry of Health (Science and Technology Department) and the Brazilian Ministry of Science, Technology and Innovation FINEP and CNPq, and by the Coordenaçaõ de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES). The researchers had no financial conflicts to disclose.
 

With the exception of lysergic acid diethylamide, use of hallucinogens surged between 2018 and 2021 among adults younger than 30 years in the United States, new research shows.

In 2018, the prevalence of young adults’ past-year use of non-LSD hallucinogens was 3.4%. By 2021, it had jumped to 6.6%.

The increase in non-LSD hallucinogen use occurred while LSD use remained stable at around 4% in 2018 and 2021.

“While non-LSD hallucinogen use remains substantially less prevalent than use of substances such as alcohol and cannabis, a doubling of prevalence in just three years is a dramatic increase and raises possible public health concerns,” co-author Megan Patrick, PhD, with the University of Michigan Institute for Social Research, Ann Arbor, said in a news release.

The results were published online in the journal Addiction.
 

Health concerns

The estimates are derived from the Monitoring the Future study, which includes annual assessments of adolescent and adult health in the United States.

The analysis focused on 11,304 persons (52% female) aged 9-30 years from the U.S. general population who were interviewed between 2018 and 2021.

Participants were asked about past 12-month use of LSD, as well as use of non-LSD hallucinogens, such as psilocybin.

From 2018 to 2021, past 12-month use of LSD remained relatively stable; it was 3.7% in 2018 and 4.2% in 2021.

However, non-LSD hallucinogen use increased in prevalence from 3.4% to 6.6% from 2018 to 2021.

Across years, the odds of non-LSD use were higher among males, White people, and individuals from households with higher parental education – a proxy for higher socioeconomic status.

The most commonly used non-LSD hallucinogen was psilocybin.

The survey did not ask whether young adults used non-LSD hallucinogens for therapeutic or medical reasons.

“The use of psychedelic and hallucinogenic drugs for a range of therapeutic uses is increasing, given accumulating yet still preliminary data from randomized trials on clinical effectiveness,” lead author Katherine Keyes, PhD, with Columbia University Mailman School of Public Health, New York, said in the release.

“With increased visibility for medical and therapeutic use, however, potentially comes diversion and unregulated product availability, as well as a lack of understanding among the public of potential risks,” Dr. Keyes added.

“However, approved therapeutic use of psychedelics under a trained health professional’s care remains uncommon in the United States, thus the trends we observe here are undoubtedly in nonmedical and nontherapeutic use,” Dr. Keyes noted.

Dr. Patrick said the increased use of hallucinogens raises “concern for young adult health” and is not without risk. While hallucinogen dependence has historically been rare in the U.S. population, it could become more common as use increases, she noted.

The researchers will continue to track these trends to see whether the increases continue.

“We need additional research, including about the motives for hallucinogen use and how young adults are using these substances, in order to be able to mitigate the associated negative consequences,” Dr. Patrick said.

The study was funded by the National Institute on Drug Abuse, part of the National Institutes of Health. Dr. Keyes and Dr. Patrick have disclosed no relevant financial relationships.

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

With the exception of lysergic acid diethylamide, use of hallucinogens surged between 2018 and 2021 among adults younger than 30 years in the United States, new research shows.

In 2018, the prevalence of young adults’ past-year use of non-LSD hallucinogens was 3.4%. By 2021, it had jumped to 6.6%.

The increase in non-LSD hallucinogen use occurred while LSD use remained stable at around 4% in 2018 and 2021.

“While non-LSD hallucinogen use remains substantially less prevalent than use of substances such as alcohol and cannabis, a doubling of prevalence in just three years is a dramatic increase and raises possible public health concerns,” co-author Megan Patrick, PhD, with the University of Michigan Institute for Social Research, Ann Arbor, said in a news release.

The results were published online in the journal Addiction.
 

Health concerns

The estimates are derived from the Monitoring the Future study, which includes annual assessments of adolescent and adult health in the United States.

The analysis focused on 11,304 persons (52% female) aged 9-30 years from the U.S. general population who were interviewed between 2018 and 2021.

Participants were asked about past 12-month use of LSD, as well as use of non-LSD hallucinogens, such as psilocybin.

From 2018 to 2021, past 12-month use of LSD remained relatively stable; it was 3.7% in 2018 and 4.2% in 2021.

However, non-LSD hallucinogen use increased in prevalence from 3.4% to 6.6% from 2018 to 2021.

Across years, the odds of non-LSD use were higher among males, White people, and individuals from households with higher parental education – a proxy for higher socioeconomic status.

The most commonly used non-LSD hallucinogen was psilocybin.

The survey did not ask whether young adults used non-LSD hallucinogens for therapeutic or medical reasons.

“The use of psychedelic and hallucinogenic drugs for a range of therapeutic uses is increasing, given accumulating yet still preliminary data from randomized trials on clinical effectiveness,” lead author Katherine Keyes, PhD, with Columbia University Mailman School of Public Health, New York, said in the release.

“With increased visibility for medical and therapeutic use, however, potentially comes diversion and unregulated product availability, as well as a lack of understanding among the public of potential risks,” Dr. Keyes added.

“However, approved therapeutic use of psychedelics under a trained health professional’s care remains uncommon in the United States, thus the trends we observe here are undoubtedly in nonmedical and nontherapeutic use,” Dr. Keyes noted.

Dr. Patrick said the increased use of hallucinogens raises “concern for young adult health” and is not without risk. While hallucinogen dependence has historically been rare in the U.S. population, it could become more common as use increases, she noted.

The researchers will continue to track these trends to see whether the increases continue.

“We need additional research, including about the motives for hallucinogen use and how young adults are using these substances, in order to be able to mitigate the associated negative consequences,” Dr. Patrick said.

The study was funded by the National Institute on Drug Abuse, part of the National Institutes of Health. Dr. Keyes and Dr. Patrick have disclosed no relevant financial relationships.

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

With the exception of lysergic acid diethylamide, use of hallucinogens surged between 2018 and 2021 among adults younger than 30 years in the United States, new research shows.

In 2018, the prevalence of young adults’ past-year use of non-LSD hallucinogens was 3.4%. By 2021, it had jumped to 6.6%.

The increase in non-LSD hallucinogen use occurred while LSD use remained stable at around 4% in 2018 and 2021.

“While non-LSD hallucinogen use remains substantially less prevalent than use of substances such as alcohol and cannabis, a doubling of prevalence in just three years is a dramatic increase and raises possible public health concerns,” co-author Megan Patrick, PhD, with the University of Michigan Institute for Social Research, Ann Arbor, said in a news release.

The results were published online in the journal Addiction.
 

Health concerns

The estimates are derived from the Monitoring the Future study, which includes annual assessments of adolescent and adult health in the United States.

The analysis focused on 11,304 persons (52% female) aged 9-30 years from the U.S. general population who were interviewed between 2018 and 2021.

Participants were asked about past 12-month use of LSD, as well as use of non-LSD hallucinogens, such as psilocybin.

From 2018 to 2021, past 12-month use of LSD remained relatively stable; it was 3.7% in 2018 and 4.2% in 2021.

However, non-LSD hallucinogen use increased in prevalence from 3.4% to 6.6% from 2018 to 2021.

Across years, the odds of non-LSD use were higher among males, White people, and individuals from households with higher parental education – a proxy for higher socioeconomic status.

The most commonly used non-LSD hallucinogen was psilocybin.

The survey did not ask whether young adults used non-LSD hallucinogens for therapeutic or medical reasons.

“The use of psychedelic and hallucinogenic drugs for a range of therapeutic uses is increasing, given accumulating yet still preliminary data from randomized trials on clinical effectiveness,” lead author Katherine Keyes, PhD, with Columbia University Mailman School of Public Health, New York, said in the release.

“With increased visibility for medical and therapeutic use, however, potentially comes diversion and unregulated product availability, as well as a lack of understanding among the public of potential risks,” Dr. Keyes added.

“However, approved therapeutic use of psychedelics under a trained health professional’s care remains uncommon in the United States, thus the trends we observe here are undoubtedly in nonmedical and nontherapeutic use,” Dr. Keyes noted.

Dr. Patrick said the increased use of hallucinogens raises “concern for young adult health” and is not without risk. While hallucinogen dependence has historically been rare in the U.S. population, it could become more common as use increases, she noted.

The researchers will continue to track these trends to see whether the increases continue.

“We need additional research, including about the motives for hallucinogen use and how young adults are using these substances, in order to be able to mitigate the associated negative consequences,” Dr. Patrick said.

The study was funded by the National Institute on Drug Abuse, part of the National Institutes of Health. Dr. Keyes and Dr. Patrick have disclosed no relevant financial relationships.

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

TOPLINE:

Prepandemic cortisol response to stress and amygdala emotion-evoked activation predicted persistent teen engagement in nonsuicidal self-injury (NSSI) among teensduring the COVID-19 pandemic.

METHODOLOGY:

The analysis included 64 mostly White and middle class or upper middle class female patients in Minneapolis, Minnesota (mean age, 16.2 years) who were part of a larger study of the neurobiology of NSSI.

Before the pandemic, researchers assessed the presence of NSSI and measured cortisol levels in saliva while the participant was experiencing stress, such as when giving a speech (less cortisol in response to stress is a sign of HPA axis hyporeactivity); adolescents were assessed for depression and underwent neuroimaging.

In the early stages of the pandemic, adolescents were assessed for recent engagement in NSSI.

Researchers classified adolescents into three NSSI groups: never (n = 17), desist (a history of NSSI but did not report it during the pandemic; n = 26), or persist (a history of NSSI and reported it during the pandemic; n = 21).
 

TAKEAWAY:

Lower prepandemic levels of under the curve ground (AUCg), an index of overall activation of cortisol levels (B = −0.250; standard error, 0.109; P = .022) and lower prepandemic amygdala activation (B = −0.789; SE = 0.352; P = .025) predicted desistance of NSSI, compared to persistence of NSSI, during the pandemic.

This remained significant after controlling for pandemic-related stressors that could exacerbate underlying risk factors

When depression was included as a covariate, decreased cortisol AUCg and amygdala activation remained significantly predictive of desistance. Decreased medial prefrontal cortex resting state functional connectivity and decreased depressive symptoms were also predictive of desistance of NSSI.
 

IN PRACTICE:

The results “may give insight into predictors of maladaptive patterns of coping with negative emotions” for those with a history of NSSI, the authors noted.

STUDY DETAILS:

The study was conducted by Katherine A. Carosella, department of psychology, University of Minnesota, Minneapolis, and colleagues. It was published online in Psychoneuroendocrinology.

LIMITATIONS:

The study was relatively small, and the investigators could not make causal inferences or rule out the possibility that different stages of development affected the data. Measures employed during COVID were not identical to those used in the prepandemic assessment.

DISCLOSURES:

The study received support from the National Institute of Mental Health and the University of Minnesota. The authors have disclosed no relevant financial relationships.

