Mental Health

Study 1 Overview (Chang et al)

Objective: To assess the incidence of postoperative delirium (POD) following propofol- vs sevoflurane-based anesthesia in geriatric spine surgery patients.

Design: Retrospective, single-blinded observational study of propofol- and sevoflurane-based anesthesia cohorts.

Setting and participants: Patients eligible for this study were aged 65 years or older admitted to the SMG-SNU Boramae Medical Center (Seoul, South Korea). All patients underwent general anesthesia either via intravenous propofol or inhalational sevoflurane for spine surgery between January 2015 and December 2019. Patients were retrospectively identified via electronic medical records. Patient exclusion criteria included preoperative delirium, history of dementia, psychiatric disease, alcoholism, hepatic or renal dysfunction, postoperative mechanical ventilation dependence, other surgery within the recent 6 months, maintenance of intraoperative anesthesia with combined anesthetics, or incomplete medical record.

Main outcome measures: The primary outcome was the incidence of POD after administration of propofol- and sevoflurane-based anesthesia during hospitalization. Patients were screened for POD regularly by attending nurses using the Nursing Delirium Screening Scale (disorientation, inappropriate behavior, inappropriate communication, hallucination, and psychomotor retardation) during the entirety of the patient’s hospital stay; if 1 or more screening criteria were met, a psychiatrist was consulted for the proper diagnosis and management of delirium. A psychiatric diagnosis was required for a case to be counted toward the incidence of POD in this study. Secondary outcomes included postoperative 30-day complications (angina, myocardial infarction, transient ischemic attack/stroke, pneumonia, deep vein thrombosis, pulmonary embolism, acute kidney injury, or infection) and length of postoperative hospital stay.

Main results: POD occurred in 29 patients (10.3%) out of the total cohort of 281. POD was more common in the sevoflurane group than in the propofol group (15.7% vs 5.0%; P = .003). Using multivariable logistic regression, inhalational sevoflurane was associated with an increased risk of POD as compared to propofol-based anesthesia (odds ratio [OR], 4.120; 95% CI, 1.549-10.954; P = .005). There was no association between choice of anesthetic and postoperative 30-day complications or the length of postoperative hospital stay. Both older age (OR, 1.242; 95% CI, 1.130-1.366; P < .001) and higher pain score at postoperative day 1 (OR, 1.338; 95% CI, 1.056-1.696; P = .016) were associated with increased risk of POD.

Conclusion: Propofol-based anesthesia was associated with a lower incidence of and risk for POD than sevoflurane-based anesthesia in older patients undergoing spine surgery.

Study 2 Overview (Mei et al)

Objective: To determine the incidence and duration of POD in older patients after total knee/hip replacement (TKR/THR) under intravenous propofol or inhalational sevoflurane general anesthesia.

Design: Randomized clinical trial of propofol and sevoflurane groups.

Setting and participants: This study was conducted at the Shanghai Tenth People’s Hospital and involved 209 participants enrolled between June 2016 and November 2019. All participants were 60 years of age or older, scheduled for TKR/THR surgery under general anesthesia, American Society of Anesthesiologists (ASA) class I to III, and assessed to be of normal cognitive function preoperatively via a Mini-Mental State Examination. Participant exclusion criteria included preexisting delirium as assessed by the Confusion Assessment Method (CAM), prior diagnosed neurological diseases (eg, Parkinson’s disease), prior diagnosed mental disorders (eg, schizophrenia), or impaired vision or hearing that would influence cognitive assessments. All participants were randomly assigned to either sevoflurane or propofol anesthesia for their surgery via a computer-generated list. Of these, 103 received inhalational sevoflurane and 106 received intravenous propofol. All participants received standardized postoperative care.

Main outcome measures: All participants were interviewed by investigators, who were blinded to the anesthesia regimen, twice daily on postoperative days 1, 2, and 3 using CAM and a CAM-based scoring system (CAM-S) to assess delirium severity. The CAM encapsulated 4 criteria: acute onset and fluctuating course, agitation, disorganized thinking, and altered level of consciousness. To diagnose delirium, both the first and second criteria must be met, in addition to either the third or fourth criterion. The averages of the scores across the 3 postoperative days indicated delirium severity, while the incidence and duration of delirium was assessed by the presence of delirium as determined by CAM on any postoperative day.

Main results: All eligible participants (N = 209; mean [SD] age 71.2 [6.7] years; 29.2% male) were included in the final analysis. The incidence of POD was not statistically different between the propofol and sevoflurane groups (33.0% vs 23.3%; P = .119, Chi-square test). It was estimated that 316 participants in each arm of the study were needed to detect statistical differences. The number of days of POD per person were higher with propofol anesthesia as compared to sevoflurane (0.5 [0.8] vs 0.3 [0.5]; P =  .049, Student’s t-test).

Conclusion: This underpowered study showed a 9.7% difference in the incidence of POD between older adults who received propofol (33.0%) and sevoflurane (23.3%) after THR/TKR. Further studies with a larger sample size are needed to compare general anesthetics and their role in POD.

Commentary

Delirium is characterized by an acute state of confusion with fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is often caused by medications and/or their related adverse effects, infections, electrolyte imbalances, and other clinical etiologies. Delirium often manifests in post-surgical settings, disproportionately affecting older patients and leading to increased risk of morbidity, mortality, hospital length of stay, and health care costs.¹ Intraoperative risk factors for POD are determined by the degree of operative stress (eg, lower-risk surgeries put the patient at reduced risk for POD as compared to higher-risk surgeries) and are additive to preexisting patient-specific risk factors, such as older age and functional impairment.¹ Because operative stress is associated with risk for POD, limiting operative stress in controlled ways, such as through the choice of anesthetic agent administered, may be a pragmatic way to manage operative risks and optimize outcomes, especially when serving a surgically vulnerable population.