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

TOPLINE:

Prepandemic cortisol response to stress and amygdala emotion-evoked activation predicted persistent teen engagement in nonsuicidal self-injury (NSSI) among teensduring the COVID-19 pandemic.

METHODOLOGY:

The analysis included 64 mostly White and middle class or upper middle class female patients in Minneapolis, Minnesota (mean age, 16.2 years) who were part of a larger study of the neurobiology of NSSI.

Before the pandemic, researchers assessed the presence of NSSI and measured cortisol levels in saliva while the participant was experiencing stress, such as when giving a speech (less cortisol in response to stress is a sign of HPA axis hyporeactivity); adolescents were assessed for depression and underwent neuroimaging.

In the early stages of the pandemic, adolescents were assessed for recent engagement in NSSI.

Researchers classified adolescents into three NSSI groups: never (n = 17), desist (a history of NSSI but did not report it during the pandemic; n = 26), or persist (a history of NSSI and reported it during the pandemic; n = 21).
 

TAKEAWAY:

Lower prepandemic levels of under the curve ground (AUCg), an index of overall activation of cortisol levels (B = −0.250; standard error, 0.109; P = .022) and lower prepandemic amygdala activation (B = −0.789; SE = 0.352; P = .025) predicted desistance of NSSI, compared to persistence of NSSI, during the pandemic.

This remained significant after controlling for pandemic-related stressors that could exacerbate underlying risk factors

When depression was included as a covariate, decreased cortisol AUCg and amygdala activation remained significantly predictive of desistance. Decreased medial prefrontal cortex resting state functional connectivity and decreased depressive symptoms were also predictive of desistance of NSSI.
 

IN PRACTICE:

The results “may give insight into predictors of maladaptive patterns of coping with negative emotions” for those with a history of NSSI, the authors noted.

STUDY DETAILS:

The study was conducted by Katherine A. Carosella, department of psychology, University of Minnesota, Minneapolis, and colleagues. It was published online in Psychoneuroendocrinology.

LIMITATIONS:

The study was relatively small, and the investigators could not make causal inferences or rule out the possibility that different stages of development affected the data. Measures employed during COVID were not identical to those used in the prepandemic assessment.

DISCLOSURES:

The study received support from the National Institute of Mental Health and the University of Minnesota. The authors have disclosed no relevant financial relationships.

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

TOPLINE:

Prepandemic cortisol response to stress and amygdala emotion-evoked activation predicted persistent teen engagement in nonsuicidal self-injury (NSSI) among teensduring the COVID-19 pandemic.

METHODOLOGY:

The analysis included 64 mostly White and middle class or upper middle class female patients in Minneapolis, Minnesota (mean age, 16.2 years) who were part of a larger study of the neurobiology of NSSI.

Before the pandemic, researchers assessed the presence of NSSI and measured cortisol levels in saliva while the participant was experiencing stress, such as when giving a speech (less cortisol in response to stress is a sign of HPA axis hyporeactivity); adolescents were assessed for depression and underwent neuroimaging.

In the early stages of the pandemic, adolescents were assessed for recent engagement in NSSI.

Researchers classified adolescents into three NSSI groups: never (n = 17), desist (a history of NSSI but did not report it during the pandemic; n = 26), or persist (a history of NSSI and reported it during the pandemic; n = 21).
 

TAKEAWAY:

Lower prepandemic levels of under the curve ground (AUCg), an index of overall activation of cortisol levels (B = −0.250; standard error, 0.109; P = .022) and lower prepandemic amygdala activation (B = −0.789; SE = 0.352; P = .025) predicted desistance of NSSI, compared to persistence of NSSI, during the pandemic.

This remained significant after controlling for pandemic-related stressors that could exacerbate underlying risk factors

When depression was included as a covariate, decreased cortisol AUCg and amygdala activation remained significantly predictive of desistance. Decreased medial prefrontal cortex resting state functional connectivity and decreased depressive symptoms were also predictive of desistance of NSSI.
 

IN PRACTICE:

The results “may give insight into predictors of maladaptive patterns of coping with negative emotions” for those with a history of NSSI, the authors noted.

STUDY DETAILS:

The study was conducted by Katherine A. Carosella, department of psychology, University of Minnesota, Minneapolis, and colleagues. It was published online in Psychoneuroendocrinology.

LIMITATIONS:

The study was relatively small, and the investigators could not make causal inferences or rule out the possibility that different stages of development affected the data. Measures employed during COVID were not identical to those used in the prepandemic assessment.

DISCLOSURES:

The study received support from the National Institute of Mental Health and the University of Minnesota. The authors have disclosed no relevant financial relationships.

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

Not everyone will suffer an episode of posttraumatic stress disorder, even though everyday American life is characterized by a lot of uncertainty these days, particularly considering the proliferation of gun violence.

Robert T. London

Also, everyone who does experience a traumatic event will not suffer an episode of PTSD – just as not everyone develops a heart attack or cancer, nor will everyone get every illness.

The data suggest that of those exposed to trauma, up to 25% of people will develop PTSD, according to Massachusetts General/McLean Hospital, Belmont, psychiatrist Kerry J. Ressler, MD, PhD, chief of the division of depression and anxiety disorders.

As I wrote in December 2022, our “kids” are not all right and psychiatry can help. I would say that many adolescents, and adults as well, may not be all right as we are terrorized not only by mass school shootings, but shootings happening almost anywhere and everywhere in our country: in supermarkets, hospitals, and shopping malls, at graduation parties, and on the streets.

According to a report published in Clinical Psychiatry News, a poll conducted by the American Psychiatric Association showed that most American adults [70%] reported that they were anxious or extremely anxious about keeping themselves or their families safe. APA President Rebecca W. Brendel, MD, JD, pointed out that there is “a lot of worry out there about economic uncertainty, about violence and how we are going to come out of this time period.”

Meanwhile, PTSD is still defined in the DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence experienced directly, witnessing the traumatic event as it occurs to others, learning that a traumatic event occurred to a close family member or friend, or experiencing of traumatic events plus extreme exposure to aversive details of the event.

Examples of traumatic events can be numerous. They include natural disasters, man-made disasters, various types of assaults, war trauma, and severe illness with ICU experiences. I would add encounters with racism and bigotry – including homophobia when one fears for their very life or physical injury. This list includes only a few triggers that may invoke this disorder.

Interestingly, the DSM-5 excludes aversive exposure through electronic media, television, movies, or pictures. Including these aspects of trauma exposure would indeed increase PTSD diagnoses, and I believe this type of exposure needs to be included, especially considering how different people process information. Some viewers of media remain “outside” the events depicted on television, movies, or electronic media while others fit directly “into” the film or TV show. Even, for example, a news program, as evidenced by those people suffering from PTSD after viewing the Sept. 11, 2001, disaster on TV.

I have interviewed numerous people who witnessed Sept. 11 tragedies on TV, some during and some after the event, and they genuinely had experienced key factors of PTSD, including nightmares and intrusive recollections of the event. It’s important to include the ways in which people process information and events in order to make a correct diagnosis, in that “one [diagnostic] size does not fit all.”
 

PTSD at school

In my December column, I noted the fear of death that my generation and beyond experienced with the endless threat of nuclear war, which by its very nature meant death, and if not, the saying went “the living would envy the dead” – that is, in post–nuclear war.

As I pointed out in the column, that war never came and hopefully never will, yet the intensity of those many decades of threatened terror with regular school exercises of “hide under the desk” and “don’t look at the flash” left some with intrusive fearful thoughts, nightmares, and even visualization of atomic destruction, as well as the many scenes of destruction portrayed in news casts and films of nuclear explosions.

Clearly, most U.S. school children who participate in school lockdown drills will not suffer from PTSD episodes, but some will. If that “some” approaches 20% or even 10% or less, that will amount to a lot of kids.

I decided to interview two of my grandchildren, each living in different communities and attending different school systems, but both experiencing “lockdown drills.”

Jack, who is 13 and going into eighth grade, was quite clear regarding the drills and reported that in his age group, both he and the kids in his class felt scared while in lockdown. He told me some kids looked nervous. He mentioned that they were taught in school that if the “real thing” happened, the message was “hide, run, and fight.” I was curious and asked why not run first. He was quick to answer and said if you run, you might run into danger, so it’s better to hide and wait for help to arrive. I said to myself, if not PTSD, then being scared or nervous may also lead to anxiety or even to an anxiety disorder.

Next, I interviewed almost 11-year-old Charley, who is going into sixth grade. She was very clear about not at all being fearful or nervous during these drills and was confident that her classmates felt the same way. Then she explained that the school did a great job with a security officer and had locked doors all around that only opened from the inside. She was proud of the school and not fearful or worried at all.

The diverse views of these two young people surprised me but confirm that PTSD is not at all a given based on what is occurring in society. However, it should always be considered by clinicians if a child or adolescent begins to show signs consistent with PTSD.

These two interviews were quite short, but after I finished talking with Charley, she reported spontaneously that while she and her classmates were neither worried nor scared, some of their teachers did look nervous and seemed scared.

I was quite impressed with her sharpness and nuanced observation, and as noted, adults as well may be adversely affected by the entire concept of school lockdowns, as the awareness of their purpose rests in the forefront of their minds.
 

The way forward

So how do we prepare kids and adolescents for potential emotional problems like PTSD arising from lockdowns, even though most children or adults will not suffer any of these PTSD issues?

First, I believe that as we develop and teach health education in schools, mental health issues should be included according to grade level without generating fear or worry. Second, it is important that school children be aware that if they feel bad in any way emotionally, they should speak to their parents, guardians, teachers, or school nurses.

Clearly, communicating simple problems without embarrassment or shame can lead to solutions, often quickly. Larger, more complicated issues may need professional intervention. Equally important, many mental health interventions need not be long in duration but client-centered, focused, and short term.

But what needs to be emphasized is that speaking and addressing what’s going on, if your thoughts and emotions are troubling, are in themselves therapeutic. Talk therapy works – especially if you get a new perspective on the old set of problems.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Not everyone will suffer an episode of posttraumatic stress disorder, even though everyday American life is characterized by a lot of uncertainty these days, particularly considering the proliferation of gun violence.

Robert T. London

Also, everyone who does experience a traumatic event will not suffer an episode of PTSD – just as not everyone develops a heart attack or cancer, nor will everyone get every illness.

The data suggest that of those exposed to trauma, up to 25% of people will develop PTSD, according to Massachusetts General/McLean Hospital, Belmont, psychiatrist Kerry J. Ressler, MD, PhD, chief of the division of depression and anxiety disorders.

As I wrote in December 2022, our “kids” are not all right and psychiatry can help. I would say that many adolescents, and adults as well, may not be all right as we are terrorized not only by mass school shootings, but shootings happening almost anywhere and everywhere in our country: in supermarkets, hospitals, and shopping malls, at graduation parties, and on the streets.