In Study 1, Chang et al sought to assess whether 2 commonly utilized general anesthetics, propofol and sevoflurane, in older patients undergoing spine surgery differentially affected the incidence of POD. In this retrospective, single-blinded observational study of 281 geriatric patients, the researchers found that sevoflurane was associated with a higher risk of POD as compared to propofol. However, these anesthetics were not associated with surgical outcomes such as postoperative 30-day complications or the length of postoperative hospital stay. While these findings added new knowledge to this field of research, several limitations should be kept in mind when interpreting this study’s results. For instance, the sample size was relatively small, with all cases selected from a single center utilizing a retrospective analysis. In addition, although a standardized nursing screening tool was used as a method for delirium detection, hypoactive delirium or less symptomatic delirium may have been missed, which in turn would lead to an underestimation of POD incidence. The latter is a common limitation in delirium research.

In Study 2, Mei et al similarly explored the effects of general anesthetics on POD in older surgical patients. Specifically, using a randomized clinical trial design, the investigators compared propofol with sevoflurane in older patients who underwent TKR/THR, and their roles in POD severity and duration. Although the incidence of POD was higher in those who received propofol compared to sevoflurane, this trial was underpowered and the results did not reach statistical significance. In addition, while the duration of POD was slightly longer in the propofol group compared to the sevoflurane group (0.5 vs 0.3 days), it was unclear if this finding was clinically significant. Similar to many research studies in POD, limitations of Study 2 included a small sample size of 209 patients, with all participants enrolled from a single center. On the other hand, this study illustrated the feasibility of a method that allowed reproducible prospective assessment of POD time course using CAM and CAM-S.

Applications for Clinical Practice and System Implementation

The delineation of risk factors that contribute to delirium after surgery in older patients is key to mitigating risks for POD and improving clinical outcomes. An important step towards a better understanding of these modifiable risk factors is to clearly quantify intraoperative risk of POD attributable to specific anesthetics. While preclinical studies have shown differential neurotoxicity effects of propofol and sevoflurane, their impact on clinically important neurologic outcomes such as delirium and cognitive decline remains poorly understood. Although Studies 1 and 2 both provided head-to-head comparisons of propofol and sevoflurane as risk factors for POD in high-operative-stress surgeries in older patients, the results were inconsistent. That being said, this small incremental increase in knowledge was not unexpected in the course of discovery around a clinically complex research question. Importantly, these studies provided evidence regarding the methodological approaches that could be taken to further this line of research.

The mediating factors of the differences on neurologic outcomes between anesthetic agents are likely pharmacological, biological, and methodological. Pharmacologically, the differences between target receptors, such as GABAA (propofol, etomidate) or NMDA (ketamine), could be a defining feature in the difference in incidence of POD. Additionally, secondary actions of anesthetic agents on glycine, nicotinic, and acetylcholine receptors could play a role as well. Biologically, genes such as CYP2E1, CYP2B6, CYP2C9, GSTP1, UGT1A9, SULT1A1, and NQO1 have all been identified as genetic factors in the metabolism of anesthetics, and variations in such genes could result in different responses to anesthetics.² Methodologically, routes of anesthetic administration (eg, inhalation vs intravenous), preexisting anatomical structures, or confounding medical conditions (eg, lower respiratory volume due to older age) may influence POD incidence, duration, or severity. Moreover, methodological differences between Studies 1 and 2, such as surgeries performed (spinal vs TKR/THR), patient populations (South Korean vs Chinese), and the diagnosis and monitoring of delirium (retrospective screening and diagnosis vs prospective CAM/CAM-S) may impact delirium outcomes. Thus, these factors should be considered in the design of future clinical trials undertaken to investigate the effects of anesthetics on POD.

Given the high prevalence of delirium and its associated adverse outcomes in the immediate postoperative period in older patients, further research is warranted to determine how anesthetics affect POD in order to optimize perioperative care and mitigate risks in this vulnerable population. Moreover, parallel investigations into how anesthetics differentially impact the development of transient or longer-term cognitive impairment after a surgical procedure (ie, postoperative cognitive dysfunction) in older adults are urgently needed in order to improve their cognitive health.

Practice Points

• Intravenous propofol and inhalational sevoflurane may be differentially associated with incidence, duration, and severity of POD in geriatric surgical patients.
• Further larger-scale studies are warranted to clarify the role of anesthetic choice in POD in order to optimize surgical outcomes in older patients.

–Jared Doan, BS, and Fred Ko, MD
Icahn School of Medicine at Mount Sinai

Study 1 Overview (Chang et al)

Objective: To assess the incidence of postoperative delirium (POD) following propofol- vs sevoflurane-based anesthesia in geriatric spine surgery patients.

Design: Retrospective, single-blinded observational study of propofol- and sevoflurane-based anesthesia cohorts.

Setting and participants: Patients eligible for this study were aged 65 years or older admitted to the SMG-SNU Boramae Medical Center (Seoul, South Korea). All patients underwent general anesthesia either via intravenous propofol or inhalational sevoflurane for spine surgery between January 2015 and December 2019. Patients were retrospectively identified via electronic medical records. Patient exclusion criteria included preoperative delirium, history of dementia, psychiatric disease, alcoholism, hepatic or renal dysfunction, postoperative mechanical ventilation dependence, other surgery within the recent 6 months, maintenance of intraoperative anesthesia with combined anesthetics, or incomplete medical record.

Main outcome measures: The primary outcome was the incidence of POD after administration of propofol- and sevoflurane-based anesthesia during hospitalization. Patients were screened for POD regularly by attending nurses using the Nursing Delirium Screening Scale (disorientation, inappropriate behavior, inappropriate communication, hallucination, and psychomotor retardation) during the entirety of the patient’s hospital stay; if 1 or more screening criteria were met, a psychiatrist was consulted for the proper diagnosis and management of delirium. A psychiatric diagnosis was required for a case to be counted toward the incidence of POD in this study. Secondary outcomes included postoperative 30-day complications (angina, myocardial infarction, transient ischemic attack/stroke, pneumonia, deep vein thrombosis, pulmonary embolism, acute kidney injury, or infection) and length of postoperative hospital stay.

Main results: POD occurred in 29 patients (10.3%) out of the total cohort of 281. POD was more common in the sevoflurane group than in the propofol group (15.7% vs 5.0%; P = .003). Using multivariable logistic regression, inhalational sevoflurane was associated with an increased risk of POD as compared to propofol-based anesthesia (odds ratio [OR], 4.120; 95% CI, 1.549-10.954; P = .005). There was no association between choice of anesthetic and postoperative 30-day complications or the length of postoperative hospital stay. Both older age (OR, 1.242; 95% CI, 1.130-1.366; P < .001) and higher pain score at postoperative day 1 (OR, 1.338; 95% CI, 1.056-1.696; P = .016) were associated with increased risk of POD.

Conclusion: Propofol-based anesthesia was associated with a lower incidence of and risk for POD than sevoflurane-based anesthesia in older patients undergoing spine surgery.

Study 2 Overview (Mei et al)

Objective: To determine the incidence and duration of POD in older patients after total knee/hip replacement (TKR/THR) under intravenous propofol or inhalational sevoflurane general anesthesia.

Design: Randomized clinical trial of propofol and sevoflurane groups.

Setting and participants: This study was conducted at the Shanghai Tenth People’s Hospital and involved 209 participants enrolled between June 2016 and November 2019. All participants were 60 years of age or older, scheduled for TKR/THR surgery under general anesthesia, American Society of Anesthesiologists (ASA) class I to III, and assessed to be of normal cognitive function preoperatively via a Mini-Mental State Examination. Participant exclusion criteria included preexisting delirium as assessed by the Confusion Assessment Method (CAM), prior diagnosed neurological diseases (eg, Parkinson’s disease), prior diagnosed mental disorders (eg, schizophrenia), or impaired vision or hearing that would influence cognitive assessments. All participants were randomly assigned to either sevoflurane or propofol anesthesia for their surgery via a computer-generated list. Of these, 103 received inhalational sevoflurane and 106 received intravenous propofol. All participants received standardized postoperative care.

Main outcome measures: All participants were interviewed by investigators, who were blinded to the anesthesia regimen, twice daily on postoperative days 1, 2, and 3 using CAM and a CAM-based scoring system (CAM-S) to assess delirium severity. The CAM encapsulated 4 criteria: acute onset and fluctuating course, agitation, disorganized thinking, and altered level of consciousness. To diagnose delirium, both the first and second criteria must be met, in addition to either the third or fourth criterion. The averages of the scores across the 3 postoperative days indicated delirium severity, while the incidence and duration of delirium was assessed by the presence of delirium as determined by CAM on any postoperative day.

Main results: All eligible participants (N = 209; mean [SD] age 71.2 [6.7] years; 29.2% male) were included in the final analysis. The incidence of POD was not statistically different between the propofol and sevoflurane groups (33.0% vs 23.3%; P = .119, Chi-square test). It was estimated that 316 participants in each arm of the study were needed to detect statistical differences. The number of days of POD per person were higher with propofol anesthesia as compared to sevoflurane (0.5 [0.8] vs 0.3 [0.5]; P =  .049, Student’s t-test).

Conclusion: This underpowered study showed a 9.7% difference in the incidence of POD between older adults who received propofol (33.0%) and sevoflurane (23.3%) after THR/TKR. Further studies with a larger sample size are needed to compare general anesthetics and their role in POD.

Commentary

Delirium is characterized by an acute state of confusion with fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is often caused by medications and/or their related adverse effects, infections, electrolyte imbalances, and other clinical etiologies. Delirium often manifests in post-surgical settings, disproportionately affecting older patients and leading to increased risk of morbidity, mortality, hospital length of stay, and health care costs.¹ Intraoperative risk factors for POD are determined by the degree of operative stress (eg, lower-risk surgeries put the patient at reduced risk for POD as compared to higher-risk surgeries) and are additive to preexisting patient-specific risk factors, such as older age and functional impairment.¹ Because operative stress is associated with risk for POD, limiting operative stress in controlled ways, such as through the choice of anesthetic agent administered, may be a pragmatic way to manage operative risks and optimize outcomes, especially when serving a surgically vulnerable population.

In Study 1, Chang et al sought to assess whether 2 commonly utilized general anesthetics, propofol and sevoflurane, in older patients undergoing spine surgery differentially affected the incidence of POD. In this retrospective, single-blinded observational study of 281 geriatric patients, the researchers found that sevoflurane was associated with a higher risk of POD as compared to propofol. However, these anesthetics were not associated with surgical outcomes such as postoperative 30-day complications or the length of postoperative hospital stay. While these findings added new knowledge to this field of research, several limitations should be kept in mind when interpreting this study’s results. For instance, the sample size was relatively small, with all cases selected from a single center utilizing a retrospective analysis. In addition, although a standardized nursing screening tool was used as a method for delirium detection, hypoactive delirium or less symptomatic delirium may have been missed, which in turn would lead to an underestimation of POD incidence. The latter is a common limitation in delirium research.