According to a report published in Clinical Psychiatry News, a poll conducted by the American Psychiatric Association showed that most American adults [70%] reported that they were anxious or extremely anxious about keeping themselves or their families safe. APA President Rebecca W. Brendel, MD, JD, pointed out that there is “a lot of worry out there about economic uncertainty, about violence and how we are going to come out of this time period.”

Meanwhile, PTSD is still defined in the DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence experienced directly, witnessing the traumatic event as it occurs to others, learning that a traumatic event occurred to a close family member or friend, or experiencing of traumatic events plus extreme exposure to aversive details of the event.

Examples of traumatic events can be numerous. They include natural disasters, man-made disasters, various types of assaults, war trauma, and severe illness with ICU experiences. I would add encounters with racism and bigotry – including homophobia when one fears for their very life or physical injury. This list includes only a few triggers that may invoke this disorder.

Interestingly, the DSM-5 excludes aversive exposure through electronic media, television, movies, or pictures. Including these aspects of trauma exposure would indeed increase PTSD diagnoses, and I believe this type of exposure needs to be included, especially considering how different people process information. Some viewers of media remain “outside” the events depicted on television, movies, or electronic media while others fit directly “into” the film or TV show. Even, for example, a news program, as evidenced by those people suffering from PTSD after viewing the Sept. 11, 2001, disaster on TV.

I have interviewed numerous people who witnessed Sept. 11 tragedies on TV, some during and some after the event, and they genuinely had experienced key factors of PTSD, including nightmares and intrusive recollections of the event. It’s important to include the ways in which people process information and events in order to make a correct diagnosis, in that “one [diagnostic] size does not fit all.”
 

PTSD at school

In my December column, I noted the fear of death that my generation and beyond experienced with the endless threat of nuclear war, which by its very nature meant death, and if not, the saying went “the living would envy the dead” – that is, in post–nuclear war.

As I pointed out in the column, that war never came and hopefully never will, yet the intensity of those many decades of threatened terror with regular school exercises of “hide under the desk” and “don’t look at the flash” left some with intrusive fearful thoughts, nightmares, and even visualization of atomic destruction, as well as the many scenes of destruction portrayed in news casts and films of nuclear explosions.

Clearly, most U.S. school children who participate in school lockdown drills will not suffer from PTSD episodes, but some will. If that “some” approaches 20% or even 10% or less, that will amount to a lot of kids.

I decided to interview two of my grandchildren, each living in different communities and attending different school systems, but both experiencing “lockdown drills.”

Jack, who is 13 and going into eighth grade, was quite clear regarding the drills and reported that in his age group, both he and the kids in his class felt scared while in lockdown. He told me some kids looked nervous. He mentioned that they were taught in school that if the “real thing” happened, the message was “hide, run, and fight.” I was curious and asked why not run first. He was quick to answer and said if you run, you might run into danger, so it’s better to hide and wait for help to arrive. I said to myself, if not PTSD, then being scared or nervous may also lead to anxiety or even to an anxiety disorder.

Next, I interviewed almost 11-year-old Charley, who is going into sixth grade. She was very clear about not at all being fearful or nervous during these drills and was confident that her classmates felt the same way. Then she explained that the school did a great job with a security officer and had locked doors all around that only opened from the inside. She was proud of the school and not fearful or worried at all.

The diverse views of these two young people surprised me but confirm that PTSD is not at all a given based on what is occurring in society. However, it should always be considered by clinicians if a child or adolescent begins to show signs consistent with PTSD.

These two interviews were quite short, but after I finished talking with Charley, she reported spontaneously that while she and her classmates were neither worried nor scared, some of their teachers did look nervous and seemed scared.

I was quite impressed with her sharpness and nuanced observation, and as noted, adults as well may be adversely affected by the entire concept of school lockdowns, as the awareness of their purpose rests in the forefront of their minds.
 

The way forward

So how do we prepare kids and adolescents for potential emotional problems like PTSD arising from lockdowns, even though most children or adults will not suffer any of these PTSD issues?

First, I believe that as we develop and teach health education in schools, mental health issues should be included according to grade level without generating fear or worry. Second, it is important that school children be aware that if they feel bad in any way emotionally, they should speak to their parents, guardians, teachers, or school nurses.

Clearly, communicating simple problems without embarrassment or shame can lead to solutions, often quickly. Larger, more complicated issues may need professional intervention. Equally important, many mental health interventions need not be long in duration but client-centered, focused, and short term.

But what needs to be emphasized is that speaking and addressing what’s going on, if your thoughts and emotions are troubling, are in themselves therapeutic. Talk therapy works – especially if you get a new perspective on the old set of problems.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Not everyone will suffer an episode of posttraumatic stress disorder, even though everyday American life is characterized by a lot of uncertainty these days, particularly considering the proliferation of gun violence.

Robert T. London

Also, everyone who does experience a traumatic event will not suffer an episode of PTSD – just as not everyone develops a heart attack or cancer, nor will everyone get every illness.

The data suggest that of those exposed to trauma, up to 25% of people will develop PTSD, according to Massachusetts General/McLean Hospital, Belmont, psychiatrist Kerry J. Ressler, MD, PhD, chief of the division of depression and anxiety disorders.

As I wrote in December 2022, our “kids” are not all right and psychiatry can help. I would say that many adolescents, and adults as well, may not be all right as we are terrorized not only by mass school shootings, but shootings happening almost anywhere and everywhere in our country: in supermarkets, hospitals, and shopping malls, at graduation parties, and on the streets.

According to a report published in Clinical Psychiatry News, a poll conducted by the American Psychiatric Association showed that most American adults [70%] reported that they were anxious or extremely anxious about keeping themselves or their families safe. APA President Rebecca W. Brendel, MD, JD, pointed out that there is “a lot of worry out there about economic uncertainty, about violence and how we are going to come out of this time period.”

Meanwhile, PTSD is still defined in the DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence experienced directly, witnessing the traumatic event as it occurs to others, learning that a traumatic event occurred to a close family member or friend, or experiencing of traumatic events plus extreme exposure to aversive details of the event.

Examples of traumatic events can be numerous. They include natural disasters, man-made disasters, various types of assaults, war trauma, and severe illness with ICU experiences. I would add encounters with racism and bigotry – including homophobia when one fears for their very life or physical injury. This list includes only a few triggers that may invoke this disorder.

Interestingly, the DSM-5 excludes aversive exposure through electronic media, television, movies, or pictures. Including these aspects of trauma exposure would indeed increase PTSD diagnoses, and I believe this type of exposure needs to be included, especially considering how different people process information. Some viewers of media remain “outside” the events depicted on television, movies, or electronic media while others fit directly “into” the film or TV show. Even, for example, a news program, as evidenced by those people suffering from PTSD after viewing the Sept. 11, 2001, disaster on TV.

I have interviewed numerous people who witnessed Sept. 11 tragedies on TV, some during and some after the event, and they genuinely had experienced key factors of PTSD, including nightmares and intrusive recollections of the event. It’s important to include the ways in which people process information and events in order to make a correct diagnosis, in that “one [diagnostic] size does not fit all.”
 

PTSD at school

In my December column, I noted the fear of death that my generation and beyond experienced with the endless threat of nuclear war, which by its very nature meant death, and if not, the saying went “the living would envy the dead” – that is, in post–nuclear war.

As I pointed out in the column, that war never came and hopefully never will, yet the intensity of those many decades of threatened terror with regular school exercises of “hide under the desk” and “don’t look at the flash” left some with intrusive fearful thoughts, nightmares, and even visualization of atomic destruction, as well as the many scenes of destruction portrayed in news casts and films of nuclear explosions.

Clearly, most U.S. school children who participate in school lockdown drills will not suffer from PTSD episodes, but some will. If that “some” approaches 20% or even 10% or less, that will amount to a lot of kids.

I decided to interview two of my grandchildren, each living in different communities and attending different school systems, but both experiencing “lockdown drills.”

Jack, who is 13 and going into eighth grade, was quite clear regarding the drills and reported that in his age group, both he and the kids in his class felt scared while in lockdown. He told me some kids looked nervous. He mentioned that they were taught in school that if the “real thing” happened, the message was “hide, run, and fight.” I was curious and asked why not run first. He was quick to answer and said if you run, you might run into danger, so it’s better to hide and wait for help to arrive. I said to myself, if not PTSD, then being scared or nervous may also lead to anxiety or even to an anxiety disorder.

Next, I interviewed almost 11-year-old Charley, who is going into sixth grade. She was very clear about not at all being fearful or nervous during these drills and was confident that her classmates felt the same way. Then she explained that the school did a great job with a security officer and had locked doors all around that only opened from the inside. She was proud of the school and not fearful or worried at all.

The diverse views of these two young people surprised me but confirm that PTSD is not at all a given based on what is occurring in society. However, it should always be considered by clinicians if a child or adolescent begins to show signs consistent with PTSD.

These two interviews were quite short, but after I finished talking with Charley, she reported spontaneously that while she and her classmates were neither worried nor scared, some of their teachers did look nervous and seemed scared.

I was quite impressed with her sharpness and nuanced observation, and as noted, adults as well may be adversely affected by the entire concept of school lockdowns, as the awareness of their purpose rests in the forefront of their minds.
 

The way forward

So how do we prepare kids and adolescents for potential emotional problems like PTSD arising from lockdowns, even though most children or adults will not suffer any of these PTSD issues?

First, I believe that as we develop and teach health education in schools, mental health issues should be included according to grade level without generating fear or worry. Second, it is important that school children be aware that if they feel bad in any way emotionally, they should speak to their parents, guardians, teachers, or school nurses.

Clearly, communicating simple problems without embarrassment or shame can lead to solutions, often quickly. Larger, more complicated issues may need professional intervention. Equally important, many mental health interventions need not be long in duration but client-centered, focused, and short term.

But what needs to be emphasized is that speaking and addressing what’s going on, if your thoughts and emotions are troubling, are in themselves therapeutic. Talk therapy works – especially if you get a new perspective on the old set of problems.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Patients with “treatment-resistant depression” may be taking other medications with side effects that interfere with antidepressant efficacy.

Investigators studied over 800 patients who were taking antidepressants for major depressive disorder (MDD) and found that close to two-thirds were taking at least one nonpsychiatric medication with potential depressive symptom side effects (PDSS), more than 30% were taking two or more such medications, and 20% at least three such medications.

These medications, which included antihypertensive medications and corticosteroids, among others, were associated with higher odds of moderate-to-severe depressive symptoms, compared with medications without PDSS.

“When evaluating the reasons for inadequate response to treatment for depression, clinicians should consider whether their patient is also receiving a nonpsychiatric medication with a potential for depressive symptom side effects,” study investigator Mark Olfson, MD, MPH, Elizabeth K. Dollard professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.

Columbia University

Previous research limited

“In earlier research, we found that people who were taking medications with a potential to cause depressive symptom side effects were at increased risk of depression, especially those adults who were taking more than one of these medications,” said Dr. Olfson.

This finding led Dr. Olfson and his team to “wonder whether the risks of depressive symptoms associated with these medications extended to people who were being actively treated with antidepressants for depression.”