In Study 2, Mei et al similarly explored the effects of general anesthetics on POD in older surgical patients. Specifically, using a randomized clinical trial design, the investigators compared propofol with sevoflurane in older patients who underwent TKR/THR, and their roles in POD severity and duration. Although the incidence of POD was higher in those who received propofol compared to sevoflurane, this trial was underpowered and the results did not reach statistical significance. In addition, while the duration of POD was slightly longer in the propofol group compared to the sevoflurane group (0.5 vs 0.3 days), it was unclear if this finding was clinically significant. Similar to many research studies in POD, limitations of Study 2 included a small sample size of 209 patients, with all participants enrolled from a single center. On the other hand, this study illustrated the feasibility of a method that allowed reproducible prospective assessment of POD time course using CAM and CAM-S.

Applications for Clinical Practice and System Implementation

The delineation of risk factors that contribute to delirium after surgery in older patients is key to mitigating risks for POD and improving clinical outcomes. An important step towards a better understanding of these modifiable risk factors is to clearly quantify intraoperative risk of POD attributable to specific anesthetics. While preclinical studies have shown differential neurotoxicity effects of propofol and sevoflurane, their impact on clinically important neurologic outcomes such as delirium and cognitive decline remains poorly understood. Although Studies 1 and 2 both provided head-to-head comparisons of propofol and sevoflurane as risk factors for POD in high-operative-stress surgeries in older patients, the results were inconsistent. That being said, this small incremental increase in knowledge was not unexpected in the course of discovery around a clinically complex research question. Importantly, these studies provided evidence regarding the methodological approaches that could be taken to further this line of research.

The mediating factors of the differences on neurologic outcomes between anesthetic agents are likely pharmacological, biological, and methodological. Pharmacologically, the differences between target receptors, such as GABAA (propofol, etomidate) or NMDA (ketamine), could be a defining feature in the difference in incidence of POD. Additionally, secondary actions of anesthetic agents on glycine, nicotinic, and acetylcholine receptors could play a role as well. Biologically, genes such as CYP2E1, CYP2B6, CYP2C9, GSTP1, UGT1A9, SULT1A1, and NQO1 have all been identified as genetic factors in the metabolism of anesthetics, and variations in such genes could result in different responses to anesthetics.² Methodologically, routes of anesthetic administration (eg, inhalation vs intravenous), preexisting anatomical structures, or confounding medical conditions (eg, lower respiratory volume due to older age) may influence POD incidence, duration, or severity. Moreover, methodological differences between Studies 1 and 2, such as surgeries performed (spinal vs TKR/THR), patient populations (South Korean vs Chinese), and the diagnosis and monitoring of delirium (retrospective screening and diagnosis vs prospective CAM/CAM-S) may impact delirium outcomes. Thus, these factors should be considered in the design of future clinical trials undertaken to investigate the effects of anesthetics on POD.

Given the high prevalence of delirium and its associated adverse outcomes in the immediate postoperative period in older patients, further research is warranted to determine how anesthetics affect POD in order to optimize perioperative care and mitigate risks in this vulnerable population. Moreover, parallel investigations into how anesthetics differentially impact the development of transient or longer-term cognitive impairment after a surgical procedure (ie, postoperative cognitive dysfunction) in older adults are urgently needed in order to improve their cognitive health.

Practice Points

• Intravenous propofol and inhalational sevoflurane may be differentially associated with incidence, duration, and severity of POD in geriatric surgical patients.
• Further larger-scale studies are warranted to clarify the role of anesthetic choice in POD in order to optimize surgical outcomes in older patients.

–Jared Doan, BS, and Fred Ko, MD
Icahn School of Medicine at Mount Sinai

Study 1 Overview (Chang et al)

Objective: To assess the incidence of postoperative delirium (POD) following propofol- vs sevoflurane-based anesthesia in geriatric spine surgery patients.

Design: Retrospective, single-blinded observational study of propofol- and sevoflurane-based anesthesia cohorts.

Setting and participants: Patients eligible for this study were aged 65 years or older admitted to the SMG-SNU Boramae Medical Center (Seoul, South Korea). All patients underwent general anesthesia either via intravenous propofol or inhalational sevoflurane for spine surgery between January 2015 and December 2019. Patients were retrospectively identified via electronic medical records. Patient exclusion criteria included preoperative delirium, history of dementia, psychiatric disease, alcoholism, hepatic or renal dysfunction, postoperative mechanical ventilation dependence, other surgery within the recent 6 months, maintenance of intraoperative anesthesia with combined anesthetics, or incomplete medical record.

Main outcome measures: The primary outcome was the incidence of POD after administration of propofol- and sevoflurane-based anesthesia during hospitalization. Patients were screened for POD regularly by attending nurses using the Nursing Delirium Screening Scale (disorientation, inappropriate behavior, inappropriate communication, hallucination, and psychomotor retardation) during the entirety of the patient’s hospital stay; if 1 or more screening criteria were met, a psychiatrist was consulted for the proper diagnosis and management of delirium. A psychiatric diagnosis was required for a case to be counted toward the incidence of POD in this study. Secondary outcomes included postoperative 30-day complications (angina, myocardial infarction, transient ischemic attack/stroke, pneumonia, deep vein thrombosis, pulmonary embolism, acute kidney injury, or infection) and length of postoperative hospital stay.

Main results: POD occurred in 29 patients (10.3%) out of the total cohort of 281. POD was more common in the sevoflurane group than in the propofol group (15.7% vs 5.0%; P = .003). Using multivariable logistic regression, inhalational sevoflurane was associated with an increased risk of POD as compared to propofol-based anesthesia (odds ratio [OR], 4.120; 95% CI, 1.549-10.954; P = .005). There was no association between choice of anesthetic and postoperative 30-day complications or the length of postoperative hospital stay. Both older age (OR, 1.242; 95% CI, 1.130-1.366; P < .001) and higher pain score at postoperative day 1 (OR, 1.338; 95% CI, 1.056-1.696; P = .016) were associated with increased risk of POD.

Conclusion: Propofol-based anesthesia was associated with a lower incidence of and risk for POD than sevoflurane-based anesthesia in older patients undergoing spine surgery.

Study 2 Overview (Mei et al)

Objective: To determine the incidence and duration of POD in older patients after total knee/hip replacement (TKR/THR) under intravenous propofol or inhalational sevoflurane general anesthesia.

Design: Randomized clinical trial of propofol and sevoflurane groups.

Setting and participants: This study was conducted at the Shanghai Tenth People’s Hospital and involved 209 participants enrolled between June 2016 and November 2019. All participants were 60 years of age or older, scheduled for TKR/THR surgery under general anesthesia, American Society of Anesthesiologists (ASA) class I to III, and assessed to be of normal cognitive function preoperatively via a Mini-Mental State Examination. Participant exclusion criteria included preexisting delirium as assessed by the Confusion Assessment Method (CAM), prior diagnosed neurological diseases (eg, Parkinson’s disease), prior diagnosed mental disorders (eg, schizophrenia), or impaired vision or hearing that would influence cognitive assessments. All participants were randomly assigned to either sevoflurane or propofol anesthesia for their surgery via a computer-generated list. Of these, 103 received inhalational sevoflurane and 106 received intravenous propofol. All participants received standardized postoperative care.

Main outcome measures: All participants were interviewed by investigators, who were blinded to the anesthesia regimen, twice daily on postoperative days 1, 2, and 3 using CAM and a CAM-based scoring system (CAM-S) to assess delirium severity. The CAM encapsulated 4 criteria: acute onset and fluctuating course, agitation, disorganized thinking, and altered level of consciousness. To diagnose delirium, both the first and second criteria must be met, in addition to either the third or fourth criterion. The averages of the scores across the 3 postoperative days indicated delirium severity, while the incidence and duration of delirium was assessed by the presence of delirium as determined by CAM on any postoperative day.

Main results: All eligible participants (N = 209; mean [SD] age 71.2 [6.7] years; 29.2% male) were included in the final analysis. The incidence of POD was not statistically different between the propofol and sevoflurane groups (33.0% vs 23.3%; P = .119, Chi-square test). It was estimated that 316 participants in each arm of the study were needed to detect statistical differences. The number of days of POD per person were higher with propofol anesthesia as compared to sevoflurane (0.5 [0.8] vs 0.3 [0.5]; P =  .049, Student’s t-test).

Conclusion: This underpowered study showed a 9.7% difference in the incidence of POD between older adults who received propofol (33.0%) and sevoflurane (23.3%) after THR/TKR. Further studies with a larger sample size are needed to compare general anesthetics and their role in POD.

Commentary

Delirium is characterized by an acute state of confusion with fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is often caused by medications and/or their related adverse effects, infections, electrolyte imbalances, and other clinical etiologies. Delirium often manifests in post-surgical settings, disproportionately affecting older patients and leading to increased risk of morbidity, mortality, hospital length of stay, and health care costs.¹ Intraoperative risk factors for POD are determined by the degree of operative stress (eg, lower-risk surgeries put the patient at reduced risk for POD as compared to higher-risk surgeries) and are additive to preexisting patient-specific risk factors, such as older age and functional impairment.¹ Because operative stress is associated with risk for POD, limiting operative stress in controlled ways, such as through the choice of anesthetic agent administered, may be a pragmatic way to manage operative risks and optimize outcomes, especially when serving a surgically vulnerable population.

In Study 1, Chang et al sought to assess whether 2 commonly utilized general anesthetics, propofol and sevoflurane, in older patients undergoing spine surgery differentially affected the incidence of POD. In this retrospective, single-blinded observational study of 281 geriatric patients, the researchers found that sevoflurane was associated with a higher risk of POD as compared to propofol. However, these anesthetics were not associated with surgical outcomes such as postoperative 30-day complications or the length of postoperative hospital stay. While these findings added new knowledge to this field of research, several limitations should be kept in mind when interpreting this study’s results. For instance, the sample size was relatively small, with all cases selected from a single center utilizing a retrospective analysis. In addition, although a standardized nursing screening tool was used as a method for delirium detection, hypoactive delirium or less symptomatic delirium may have been missed, which in turn would lead to an underestimation of POD incidence. The latter is a common limitation in delirium research.

In Study 2, Mei et al similarly explored the effects of general anesthetics on POD in older surgical patients. Specifically, using a randomized clinical trial design, the investigators compared propofol with sevoflurane in older patients who underwent TKR/THR, and their roles in POD severity and duration. Although the incidence of POD was higher in those who received propofol compared to sevoflurane, this trial was underpowered and the results did not reach statistical significance. In addition, while the duration of POD was slightly longer in the propofol group compared to the sevoflurane group (0.5 vs 0.3 days), it was unclear if this finding was clinically significant. Similar to many research studies in POD, limitations of Study 2 included a small sample size of 209 patients, with all participants enrolled from a single center. On the other hand, this study illustrated the feasibility of a method that allowed reproducible prospective assessment of POD time course using CAM and CAM-S.

Applications for Clinical Practice and System Implementation

The delineation of risk factors that contribute to delirium after surgery in older patients is key to mitigating risks for POD and improving clinical outcomes. An important step towards a better understanding of these modifiable risk factors is to clearly quantify intraoperative risk of POD attributable to specific anesthetics. While preclinical studies have shown differential neurotoxicity effects of propofol and sevoflurane, their impact on clinically important neurologic outcomes such as delirium and cognitive decline remains poorly understood. Although Studies 1 and 2 both provided head-to-head comparisons of propofol and sevoflurane as risk factors for POD in high-operative-stress surgeries in older patients, the results were inconsistent. That being said, this small incremental increase in knowledge was not unexpected in the course of discovery around a clinically complex research question. Importantly, these studies provided evidence regarding the methodological approaches that could be taken to further this line of research.