To investigate, they turned to the National Health and Nutrition Examination Survey (NHANES) – a nationally representative cross-sectional survey of the United States general population.

The study was based on the 2013-2014, 2015-2016, and 2017-2018 waves and included 885 adults who reported using antidepressant medications for greater than or equal to 6 weeks for depression and whose depression could be ascertained.

Prescription medications with PDSS were identified through Micromedex, whose accuracy is “established” and primarily based on the U.S. Food and Drug Administration’s labeled side effects.

Nonantidepressant psychiatric medications and medications for Alzheimer’s disease or substance use disorders were not included in the analysis.

Antidepressant-treated MDD was defined as taking an antidepressant for MDD for greater than or equal to 6 weeks. Depressive symptoms were ascertained using the Patient Health Questionnaire-9 (PHQ-9) with a score of less than 5 representing no/minimal depressive symptoms and a score of greater than or equal to 10 indicating moderate/severe symptoms.

Other variables included self-reported sex, age, race/ethnicity, income, education, health insurance, and common chronic medical conditions such as hypertension, arthritis, lung disease, diabetes mellitus, thyroid disease, cancer, heart disease, liver disease, stroke, and congestive heart failure.
 

Recovery interrupted

Of the patients in the study treated with antidepressants, most were female, greater than or equal to 50 years, non-Hispanic White, and with a college education (70.55, 62.0%, 81.7%, and 69.4%, respectively).

Selective serotonin reuptake inhibitors were used by 67.9% of participants with MDD. Most had been on the same antidepressant medication for a “long time,” the authors report, with 79.2% and 67.8% taking them for greater than 1 year and greater than 2 years, respectively.

Despite the large number of patients on antidepressants, only 43.0% scored in the no/minimal symptoms range, based on the PHQ-9, while 28.4% scored in the moderate/severe range.

Most patients (85%) took at least one medication for medical conditions, with the majority medications with PDSS: 66.7% took at least one medication with PDSS, 37.3% took at least two, 21.6% took at least three, 10.7% took at least four, and 4.9% took at least five.

Almost 75% were using greater than or equal to 1 medication without PDSS, and about 50% were using greater than 1.

The number of medications with PDSS was significantly associated with lower odds of no/minimal depressive symptoms (AOR, 0.75 [95% CI, 0.64-0.87]; P < .001) and higher odds of moderate/severe symptoms (AOR, 1.14 [1.004-1.29]; P = .044).

“The predicted probability of no/minimal symptoms in those taking 5 medications with PDSS was less than half the predicted probability in those taking no medications with PDSS (0.23 vs. 0.52),” the authors report.

Conversely, the predicted probability of moderate/severe symptoms was ~50% higher in individuals taking 5 versus 0 medications with PDSS (0.36 vs. 0.24).

No corresponding associations were found for medications without PDSS.

The results were even stronger when the researchers repeated their adjusted regression analyses to focus on the 10 individual medications most associated with the severity of depressive symptoms. These were omeprazole, gabapentin, meloxicam, tramadol, ranitidine, baclofen, oxycodone, tizanidine, propranolol, and morphine, with an AOR of 0.42 [0.30-0.60] for no/minimal symptoms and 1.68 [1.24-2.27] for moderate/severe symptoms.

“Many widely prescribed medications, from antihypertensives, such as atenolol and metoprolol to corticosteroids, such as dexamethasone and triamcinolone, are associated with depression side effects,” said Dr. Olfson.

“These medications could interfere with recovery from depression. When available, consideration should be given to selecting a substitute with lower risk for depressive symptoms,” he said.
 

Role in treatment-resistant depression

In a comment, Dima Qato, PharmD, MPH, PhD, Hygeia Centennial chair and associate professor, University of Southern California School of Pharmacy, Los Angeles, said the study “is an important reminder that the use of medications with depressive symptoms side effects is increasingly common and may contribute to delays in responsiveness or worsen depressive symptoms among individuals being treated for depression.”

University of Southern California

Dr. Qato, who is also the director of the Program on Medicines and Public Health, USC School of Pharmacy, and was not involved with the study, recommended that clinicians “consider the role of medications with depression side effects when evaluating patients with treatment-resistant depression.”

The study was not supported by any funding agency. Dr. Olfson and coauthors have disclosed no relevant financial relationships. Dr. Qato is a consultant for the Public Citizen Health Research Group.

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

Patients with “treatment-resistant depression” may be taking other medications with side effects that interfere with antidepressant efficacy.

Investigators studied over 800 patients who were taking antidepressants for major depressive disorder (MDD) and found that close to two-thirds were taking at least one nonpsychiatric medication with potential depressive symptom side effects (PDSS), more than 30% were taking two or more such medications, and 20% at least three such medications.

These medications, which included antihypertensive medications and corticosteroids, among others, were associated with higher odds of moderate-to-severe depressive symptoms, compared with medications without PDSS.

“When evaluating the reasons for inadequate response to treatment for depression, clinicians should consider whether their patient is also receiving a nonpsychiatric medication with a potential for depressive symptom side effects,” study investigator Mark Olfson, MD, MPH, Elizabeth K. Dollard professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.

Columbia University

Previous research limited

“In earlier research, we found that people who were taking medications with a potential to cause depressive symptom side effects were at increased risk of depression, especially those adults who were taking more than one of these medications,” said Dr. Olfson.

This finding led Dr. Olfson and his team to “wonder whether the risks of depressive symptoms associated with these medications extended to people who were being actively treated with antidepressants for depression.”

To investigate, they turned to the National Health and Nutrition Examination Survey (NHANES) – a nationally representative cross-sectional survey of the United States general population.

The study was based on the 2013-2014, 2015-2016, and 2017-2018 waves and included 885 adults who reported using antidepressant medications for greater than or equal to 6 weeks for depression and whose depression could be ascertained.

Prescription medications with PDSS were identified through Micromedex, whose accuracy is “established” and primarily based on the U.S. Food and Drug Administration’s labeled side effects.

Nonantidepressant psychiatric medications and medications for Alzheimer’s disease or substance use disorders were not included in the analysis.

Antidepressant-treated MDD was defined as taking an antidepressant for MDD for greater than or equal to 6 weeks. Depressive symptoms were ascertained using the Patient Health Questionnaire-9 (PHQ-9) with a score of less than 5 representing no/minimal depressive symptoms and a score of greater than or equal to 10 indicating moderate/severe symptoms.

Other variables included self-reported sex, age, race/ethnicity, income, education, health insurance, and common chronic medical conditions such as hypertension, arthritis, lung disease, diabetes mellitus, thyroid disease, cancer, heart disease, liver disease, stroke, and congestive heart failure.
 

Recovery interrupted

Of the patients in the study treated with antidepressants, most were female, greater than or equal to 50 years, non-Hispanic White, and with a college education (70.55, 62.0%, 81.7%, and 69.4%, respectively).

Selective serotonin reuptake inhibitors were used by 67.9% of participants with MDD. Most had been on the same antidepressant medication for a “long time,” the authors report, with 79.2% and 67.8% taking them for greater than 1 year and greater than 2 years, respectively.

Despite the large number of patients on antidepressants, only 43.0% scored in the no/minimal symptoms range, based on the PHQ-9, while 28.4% scored in the moderate/severe range.

Most patients (85%) took at least one medication for medical conditions, with the majority medications with PDSS: 66.7% took at least one medication with PDSS, 37.3% took at least two, 21.6% took at least three, 10.7% took at least four, and 4.9% took at least five.

Almost 75% were using greater than or equal to 1 medication without PDSS, and about 50% were using greater than 1.

The number of medications with PDSS was significantly associated with lower odds of no/minimal depressive symptoms (AOR, 0.75 [95% CI, 0.64-0.87]; P < .001) and higher odds of moderate/severe symptoms (AOR, 1.14 [1.004-1.29]; P = .044).

“The predicted probability of no/minimal symptoms in those taking 5 medications with PDSS was less than half the predicted probability in those taking no medications with PDSS (0.23 vs. 0.52),” the authors report.

Conversely, the predicted probability of moderate/severe symptoms was ~50% higher in individuals taking 5 versus 0 medications with PDSS (0.36 vs. 0.24).

No corresponding associations were found for medications without PDSS.

The results were even stronger when the researchers repeated their adjusted regression analyses to focus on the 10 individual medications most associated with the severity of depressive symptoms. These were omeprazole, gabapentin, meloxicam, tramadol, ranitidine, baclofen, oxycodone, tizanidine, propranolol, and morphine, with an AOR of 0.42 [0.30-0.60] for no/minimal symptoms and 1.68 [1.24-2.27] for moderate/severe symptoms.

“Many widely prescribed medications, from antihypertensives, such as atenolol and metoprolol to corticosteroids, such as dexamethasone and triamcinolone, are associated with depression side effects,” said Dr. Olfson.

“These medications could interfere with recovery from depression. When available, consideration should be given to selecting a substitute with lower risk for depressive symptoms,” he said.
 

Role in treatment-resistant depression

In a comment, Dima Qato, PharmD, MPH, PhD, Hygeia Centennial chair and associate professor, University of Southern California School of Pharmacy, Los Angeles, said the study “is an important reminder that the use of medications with depressive symptoms side effects is increasingly common and may contribute to delays in responsiveness or worsen depressive symptoms among individuals being treated for depression.”

University of Southern California

Dr. Qato, who is also the director of the Program on Medicines and Public Health, USC School of Pharmacy, and was not involved with the study, recommended that clinicians “consider the role of medications with depression side effects when evaluating patients with treatment-resistant depression.”

The study was not supported by any funding agency. Dr. Olfson and coauthors have disclosed no relevant financial relationships. Dr. Qato is a consultant for the Public Citizen Health Research Group.

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

Patients with “treatment-resistant depression” may be taking other medications with side effects that interfere with antidepressant efficacy.

Investigators studied over 800 patients who were taking antidepressants for major depressive disorder (MDD) and found that close to two-thirds were taking at least one nonpsychiatric medication with potential depressive symptom side effects (PDSS), more than 30% were taking two or more such medications, and 20% at least three such medications.

These medications, which included antihypertensive medications and corticosteroids, among others, were associated with higher odds of moderate-to-severe depressive symptoms, compared with medications without PDSS.

“When evaluating the reasons for inadequate response to treatment for depression, clinicians should consider whether their patient is also receiving a nonpsychiatric medication with a potential for depressive symptom side effects,” study investigator Mark Olfson, MD, MPH, Elizabeth K. Dollard professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.

Columbia University

Previous research limited

“In earlier research, we found that people who were taking medications with a potential to cause depressive symptom side effects were at increased risk of depression, especially those adults who were taking more than one of these medications,” said Dr. Olfson.

This finding led Dr. Olfson and his team to “wonder whether the risks of depressive symptoms associated with these medications extended to people who were being actively treated with antidepressants for depression.”