The mediating factors of the differences on neurologic outcomes between anesthetic agents are likely pharmacological, biological, and methodological. Pharmacologically, the differences between target receptors, such as GABAA (propofol, etomidate) or NMDA (ketamine), could be a defining feature in the difference in incidence of POD. Additionally, secondary actions of anesthetic agents on glycine, nicotinic, and acetylcholine receptors could play a role as well. Biologically, genes such as CYP2E1, CYP2B6, CYP2C9, GSTP1, UGT1A9, SULT1A1, and NQO1 have all been identified as genetic factors in the metabolism of anesthetics, and variations in such genes could result in different responses to anesthetics.² Methodologically, routes of anesthetic administration (eg, inhalation vs intravenous), preexisting anatomical structures, or confounding medical conditions (eg, lower respiratory volume due to older age) may influence POD incidence, duration, or severity. Moreover, methodological differences between Studies 1 and 2, such as surgeries performed (spinal vs TKR/THR), patient populations (South Korean vs Chinese), and the diagnosis and monitoring of delirium (retrospective screening and diagnosis vs prospective CAM/CAM-S) may impact delirium outcomes. Thus, these factors should be considered in the design of future clinical trials undertaken to investigate the effects of anesthetics on POD.

Given the high prevalence of delirium and its associated adverse outcomes in the immediate postoperative period in older patients, further research is warranted to determine how anesthetics affect POD in order to optimize perioperative care and mitigate risks in this vulnerable population. Moreover, parallel investigations into how anesthetics differentially impact the development of transient or longer-term cognitive impairment after a surgical procedure (ie, postoperative cognitive dysfunction) in older adults are urgently needed in order to improve their cognitive health.

Practice Points

• Intravenous propofol and inhalational sevoflurane may be differentially associated with incidence, duration, and severity of POD in geriatric surgical patients.
• Further larger-scale studies are warranted to clarify the role of anesthetic choice in POD in order to optimize surgical outcomes in older patients.

–Jared Doan, BS, and Fred Ko, MD
Icahn School of Medicine at Mount Sinai

Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.

Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.

“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.

“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.

The study was published online in JAMA Network Open.
 

Tailored screening?

Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.

To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.

They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).

An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).

The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).

Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.

Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.

The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.

The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.

Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.

Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.

They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
 

Underdiagnosed, undertreated

Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”

“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.

“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.

“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.

This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.

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

Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.

Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.

“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.

“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.

The study was published online in JAMA Network Open.
 

Tailored screening?

Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.

To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.

They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).

An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).

The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).

Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.

Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.

The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.

The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.

Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.

Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.

They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
 

Underdiagnosed, undertreated

Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”

“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.

“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.

“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.

This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.

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

Electrolyte abnormalities may serve as a precursor to a future eating disorder diagnosis, a finding that may help pinpoint candidates for screening.

Researchers found that adolescents and adults with electrolyte abnormalities on routine outpatient lab work were twice as likely as those without these disturbances to be subsequently diagnosed with an eating disorder.

“These electrolyte abnormalities were in fact seen well ahead (> 1 year on average) of the time when patients were diagnosed with eating disorders,” study investigator Gregory Hundemer, MD, department of nephrology, University of Ottawa, told this news organization.

“Incidentally discovered outpatient electrolyte abnormalities may help to identify individuals who may benefit from more targeted screening into an underlying eating disorder. This, in turn, may allow for earlier diagnosis and therapeutic intervention,” Dr. Hundemer said.

The study was published online in JAMA Network Open.
 

Tailored screening?

Electrolyte abnormalities are often found when an individual is diagnosed with an eating disorder, but it’s largely unknown whether electrolyte abnormalities prior to the acute presentation of an eating disorder are associated with the future diagnosis of an eating disorder.

To investigate, the researchers used administrative health data to match 6,970 individuals (mean age, 28 years; 13% male) with an eating disorder diagnosis to 27,878 controls without an eating disorder diagnosis.

They found that individuals with an eating disorder were more likely to have a preceding electrolyte abnormality, compared with peers without an eating disorder (18.4% vs. 7.5%).

An outpatient electrolyte abnormality present 3 years to 30 days prior to diagnosis was associated with about a twofold higher odds for subsequent eating disorder diagnosis (adjusted odds ratio, 2.12; 95% confidence interval, 1.86-2.41).

The median time from the earliest electrolyte abnormality to eating disorder diagnosis was 386 days (range, 157-716 days).

Hypokalemia was the most common electrolyte abnormality (present in 12% of cases vs. 5% of controls), while hyponatremia, hypernatremia, hypophosphatemia, and metabolic alkalosis were the most specific for a subsequent eating disorder diagnosis.

Severe hypokalemia (serum potassium levels of 3.0 mmol/L or lower) and severe hyponatremia (serum sodium, 128 mmol/L or lower) were associated with over sevenfold and fivefold higher odds for the diagnosis of an eating disorder, respectively.

The U.S. Preventive Services Task Force issued its first-ever statement on screening for eating disorders earlier this year.

The task force concluded that there is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults with no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder.

Dr. Hundemer and colleagues believe an incidental electrolyte abnormality may identify candidates at high risk for an underlying eating disorder who many benefit from screening.

Several screening tools of varying complexity have been developed that are validated and accurate in identifying individuals with a potential eating disorder.

They include the SCOFF questionnaire, the Eating Disorder Screen for Primary Care, the Eating Attitudes Test, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire.
 

Underdiagnosed, undertreated

Offering perspective on the findings, Kamryn T. Eddy, PhD, codirector, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, said the notion “that a physical sign may help to promote eating disorder assessment is important particularly given that early detection can improve outcomes.”

“But this finding appears in the current context of eating disorders going largely underdetected, underdiagnosed, and undertreated across medical and psychiatric settings,” said Dr. Eddy, associate professor, department of psychiatry, Harvard Medical School, Boston.