To investigate, they turned to the National Health and Nutrition Examination Survey (NHANES) – a nationally representative cross-sectional survey of the United States general population.

The study was based on the 2013-2014, 2015-2016, and 2017-2018 waves and included 885 adults who reported using antidepressant medications for greater than or equal to 6 weeks for depression and whose depression could be ascertained.

Prescription medications with PDSS were identified through Micromedex, whose accuracy is “established” and primarily based on the U.S. Food and Drug Administration’s labeled side effects.

Nonantidepressant psychiatric medications and medications for Alzheimer’s disease or substance use disorders were not included in the analysis.

Antidepressant-treated MDD was defined as taking an antidepressant for MDD for greater than or equal to 6 weeks. Depressive symptoms were ascertained using the Patient Health Questionnaire-9 (PHQ-9) with a score of less than 5 representing no/minimal depressive symptoms and a score of greater than or equal to 10 indicating moderate/severe symptoms.

Other variables included self-reported sex, age, race/ethnicity, income, education, health insurance, and common chronic medical conditions such as hypertension, arthritis, lung disease, diabetes mellitus, thyroid disease, cancer, heart disease, liver disease, stroke, and congestive heart failure.
 

Recovery interrupted

Of the patients in the study treated with antidepressants, most were female, greater than or equal to 50 years, non-Hispanic White, and with a college education (70.55, 62.0%, 81.7%, and 69.4%, respectively).

Selective serotonin reuptake inhibitors were used by 67.9% of participants with MDD. Most had been on the same antidepressant medication for a “long time,” the authors report, with 79.2% and 67.8% taking them for greater than 1 year and greater than 2 years, respectively.

Despite the large number of patients on antidepressants, only 43.0% scored in the no/minimal symptoms range, based on the PHQ-9, while 28.4% scored in the moderate/severe range.

Most patients (85%) took at least one medication for medical conditions, with the majority medications with PDSS: 66.7% took at least one medication with PDSS, 37.3% took at least two, 21.6% took at least three, 10.7% took at least four, and 4.9% took at least five.

Almost 75% were using greater than or equal to 1 medication without PDSS, and about 50% were using greater than 1.

The number of medications with PDSS was significantly associated with lower odds of no/minimal depressive symptoms (AOR, 0.75 [95% CI, 0.64-0.87]; P < .001) and higher odds of moderate/severe symptoms (AOR, 1.14 [1.004-1.29]; P = .044).

“The predicted probability of no/minimal symptoms in those taking 5 medications with PDSS was less than half the predicted probability in those taking no medications with PDSS (0.23 vs. 0.52),” the authors report.

Conversely, the predicted probability of moderate/severe symptoms was ~50% higher in individuals taking 5 versus 0 medications with PDSS (0.36 vs. 0.24).

No corresponding associations were found for medications without PDSS.

The results were even stronger when the researchers repeated their adjusted regression analyses to focus on the 10 individual medications most associated with the severity of depressive symptoms. These were omeprazole, gabapentin, meloxicam, tramadol, ranitidine, baclofen, oxycodone, tizanidine, propranolol, and morphine, with an AOR of 0.42 [0.30-0.60] for no/minimal symptoms and 1.68 [1.24-2.27] for moderate/severe symptoms.

“Many widely prescribed medications, from antihypertensives, such as atenolol and metoprolol to corticosteroids, such as dexamethasone and triamcinolone, are associated with depression side effects,” said Dr. Olfson.

“These medications could interfere with recovery from depression. When available, consideration should be given to selecting a substitute with lower risk for depressive symptoms,” he said.
 

Role in treatment-resistant depression

In a comment, Dima Qato, PharmD, MPH, PhD, Hygeia Centennial chair and associate professor, University of Southern California School of Pharmacy, Los Angeles, said the study “is an important reminder that the use of medications with depressive symptoms side effects is increasingly common and may contribute to delays in responsiveness or worsen depressive symptoms among individuals being treated for depression.”

University of Southern California

Dr. Qato, who is also the director of the Program on Medicines and Public Health, USC School of Pharmacy, and was not involved with the study, recommended that clinicians “consider the role of medications with depression side effects when evaluating patients with treatment-resistant depression.”

The study was not supported by any funding agency. Dr. Olfson and coauthors have disclosed no relevant financial relationships. Dr. Qato is a consultant for the Public Citizen Health Research Group.

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

TOPLINE

Patients who received zuranolone 50 mg/d demonstrated significantly greater improvement in depressive symptoms than those who received placebo, with a rapid onset of effect.

METHODOLOGY

The Food and Drug Administration has accepted filing of a new drug application for zuranolone, a neuroactive steroid that targets g-aminobutyric acid type A receptors (GABAAR), for the treatment of major depressive disorder (MDD) and postpartum depression.

The study included 543 mostly White female patients with MDD. The mean age of the patients was 40 years. Participants were randomly assigned to receive oral zuranolone 50 mg or placebo once daily for 14 days.

About 30% of patients were taking an antidepressant.

The primary endpoint was change in Hamilton Depression Rating Scale (HAM-D) score at day 15.
 

TAKEAWAY

The zuranolone group showed significantly greater improvement in depressive symptoms at 15 days compared with the placebo group (least square mean [LSM] change on HAM-D, –14.1, vs. –12.3; P = .01; Cohen’s d = 0.23).

Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).

Results favored zuranolone regardless of the use of antidepressant therapies.

Patients with anxiety who received the active drug experienced improvement in anxiety symptoms compared to the patients who received placebo.

The drug was well tolerated, and there were no new safety findings. The most common treatment-emergent adverse events were somnolence and headache. There was no weight gain, sexual dysfunction, withdrawal symptoms, or increased suicidal ideation or behavior.
 

IN PRACTICE

The study adds to evidence suggesting zuranolone is a promising novel therapy for treating MDD, the authors noted.

STUDY DETAILS

The study was conducted by Anita H. Clayton, MD, department of psychiatry and neurobehavioral sciences, University of Virginia, Charlottesville, and colleagues. It was published online May 3 in The American Journal of Psychiatry.

LIMITATIONS

The study was short term, and the patient population was severely depressed at study entry, which may limit application to those with mild or moderate symptoms. There was a robust placebo response, possibly partly due to the COVID-19 pandemic, when there was an increase in depressive symptoms in the U.S. population, and so frequent in-person visits may have led to an improvement in symptoms even if the patient was receiving placebo.

DISCLOSURES

The study was funded by Sage Therapeutics and Biogen.

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

TOPLINE

Patients who received zuranolone 50 mg/d demonstrated significantly greater improvement in depressive symptoms than those who received placebo, with a rapid onset of effect.

METHODOLOGY

The Food and Drug Administration has accepted filing of a new drug application for zuranolone, a neuroactive steroid that targets g-aminobutyric acid type A receptors (GABAAR), for the treatment of major depressive disorder (MDD) and postpartum depression.

The study included 543 mostly White female patients with MDD. The mean age of the patients was 40 years. Participants were randomly assigned to receive oral zuranolone 50 mg or placebo once daily for 14 days.

About 30% of patients were taking an antidepressant.

The primary endpoint was change in Hamilton Depression Rating Scale (HAM-D) score at day 15.
 

TAKEAWAY

The zuranolone group showed significantly greater improvement in depressive symptoms at 15 days compared with the placebo group (least square mean [LSM] change on HAM-D, –14.1, vs. –12.3; P = .01; Cohen’s d = 0.23).

Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).

Results favored zuranolone regardless of the use of antidepressant therapies.

Patients with anxiety who received the active drug experienced improvement in anxiety symptoms compared to the patients who received placebo.

The drug was well tolerated, and there were no new safety findings. The most common treatment-emergent adverse events were somnolence and headache. There was no weight gain, sexual dysfunction, withdrawal symptoms, or increased suicidal ideation or behavior.
 

IN PRACTICE

The study adds to evidence suggesting zuranolone is a promising novel therapy for treating MDD, the authors noted.

STUDY DETAILS

The study was conducted by Anita H. Clayton, MD, department of psychiatry and neurobehavioral sciences, University of Virginia, Charlottesville, and colleagues. It was published online May 3 in The American Journal of Psychiatry.

LIMITATIONS

The study was short term, and the patient population was severely depressed at study entry, which may limit application to those with mild or moderate symptoms. There was a robust placebo response, possibly partly due to the COVID-19 pandemic, when there was an increase in depressive symptoms in the U.S. population, and so frequent in-person visits may have led to an improvement in symptoms even if the patient was receiving placebo.

DISCLOSURES

The study was funded by Sage Therapeutics and Biogen.

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

TOPLINE

Patients who received zuranolone 50 mg/d demonstrated significantly greater improvement in depressive symptoms than those who received placebo, with a rapid onset of effect.

METHODOLOGY

The Food and Drug Administration has accepted filing of a new drug application for zuranolone, a neuroactive steroid that targets g-aminobutyric acid type A receptors (GABAAR), for the treatment of major depressive disorder (MDD) and postpartum depression.

The study included 543 mostly White female patients with MDD. The mean age of the patients was 40 years. Participants were randomly assigned to receive oral zuranolone 50 mg or placebo once daily for 14 days.

About 30% of patients were taking an antidepressant.

The primary endpoint was change in Hamilton Depression Rating Scale (HAM-D) score at day 15.
 

TAKEAWAY

The zuranolone group showed significantly greater improvement in depressive symptoms at 15 days compared with the placebo group (least square mean [LSM] change on HAM-D, –14.1, vs. –12.3; P = .01; Cohen’s d = 0.23).

Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).

Results favored zuranolone regardless of the use of antidepressant therapies.

Patients with anxiety who received the active drug experienced improvement in anxiety symptoms compared to the patients who received placebo.

The drug was well tolerated, and there were no new safety findings. The most common treatment-emergent adverse events were somnolence and headache. There was no weight gain, sexual dysfunction, withdrawal symptoms, or increased suicidal ideation or behavior.
 

IN PRACTICE

The study adds to evidence suggesting zuranolone is a promising novel therapy for treating MDD, the authors noted.

STUDY DETAILS

The study was conducted by Anita H. Clayton, MD, department of psychiatry and neurobehavioral sciences, University of Virginia, Charlottesville, and colleagues. It was published online May 3 in The American Journal of Psychiatry.

LIMITATIONS

The study was short term, and the patient population was severely depressed at study entry, which may limit application to those with mild or moderate symptoms. There was a robust placebo response, possibly partly due to the COVID-19 pandemic, when there was an increase in depressive symptoms in the U.S. population, and so frequent in-person visits may have led to an improvement in symptoms even if the patient was receiving placebo.

DISCLOSURES

The study was funded by Sage Therapeutics and Biogen.

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

This is the exciting time of year when we graduate new classes of medical students and residents. Med school graduation brings mixed emotions; the new doctors and I both know residency will bring growth and challenges. Residency graduation is a wistful passage as well. It is so rewarding to welcome the newly board-certified family physicians to family medicine, but we miss them even as we orient a new class.