“Indeed, eating disorders are prevalent and cut across age, sex, gender, weight, race, ethnicity, and socioeconomic strata, and still, many providers do not routinely assess for eating disorders,” Dr. Eddy said.

“I might suggest that perhaps in addition to letting electrolyte abnormalities be a cue to screen for eating disorders, an even more powerful shift toward routine screening and assessment of eating disorders by medical providers be made,” Dr. Eddy said in an interview.

This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Health and Long-Term Care. Dr. Hundemer and Dr. Eddy have disclosed no relevant financial relationships.

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

PAU, FRANCE – Postpartum posttraumatic stress disorder tends to get worse over the months following the birth of a child. Therefore, it’s necessary to screen for it as early on as possible and to ensure that women who are affected are given the proper treatment. This was the message delivered during the Infogyn 2022 conference by Ludivine Franchitto, MD, a child psychiatrist at Toulouse University Hospital, France. Because postpartum PTSD is still not fully recognized, treatment remains inadequate and poorly documented.

Impact on the caregivers as well

“The situation is the same as what we saw with postpartum depression. The debate went on for 20 years before its existence was formally declared,” Dr. Franchitto noted. But for her, the important thing is not knowing whether a traumatic stress state may be experienced by the mother who had complications during pregnancy or delivery. Instead, it’s about focusing on the repercussions for the child.

During her presentation, Dr. Franchitto also pointed out that it’s necessary to recognize that caregivers who work in maternity wards may also be negatively impacted, as they routinely see the complications that women have during pregnancy and delivery. These workers may also develop a PTSD state, requiring support so that they can properly carry out their duties.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), posttraumatic stress disorder arises after exposure to actual (or threatened) death, serious injury, or sexual violence. Individuals who have witnessed a traumatic event in person or who have experienced repeated (or extreme) exposure to aversive details of traumatic events may also develop PTSD.

Dr. Franchitto mentioned some of the criteria needed to make the diagnosis. “Intrusive distressing memories of the event, recurrent distressing dreams related to the event, persistent avoidance of stimuli associated with the traumatic event, or negative alterations in cognitions and mood associated with the traumatic event. And the duration of the disturbance is more than 1 month.” There may also be marked alterations in arousal and reactivity associated with the traumatic event (for example, irritable behavior, loss of awareness of present surroundings).
 

Prevalent in 18% of women in high-risk groups

According to the studies, there is a wide variability of PTSD rates. If referring only to traumatic symptoms (for example, depressive syndrome, suicidal ideation, hyperreactivity, and persistent avoidance), the rate could reach up to 40%. A 2016 meta-analysis of 59 studies found that the prevalence of childbirth-related PTSD was 5.9%.

The authors distinguished two groups of women: those without complications during pregnancy or during delivery and those with severe complications related to the pregnancy, a fear of giving birth, a difficult delivery, an emergency C-section, a baby born prematurely with birth defects, etc. Their analysis showed PTSD rates of 4% and 18.5%, respectively.

Surprisingly, the major risk factor for PTSD turned out to be uncontrollable vomiting during pregnancy (seen in 40% of postpartum PTSD cases). The birth of a baby with birth defects was the second risk factor (35%), and the third, a history of violence in the mother’s childhood (34%). Women who experienced depression during the delivery were also at higher risk.

Other risk factors identified were lack of communication with the health care team, lack of consent, lack of support from the medical staff, and a long labor. Conversely, a sense of control and the support of a partner play a protective role.
 

Early screening

“If the symptoms of posttraumatic stress disorder aren’t treated after delivery, they tend to get worse over the period of 1 to 6 months following the child’s birth,” Dr. Franchitto indicated. This is why it’s necessary to screen for it as early as possible – in particular, by having the women fill out the City Birth Trauma Scale questionnaire – and provide proper treatment accordingly. When seeking to limit the effects of stress, early intervention by a psychologist may be beneficial.

Psychotherapy is the recommended first-line treatment for PTSD, especially cognitive behavioral therapy and Eye Movement Desensitization and Reprocessing therapy. This approach aims to limit the mental and behavioral avoidance that prevents the traumatic memory from being integrated and processed as a regular memory.

The consequences that the mother’s PTSD state has on the child are well documented. “Children whose mothers had PTSD during pregnancy have a lower birth weight and a shorter breast-feeding duration,” Dr. Franchitto reported. With respect to the quality of the mother-child relationship and the long-term development of the child, “the studies have highly conflicting findings.”

At the end of the presentation, Professor Israël Nisand, MD, an ob.gyn. at the American Hospital of Paris and the former president of the National College of French Gynecologists and Obstetricians, made the following comment: “I often think that we underestimate the consequences that the mother’s posttraumatic stress has on the child postpartum.” He added, “Postpartum posttraumatic stress disorder is a reality. Yet it isn’t screened for, let alone treated, even though it has serious consequences for the child.”

Dr. Franchitto also brought up the impact on members of the health care staff, the “second victims” of the traumatic events that occur while caring for the women in the maternity ward. “The estimated prevalence of PTSD symptoms among midwives is 22.9%,” which could lead to “a loss of confidence and a desire to leave the profession.”
 

Providing psychoeducation to health care staff

Dr. Franchitto believes that it’s essential to also protect caregivers who work in maternity wards. “It’s important to have the support of colleagues” – in particular, of team leaders – “and to share one’s experiences,” as long as one knows how to recognize the symptoms of posttraumatic stress through one’s emotions and is able to verbalize them.

She went on to say that providing psychoeducation to health care staff is therefore to be encouraged, as is “simulation-based training, for learning how to manage problematic situations.”

This content was originally published on Medscape French edition. A translated version appeared on Medscape.com.