Every year, a few months (or even a few years) after graduation, I hear from a former resident, sometimes several. They ask to talk and, although it can be hard for them to explain exactly the ennui and disillusionment they’re feeling, their concerns boil down to: Is this all there is?

If what you’re doing isn’t working for you, look for opportunities (big or small) that make it better.

They are not burnt out, exactly, but they were hoping for more from their careers in family medicine.¹ They find their hopes and expectations are not fulfilled by seeing patients in the office 8 hours per day, 4.5 days per week. Even those who report rewarding relationships with patients express less overall enthusiasm for jobs they were excited to start just months or years earlier.

Some of the difficulties I hear the graduates report are expected growing pains. It is a transition to go from supervised practice with attending backup to a setting where you are on your own, typically with a 4-fold increase in volume compared with residency. But the monotony is real for family physicians in full-time outpatient practice.

Research suggests an expanded scope of practice—including hospital medicine, obstetrics, and procedures—is associated with physician well-being.^2,3 A broad scope of practice can bring stress, but it also brings meaning, and that meaning is protective to our well-being. However, a robust scope of practice is not always supported by medical groups or hospital systems, who prefer a more compartmentalized, widgetized physician.⁴ It would be easier for their algorithms if family physicians picked a lane and stayed in it. Alas, the broader our scope of practice, the healthier our population, the more equitable our care,^5,6 and the happier our physicians.

The disconnect and hopelessness experienced by family physicians is more concerning. Many of my graduates report feeling disconnected from their patients, because they begin to feel disillusioned by the demands and requests that practice and patients place on them. The paperwork, “permission slips,” and requests for tests and studies not only feel overwhelming and exhausting but also create distance between physicians and patients.⁷ We want to help our patients, so we do the forms and order the tests. As the quantity of forms, slips, and requests adds up, we begin to feel resentful at what the forms take away: time with our patients, perhaps, or time with our families. We get angry at the forms and the “asks,” and then begin to get angry at the patients simply for having needs. Administrative burden is a hassle, but it is also insidiously destructive.⁸

Family physicians confront hopelessness when, day after day, we diagnose problems that no physician is likely to fix in a single office visit: chronic stress, family dysfunction, violence, unemployment, poverty, racism, loneliness, and the hopelessness of the patients themselves. This is not to say that we ignore these concerns or their impact on health. It is because we see and feel them, and deeply understand their consequences for our patients, that we grow frustrated with the lack of solutions.^9,10

Thankfully, we have strong teams working at the policy level to improve the primary care and public health infrastructure so that we can maintain some hope that it will be better in the future. Sometimes when I counsel a former resident, they decide to join those teams so that they can work on the solutions. Others decide to expand their scope of practice. Others seek out virtual scribes to streamline charting and regain time. Some build better boundaries with their EHR inboxes.

The key is figuring out what we can do and making peace with our limits. When disillusionment hits, what we can do includes seeking connection and social contact and remembering that we are not trapped in our situation, even if we are practicing in a less-than-functional health care system. There are many ways to “be” a family physician—if what you’re doing isn’t working for you, look for opportunities (big or small) that make it better. We can all reach out to coaches, therapists, colleagues, and friends for support to remain steadfast in our purpose as family physicians. This support and the power of change means that from residency to the latter parts of our careers, we will continue to bring the tremendous good of family medicine to the communities we serve.

This is the exciting time of year when we graduate new classes of medical students and residents. Med school graduation brings mixed emotions; the new doctors and I both know residency will bring growth and challenges. Residency graduation is a wistful passage as well. It is so rewarding to welcome the newly board-certified family physicians to family medicine, but we miss them even as we orient a new class.

Every year, a few months (or even a few years) after graduation, I hear from a former resident, sometimes several. They ask to talk and, although it can be hard for them to explain exactly the ennui and disillusionment they’re feeling, their concerns boil down to: Is this all there is?

If what you’re doing isn’t working for you, look for opportunities (big or small) that make it better.

They are not burnt out, exactly, but they were hoping for more from their careers in family medicine.¹ They find their hopes and expectations are not fulfilled by seeing patients in the office 8 hours per day, 4.5 days per week. Even those who report rewarding relationships with patients express less overall enthusiasm for jobs they were excited to start just months or years earlier.

Some of the difficulties I hear the graduates report are expected growing pains. It is a transition to go from supervised practice with attending backup to a setting where you are on your own, typically with a 4-fold increase in volume compared with residency. But the monotony is real for family physicians in full-time outpatient practice.

Research suggests an expanded scope of practice—including hospital medicine, obstetrics, and procedures—is associated with physician well-being.^2,3 A broad scope of practice can bring stress, but it also brings meaning, and that meaning is protective to our well-being. However, a robust scope of practice is not always supported by medical groups or hospital systems, who prefer a more compartmentalized, widgetized physician.⁴ It would be easier for their algorithms if family physicians picked a lane and stayed in it. Alas, the broader our scope of practice, the healthier our population, the more equitable our care,^5,6 and the happier our physicians.

The disconnect and hopelessness experienced by family physicians is more concerning. Many of my graduates report feeling disconnected from their patients, because they begin to feel disillusioned by the demands and requests that practice and patients place on them. The paperwork, “permission slips,” and requests for tests and studies not only feel overwhelming and exhausting but also create distance between physicians and patients.⁷ We want to help our patients, so we do the forms and order the tests. As the quantity of forms, slips, and requests adds up, we begin to feel resentful at what the forms take away: time with our patients, perhaps, or time with our families. We get angry at the forms and the “asks,” and then begin to get angry at the patients simply for having needs. Administrative burden is a hassle, but it is also insidiously destructive.⁸

Family physicians confront hopelessness when, day after day, we diagnose problems that no physician is likely to fix in a single office visit: chronic stress, family dysfunction, violence, unemployment, poverty, racism, loneliness, and the hopelessness of the patients themselves. This is not to say that we ignore these concerns or their impact on health. It is because we see and feel them, and deeply understand their consequences for our patients, that we grow frustrated with the lack of solutions.^9,10

Thankfully, we have strong teams working at the policy level to improve the primary care and public health infrastructure so that we can maintain some hope that it will be better in the future. Sometimes when I counsel a former resident, they decide to join those teams so that they can work on the solutions. Others decide to expand their scope of practice. Others seek out virtual scribes to streamline charting and regain time. Some build better boundaries with their EHR inboxes.

The key is figuring out what we can do and making peace with our limits. When disillusionment hits, what we can do includes seeking connection and social contact and remembering that we are not trapped in our situation, even if we are practicing in a less-than-functional health care system. There are many ways to “be” a family physician—if what you’re doing isn’t working for you, look for opportunities (big or small) that make it better. We can all reach out to coaches, therapists, colleagues, and friends for support to remain steadfast in our purpose as family physicians. This support and the power of change means that from residency to the latter parts of our careers, we will continue to bring the tremendous good of family medicine to the communities we serve.

This is the exciting time of year when we graduate new classes of medical students and residents. Med school graduation brings mixed emotions; the new doctors and I both know residency will bring growth and challenges. Residency graduation is a wistful passage as well. It is so rewarding to welcome the newly board-certified family physicians to family medicine, but we miss them even as we orient a new class.

Every year, a few months (or even a few years) after graduation, I hear from a former resident, sometimes several. They ask to talk and, although it can be hard for them to explain exactly the ennui and disillusionment they’re feeling, their concerns boil down to: Is this all there is?

If what you’re doing isn’t working for you, look for opportunities (big or small) that make it better.

They are not burnt out, exactly, but they were hoping for more from their careers in family medicine.¹ They find their hopes and expectations are not fulfilled by seeing patients in the office 8 hours per day, 4.5 days per week. Even those who report rewarding relationships with patients express less overall enthusiasm for jobs they were excited to start just months or years earlier.

Some of the difficulties I hear the graduates report are expected growing pains. It is a transition to go from supervised practice with attending backup to a setting where you are on your own, typically with a 4-fold increase in volume compared with residency. But the monotony is real for family physicians in full-time outpatient practice.

Research suggests an expanded scope of practice—including hospital medicine, obstetrics, and procedures—is associated with physician well-being.^2,3 A broad scope of practice can bring stress, but it also brings meaning, and that meaning is protective to our well-being. However, a robust scope of practice is not always supported by medical groups or hospital systems, who prefer a more compartmentalized, widgetized physician.⁴ It would be easier for their algorithms if family physicians picked a lane and stayed in it. Alas, the broader our scope of practice, the healthier our population, the more equitable our care,^5,6 and the happier our physicians.

The disconnect and hopelessness experienced by family physicians is more concerning. Many of my graduates report feeling disconnected from their patients, because they begin to feel disillusioned by the demands and requests that practice and patients place on them. The paperwork, “permission slips,” and requests for tests and studies not only feel overwhelming and exhausting but also create distance between physicians and patients.⁷ We want to help our patients, so we do the forms and order the tests. As the quantity of forms, slips, and requests adds up, we begin to feel resentful at what the forms take away: time with our patients, perhaps, or time with our families. We get angry at the forms and the “asks,” and then begin to get angry at the patients simply for having needs. Administrative burden is a hassle, but it is also insidiously destructive.⁸

Family physicians confront hopelessness when, day after day, we diagnose problems that no physician is likely to fix in a single office visit: chronic stress, family dysfunction, violence, unemployment, poverty, racism, loneliness, and the hopelessness of the patients themselves. This is not to say that we ignore these concerns or their impact on health. It is because we see and feel them, and deeply understand their consequences for our patients, that we grow frustrated with the lack of solutions.^9,10

Thankfully, we have strong teams working at the policy level to improve the primary care and public health infrastructure so that we can maintain some hope that it will be better in the future. Sometimes when I counsel a former resident, they decide to join those teams so that they can work on the solutions. Others decide to expand their scope of practice. Others seek out virtual scribes to streamline charting and regain time. Some build better boundaries with their EHR inboxes.

The key is figuring out what we can do and making peace with our limits. When disillusionment hits, what we can do includes seeking connection and social contact and remembering that we are not trapped in our situation, even if we are practicing in a less-than-functional health care system. There are many ways to “be” a family physician—if what you’re doing isn’t working for you, look for opportunities (big or small) that make it better. We can all reach out to coaches, therapists, colleagues, and friends for support to remain steadfast in our purpose as family physicians. This support and the power of change means that from residency to the latter parts of our careers, we will continue to bring the tremendous good of family medicine to the communities we serve.

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

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

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

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

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

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

CHARLESTON, S.C. – Melanie Gray Miller, a 30-year-old physician, wiped away tears as she described the isolation she felt after losing a beloved patient.
 

“It was at the end of a night shift, when it seems like bad things always happen,” said Dr. Miller, who is training to become a pediatrician.

The infant had been sick for months in the Medical University of South Carolina’s pediatric intensive care unit and the possibility that he might not improve was obvious, Dr. Miller recalled during an April meeting with physicians and hospital administrators. But the suddenness of his death still caught her off guard.

“I have family and friends that I talk to about things,” she said. “But no one truly understands.”

Doctors don’t typically take time to grieve at work. But during that recent meeting, Dr. Miller and her colleagues opened up about the insomnia, emotional exhaustion, trauma, and burnout they experienced from their time in the pediatric ICU.

“This is not a normal place,” Grant Goodrich, the hospital system’s director of ethics, said to the group, acknowledging an occupational hazard the industry often downplays. “Most people don’t see kids die.”

The recurring conversation, scheduled for early-career doctors coming off month-long pediatric ICU rotations, is one way the hospital helps staffers cope with stress, according to Alyssa Rheingold, a licensed clinical psychologist who leads its resiliency program.

“Often the focus is to teach somebody how to do yoga and take a bath,” she said. “That’s not at all what well-being is about.”

Dr. Miller says working in the hospital’s pediatric intensive care unit can be tough. “In medicine, we’re just expected to be resilient 24/7,” she says. The trauma and stress from patients dying can be particularly hard to process.

Burnout in the health care industry is a widespread problem that long predates the COVID-19 pandemic, though the chaos introduced by the coronavirus’s spread made things worse, physicians and psychologists said. Health systems across the country are trying to boost morale and keep clinicians from quitting or retiring early, but the stakes are higher than workforce shortages.

Rates of physician suicide, partly fueled by burnout, have been a concern for decades. And while burnout occurs across medical specialties, some studies have shown that primary care doctors, such as pediatricians and family physicians, may run a higher risk.

“Why go into primary care when you can make twice the money doing something with half the stress?” said Daniel Crummett, a retired primary care doctor who lives in North Carolina. “I don’t know why anyone would go into primary care.”

Doctors say they are fed up with demands imposed by hospital administrators and health insurance companies, and they’re concerned about the notoriously grueling shifts assigned to medical residents during the early years of their careers. A long-standing stigma keeps physicians from prioritizing their own mental health, while their jobs require them to routinely grapple with death, grief, and trauma. The culture of medicine encourages them to simply bear it.

“Resiliency is a cringe word for me,” Dr. Miller said. “In medicine, we’re just expected to be resilient 24/7. I don’t love that culture.”

And though the pipeline of physicians entering the profession is strong, the ranks of doctors in the United States aren’t growing fast enough to meet future demand, according to the American Medical Association. That’s why burnout exacerbates workforce shortages and, if it continues, may limit the ability of some patients to access even basic care. A 2021 report published by the Association of American Medical Colleges projects the United States will be short as many as 48,000 primary care physicians by 2034, a higher number than any other single medical specialty.

A survey published last year by The Physicians Foundation, a nonprofit focused on improving health care, found more than half of the 1,501 responding doctors didn›t have positive feelings about the current or future state of the medical profession. More than 20% said they wanted to retire within a year.

Similarly, in a 2022 AMA survey of 11,000 doctors and other medical professionals, more than half reported feeling burned out and indicated they were experiencing a great deal of stress.

Those numbers appear to be even higher in primary care. Even before the pandemic, 70% of primary care providers and 89% of primary care residents reported feelings of burnout.

“Everyone in health care feels overworked,” said Gregg Coodley, a primary care physician in Portland, Ore., and author of the book “Patients in Peril: The Demise of Primary Care in America”

“I’m not saying there aren’t issues for other specialists, too, but in primary care, it’s the worst problem,” he said.

The high level of student debt most medical school graduates carry, combined with salaries more than four times as high as the average, deter many physicians from quitting medicine midcareer. Even primary care doctors, whose salaries are among the lowest of all medical specialties, are paid significantly more than the average American worker. That's why, instead of leaving the profession in their 30s or 40s, doctors often stay in their jobs but retire early.

“We go into medicine to help people, to take care of people, to do good in the world,” said Dr. Crummett, who retired from the Duke University hospital system in 2020 when he turned 65.

Dr. Crummett said he would have enjoyed working until he was 70, if not for the bureaucratic burdens of practicing medicine, including needing to get prior authorization from insurance companies before providing care, navigating cumbersome electronic health record platforms, and logging hours of administrative work outside the exam room.

“I enjoyed seeing patients. I really enjoyed my coworkers,” he said. “The administration was certainly a major factor in burnout.”

Jean Antonucci, a primary care doctor in rural Maine who retired from full-time work at 66, said she, too, would have kept working if not for the hassle of dealing with hospital administrators and insurance companies.

Once, Dr. Antonucci said, she had to call an insurance company – by landline and cellphone simultaneously, with one phone on each ear – to get prior authorization to conduct a CT scan, while her patient in need of an appendectomy waited in pain. The hospital wouldn’t conduct the scan without insurance approval.

“It was just infuriating,” said Dr. Antonucci, who now practices medicine only 1 day a week. “I could have kept working. I just got tired.”

Providers’ collective exhaustion is a crisis kept hidden by design, said Whitney Marvin, a pediatrician who works in the pediatric ICU at the Medical University of South Carolina. She said hospital culture implicitly teaches doctors to tamp down their emotions and to “keep moving.”

“I’m not supposed to be weak, and I’m not supposed to cry, and I’m not supposed to have all these emotions, because then maybe I’m not good enough at my job,” said Dr. Marvin, describing the way doctors have historically thought about their mental health.

This mentality prevents many doctors from seeking the help they need, which can lead to burnout – and much worse. An estimated 300 physicians die by suicide every year, according to the American Foundation for Suicide Prevention. The problem is particularly pronounced among female physicians, who die by suicide at a significantly higher rate than women in other professions.

A March report from this news organization found, of more than 9,000 doctors surveyed, 9% of male physicians and 11% of female physicians said they have had suicidal thoughts. But the problem isn’t new, the report noted. Elevated rates of suicide among physicians have been documented for 150 years.

“Ironically, it’s happening to a group of people who should have the easiest access to mental health care,” said Gary Price, a Connecticut surgeon and president of The Physicians Foundation.

But the reluctance to seek help isn’t unfounded, said Corey Feist, president of the Dr. Lorna Breen Heroes’ Foundation .

“There’s something known in residency as the ‘silent curriculum,’ ” Mr. Feist said in describing an often-unspoken understanding among doctors that seeking mental health treatment could jeopardize their livelihood.

Mr. Feist’s sister-in-law, emergency room physician Lorna Breen, died by suicide during the early months of the pandemic. Dr. Breen sought inpatient treatment for mental health once, Mr. Feist said, but feared that her medical license could be revoked for doing so.

The foundation works to change laws across the country to prohibit medical boards and hospitals from asking doctors invasive mental health questions on employment or license applications.

“These people need to be taken care of by us, because really, no one’s looking out for them,” Mr. Feist said.

In Charleston, psychologists are made available to physicians during group meetings like the one Dr. Miller attended, as part of the resiliency program.

But fixing the burnout problem also requires a cultural change, especially among older physicians.

“They had it worse and we know that. But it’s still not good,” Dr. Miller said. “Until that changes, we’re just going to continue burning out physicians within the first 3 years of their career.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

CHARLESTON, S.C. – Melanie Gray Miller, a 30-year-old physician, wiped away tears as she described the isolation she felt after losing a beloved patient.
 

“It was at the end of a night shift, when it seems like bad things always happen,” said Dr. Miller, who is training to become a pediatrician.

The infant had been sick for months in the Medical University of South Carolina’s pediatric intensive care unit and the possibility that he might not improve was obvious, Dr. Miller recalled during an April meeting with physicians and hospital administrators. But the suddenness of his death still caught her off guard.

“I have family and friends that I talk to about things,” she said. “But no one truly understands.”

Doctors don’t typically take time to grieve at work. But during that recent meeting, Dr. Miller and her colleagues opened up about the insomnia, emotional exhaustion, trauma, and burnout they experienced from their time in the pediatric ICU.

“This is not a normal place,” Grant Goodrich, the hospital system’s director of ethics, said to the group, acknowledging an occupational hazard the industry often downplays. “Most people don’t see kids die.”

The recurring conversation, scheduled for early-career doctors coming off month-long pediatric ICU rotations, is one way the hospital helps staffers cope with stress, according to Alyssa Rheingold, a licensed clinical psychologist who leads its resiliency program.

“Often the focus is to teach somebody how to do yoga and take a bath,” she said. “That’s not at all what well-being is about.”

Dr. Miller says working in the hospital’s pediatric intensive care unit can be tough. “In medicine, we’re just expected to be resilient 24/7,” she says. The trauma and stress from patients dying can be particularly hard to process.

Burnout in the health care industry is a widespread problem that long predates the COVID-19 pandemic, though the chaos introduced by the coronavirus’s spread made things worse, physicians and psychologists said. Health systems across the country are trying to boost morale and keep clinicians from quitting or retiring early, but the stakes are higher than workforce shortages.

Rates of physician suicide, partly fueled by burnout, have been a concern for decades. And while burnout occurs across medical specialties, some studies have shown that primary care doctors, such as pediatricians and family physicians, may run a higher risk.

“Why go into primary care when you can make twice the money doing something with half the stress?” said Daniel Crummett, a retired primary care doctor who lives in North Carolina. “I don’t know why anyone would go into primary care.”

Doctors say they are fed up with demands imposed by hospital administrators and health insurance companies, and they’re concerned about the notoriously grueling shifts assigned to medical residents during the early years of their careers. A long-standing stigma keeps physicians from prioritizing their own mental health, while their jobs require them to routinely grapple with death, grief, and trauma. The culture of medicine encourages them to simply bear it.

“Resiliency is a cringe word for me,” Dr. Miller said. “In medicine, we’re just expected to be resilient 24/7. I don’t love that culture.”

And though the pipeline of physicians entering the profession is strong, the ranks of doctors in the United States aren’t growing fast enough to meet future demand, according to the American Medical Association. That’s why burnout exacerbates workforce shortages and, if it continues, may limit the ability of some patients to access even basic care. A 2021 report published by the Association of American Medical Colleges projects the United States will be short as many as 48,000 primary care physicians by 2034, a higher number than any other single medical specialty.

A survey published last year by The Physicians Foundation, a nonprofit focused on improving health care, found more than half of the 1,501 responding doctors didn›t have positive feelings about the current or future state of the medical profession. More than 20% said they wanted to retire within a year.

Similarly, in a 2022 AMA survey of 11,000 doctors and other medical professionals, more than half reported feeling burned out and indicated they were experiencing a great deal of stress.

Those numbers appear to be even higher in primary care. Even before the pandemic, 70% of primary care providers and 89% of primary care residents reported feelings of burnout.

“Everyone in health care feels overworked,” said Gregg Coodley, a primary care physician in Portland, Ore., and author of the book “Patients in Peril: The Demise of Primary Care in America”

“I’m not saying there aren’t issues for other specialists, too, but in primary care, it’s the worst problem,” he said.

The high level of student debt most medical school graduates carry, combined with salaries more than four times as high as the average, deter many physicians from quitting medicine midcareer. Even primary care doctors, whose salaries are among the lowest of all medical specialties, are paid significantly more than the average American worker. That's why, instead of leaving the profession in their 30s or 40s, doctors often stay in their jobs but retire early.

“We go into medicine to help people, to take care of people, to do good in the world,” said Dr. Crummett, who retired from the Duke University hospital system in 2020 when he turned 65.

Dr. Crummett said he would have enjoyed working until he was 70, if not for the bureaucratic burdens of practicing medicine, including needing to get prior authorization from insurance companies before providing care, navigating cumbersome electronic health record platforms, and logging hours of administrative work outside the exam room.

“I enjoyed seeing patients. I really enjoyed my coworkers,” he said. “The administration was certainly a major factor in burnout.”

Jean Antonucci, a primary care doctor in rural Maine who retired from full-time work at 66, said she, too, would have kept working if not for the hassle of dealing with hospital administrators and insurance companies.

Once, Dr. Antonucci said, she had to call an insurance company – by landline and cellphone simultaneously, with one phone on each ear – to get prior authorization to conduct a CT scan, while her patient in need of an appendectomy waited in pain. The hospital wouldn’t conduct the scan without insurance approval.

“It was just infuriating,” said Dr. Antonucci, who now practices medicine only 1 day a week. “I could have kept working. I just got tired.”

Providers’ collective exhaustion is a crisis kept hidden by design, said Whitney Marvin, a pediatrician who works in the pediatric ICU at the Medical University of South Carolina. She said hospital culture implicitly teaches doctors to tamp down their emotions and to “keep moving.”

“I’m not supposed to be weak, and I’m not supposed to cry, and I’m not supposed to have all these emotions, because then maybe I’m not good enough at my job,” said Dr. Marvin, describing the way doctors have historically thought about their mental health.

This mentality prevents many doctors from seeking the help they need, which can lead to burnout – and much worse. An estimated 300 physicians die by suicide every year, according to the American Foundation for Suicide Prevention. The problem is particularly pronounced among female physicians, who die by suicide at a significantly higher rate than women in other professions.

A March report from this news organization found, of more than 9,000 doctors surveyed, 9% of male physicians and 11% of female physicians said they have had suicidal thoughts. But the problem isn’t new, the report noted. Elevated rates of suicide among physicians have been documented for 150 years.

“Ironically, it’s happening to a group of people who should have the easiest access to mental health care,” said Gary Price, a Connecticut surgeon and president of The Physicians Foundation.

But the reluctance to seek help isn’t unfounded, said Corey Feist, president of the Dr. Lorna Breen Heroes’ Foundation .

“There’s something known in residency as the ‘silent curriculum,’ ” Mr. Feist said in describing an often-unspoken understanding among doctors that seeking mental health treatment could jeopardize their livelihood.

Mr. Feist’s sister-in-law, emergency room physician Lorna Breen, died by suicide during the early months of the pandemic. Dr. Breen sought inpatient treatment for mental health once, Mr. Feist said, but feared that her medical license could be revoked for doing so.

The foundation works to change laws across the country to prohibit medical boards and hospitals from asking doctors invasive mental health questions on employment or license applications.

“These people need to be taken care of by us, because really, no one’s looking out for them,” Mr. Feist said.

In Charleston, psychologists are made available to physicians during group meetings like the one Dr. Miller attended, as part of the resiliency program.

But fixing the burnout problem also requires a cultural change, especially among older physicians.

“They had it worse and we know that. But it’s still not good,” Dr. Miller said. “Until that changes, we’re just going to continue burning out physicians within the first 3 years of their career.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

CHARLESTON, S.C. – Melanie Gray Miller, a 30-year-old physician, wiped away tears as she described the isolation she felt after losing a beloved patient.
 

“It was at the end of a night shift, when it seems like bad things always happen,” said Dr. Miller, who is training to become a pediatrician.

The infant had been sick for months in the Medical University of South Carolina’s pediatric intensive care unit and the possibility that he might not improve was obvious, Dr. Miller recalled during an April meeting with physicians and hospital administrators. But the suddenness of his death still caught her off guard.

“I have family and friends that I talk to about things,” she said. “But no one truly understands.”

Doctors don’t typically take time to grieve at work. But during that recent meeting, Dr. Miller and her colleagues opened up about the insomnia, emotional exhaustion, trauma, and burnout they experienced from their time in the pediatric ICU.

“This is not a normal place,” Grant Goodrich, the hospital system’s director of ethics, said to the group, acknowledging an occupational hazard the industry often downplays. “Most people don’t see kids die.”

The recurring conversation, scheduled for early-career doctors coming off month-long pediatric ICU rotations, is one way the hospital helps staffers cope with stress, according to Alyssa Rheingold, a licensed clinical psychologist who leads its resiliency program.

“Often the focus is to teach somebody how to do yoga and take a bath,” she said. “That’s not at all what well-being is about.”

Dr. Miller says working in the hospital’s pediatric intensive care unit can be tough. “In medicine, we’re just expected to be resilient 24/7,” she says. The trauma and stress from patients dying can be particularly hard to process.

Burnout in the health care industry is a widespread problem that long predates the COVID-19 pandemic, though the chaos introduced by the coronavirus’s spread made things worse, physicians and psychologists said. Health systems across the country are trying to boost morale and keep clinicians from quitting or retiring early, but the stakes are higher than workforce shortages.

Rates of physician suicide, partly fueled by burnout, have been a concern for decades. And while burnout occurs across medical specialties, some studies have shown that primary care doctors, such as pediatricians and family physicians, may run a higher risk.

“Why go into primary care when you can make twice the money doing something with half the stress?” said Daniel Crummett, a retired primary care doctor who lives in North Carolina. “I don’t know why anyone would go into primary care.”

Doctors say they are fed up with demands imposed by hospital administrators and health insurance companies, and they’re concerned about the notoriously grueling shifts assigned to medical residents during the early years of their careers. A long-standing stigma keeps physicians from prioritizing their own mental health, while their jobs require them to routinely grapple with death, grief, and trauma. The culture of medicine encourages them to simply bear it.

“Resiliency is a cringe word for me,” Dr. Miller said. “In medicine, we’re just expected to be resilient 24/7. I don’t love that culture.”

And though the pipeline of physicians entering the profession is strong, the ranks of doctors in the United States aren’t growing fast enough to meet future demand, according to the American Medical Association. That’s why burnout exacerbates workforce shortages and, if it continues, may limit the ability of some patients to access even basic care. A 2021 report published by the Association of American Medical Colleges projects the United States will be short as many as 48,000 primary care physicians by 2034, a higher number than any other single medical specialty.

A survey published last year by The Physicians Foundation, a nonprofit focused on improving health care, found more than half of the 1,501 responding doctors didn›t have positive feelings about the current or future state of the medical profession. More than 20% said they wanted to retire within a year.

Similarly, in a 2022 AMA survey of 11,000 doctors and other medical professionals, more than half reported feeling burned out and indicated they were experiencing a great deal of stress.

Those numbers appear to be even higher in primary care. Even before the pandemic, 70% of primary care providers and 89% of primary care residents reported feelings of burnout.

“Everyone in health care feels overworked,” said Gregg Coodley, a primary care physician in Portland, Ore., and author of the book “Patients in Peril: The Demise of Primary Care in America”

“I’m not saying there aren’t issues for other specialists, too, but in primary care, it’s the worst problem,” he said.

The high level of student debt most medical school graduates carry, combined with salaries more than four times as high as the average, deter many physicians from quitting medicine midcareer. Even primary care doctors, whose salaries are among the lowest of all medical specialties, are paid significantly more than the average American worker. That's why, instead of leaving the profession in their 30s or 40s, doctors often stay in their jobs but retire early.

“We go into medicine to help people, to take care of people, to do good in the world,” said Dr. Crummett, who retired from the Duke University hospital system in 2020 when he turned 65.

Dr. Crummett said he would have enjoyed working until he was 70, if not for the bureaucratic burdens of practicing medicine, including needing to get prior authorization from insurance companies before providing care, navigating cumbersome electronic health record platforms, and logging hours of administrative work outside the exam room.

“I enjoyed seeing patients. I really enjoyed my coworkers,” he said. “The administration was certainly a major factor in burnout.”

Jean Antonucci, a primary care doctor in rural Maine who retired from full-time work at 66, said she, too, would have kept working if not for the hassle of dealing with hospital administrators and insurance companies.

Once, Dr. Antonucci said, she had to call an insurance company – by landline and cellphone simultaneously, with one phone on each ear – to get prior authorization to conduct a CT scan, while her patient in need of an appendectomy waited in pain. The hospital wouldn’t conduct the scan without insurance approval.

“It was just infuriating,” said Dr. Antonucci, who now practices medicine only 1 day a week. “I could have kept working. I just got tired.”

Providers’ collective exhaustion is a crisis kept hidden by design, said Whitney Marvin, a pediatrician who works in the pediatric ICU at the Medical University of South Carolina. She said hospital culture implicitly teaches doctors to tamp down their emotions and to “keep moving.”

“I’m not supposed to be weak, and I’m not supposed to cry, and I’m not supposed to have all these emotions, because then maybe I’m not good enough at my job,” said Dr. Marvin, describing the way doctors have historically thought about their mental health.

This mentality prevents many doctors from seeking the help they need, which can lead to burnout – and much worse. An estimated 300 physicians die by suicide every year, according to the American Foundation for Suicide Prevention. The problem is particularly pronounced among female physicians, who die by suicide at a significantly higher rate than women in other professions.

A March report from this news organization found, of more than 9,000 doctors surveyed, 9% of male physicians and 11% of female physicians said they have had suicidal thoughts. But the problem isn’t new, the report noted. Elevated rates of suicide among physicians have been documented for 150 years.

“Ironically, it’s happening to a group of people who should have the easiest access to mental health care,” said Gary Price, a Connecticut surgeon and president of The Physicians Foundation.

But the reluctance to seek help isn’t unfounded, said Corey Feist, president of the Dr. Lorna Breen Heroes’ Foundation .

“There’s something known in residency as the ‘silent curriculum,’ ” Mr. Feist said in describing an often-unspoken understanding among doctors that seeking mental health treatment could jeopardize their livelihood.

Mr. Feist’s sister-in-law, emergency room physician Lorna Breen, died by suicide during the early months of the pandemic. Dr. Breen sought inpatient treatment for mental health once, Mr. Feist said, but feared that her medical license could be revoked for doing so.

The foundation works to change laws across the country to prohibit medical boards and hospitals from asking doctors invasive mental health questions on employment or license applications.

“These people need to be taken care of by us, because really, no one’s looking out for them,” Mr. Feist said.

In Charleston, psychologists are made available to physicians during group meetings like the one Dr. Miller attended, as part of the resiliency program.

But fixing the burnout problem also requires a cultural change, especially among older physicians.

“They had it worse and we know that. But it’s still not good,” Dr. Miller said. “Until that changes, we’re just going to continue burning out physicians within the first 3 years of their career.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.