PAU, FRANCE – Postpartum posttraumatic stress disorder tends to get worse over the months following the birth of a child. Therefore, it’s necessary to screen for it as early on as possible and to ensure that women who are affected are given the proper treatment. This was the message delivered during the Infogyn 2022 conference by Ludivine Franchitto, MD, a child psychiatrist at Toulouse University Hospital, France. Because postpartum PTSD is still not fully recognized, treatment remains inadequate and poorly documented.

Impact on the caregivers as well

“The situation is the same as what we saw with postpartum depression. The debate went on for 20 years before its existence was formally declared,” Dr. Franchitto noted. But for her, the important thing is not knowing whether a traumatic stress state may be experienced by the mother who had complications during pregnancy or delivery. Instead, it’s about focusing on the repercussions for the child.

During her presentation, Dr. Franchitto also pointed out that it’s necessary to recognize that caregivers who work in maternity wards may also be negatively impacted, as they routinely see the complications that women have during pregnancy and delivery. These workers may also develop a PTSD state, requiring support so that they can properly carry out their duties.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), posttraumatic stress disorder arises after exposure to actual (or threatened) death, serious injury, or sexual violence. Individuals who have witnessed a traumatic event in person or who have experienced repeated (or extreme) exposure to aversive details of traumatic events may also develop PTSD.

Dr. Franchitto mentioned some of the criteria needed to make the diagnosis. “Intrusive distressing memories of the event, recurrent distressing dreams related to the event, persistent avoidance of stimuli associated with the traumatic event, or negative alterations in cognitions and mood associated with the traumatic event. And the duration of the disturbance is more than 1 month.” There may also be marked alterations in arousal and reactivity associated with the traumatic event (for example, irritable behavior, loss of awareness of present surroundings).
 

Prevalent in 18% of women in high-risk groups

According to the studies, there is a wide variability of PTSD rates. If referring only to traumatic symptoms (for example, depressive syndrome, suicidal ideation, hyperreactivity, and persistent avoidance), the rate could reach up to 40%. A 2016 meta-analysis of 59 studies found that the prevalence of childbirth-related PTSD was 5.9%.

The authors distinguished two groups of women: those without complications during pregnancy or during delivery and those with severe complications related to the pregnancy, a fear of giving birth, a difficult delivery, an emergency C-section, a baby born prematurely with birth defects, etc. Their analysis showed PTSD rates of 4% and 18.5%, respectively.

Surprisingly, the major risk factor for PTSD turned out to be uncontrollable vomiting during pregnancy (seen in 40% of postpartum PTSD cases). The birth of a baby with birth defects was the second risk factor (35%), and the third, a history of violence in the mother’s childhood (34%). Women who experienced depression during the delivery were also at higher risk.

Other risk factors identified were lack of communication with the health care team, lack of consent, lack of support from the medical staff, and a long labor. Conversely, a sense of control and the support of a partner play a protective role.
 

Early screening

“If the symptoms of posttraumatic stress disorder aren’t treated after delivery, they tend to get worse over the period of 1 to 6 months following the child’s birth,” Dr. Franchitto indicated. This is why it’s necessary to screen for it as early as possible – in particular, by having the women fill out the City Birth Trauma Scale questionnaire – and provide proper treatment accordingly. When seeking to limit the effects of stress, early intervention by a psychologist may be beneficial.

Psychotherapy is the recommended first-line treatment for PTSD, especially cognitive behavioral therapy and Eye Movement Desensitization and Reprocessing therapy. This approach aims to limit the mental and behavioral avoidance that prevents the traumatic memory from being integrated and processed as a regular memory.

The consequences that the mother’s PTSD state has on the child are well documented. “Children whose mothers had PTSD during pregnancy have a lower birth weight and a shorter breast-feeding duration,” Dr. Franchitto reported. With respect to the quality of the mother-child relationship and the long-term development of the child, “the studies have highly conflicting findings.”

At the end of the presentation, Professor Israël Nisand, MD, an ob.gyn. at the American Hospital of Paris and the former president of the National College of French Gynecologists and Obstetricians, made the following comment: “I often think that we underestimate the consequences that the mother’s posttraumatic stress has on the child postpartum.” He added, “Postpartum posttraumatic stress disorder is a reality. Yet it isn’t screened for, let alone treated, even though it has serious consequences for the child.”

Dr. Franchitto also brought up the impact on members of the health care staff, the “second victims” of the traumatic events that occur while caring for the women in the maternity ward. “The estimated prevalence of PTSD symptoms among midwives is 22.9%,” which could lead to “a loss of confidence and a desire to leave the profession.”
 

Providing psychoeducation to health care staff

Dr. Franchitto believes that it’s essential to also protect caregivers who work in maternity wards. “It’s important to have the support of colleagues” – in particular, of team leaders – “and to share one’s experiences,” as long as one knows how to recognize the symptoms of posttraumatic stress through one’s emotions and is able to verbalize them.

She went on to say that providing psychoeducation to health care staff is therefore to be encouraged, as is “simulation-based training, for learning how to manage problematic situations.”

This content was originally published on Medscape French edition. A translated version appeared on Medscape.com.

PAU, FRANCE – Postpartum posttraumatic stress disorder tends to get worse over the months following the birth of a child. Therefore, it’s necessary to screen for it as early on as possible and to ensure that women who are affected are given the proper treatment. This was the message delivered during the Infogyn 2022 conference by Ludivine Franchitto, MD, a child psychiatrist at Toulouse University Hospital, France. Because postpartum PTSD is still not fully recognized, treatment remains inadequate and poorly documented.

Impact on the caregivers as well

“The situation is the same as what we saw with postpartum depression. The debate went on for 20 years before its existence was formally declared,” Dr. Franchitto noted. But for her, the important thing is not knowing whether a traumatic stress state may be experienced by the mother who had complications during pregnancy or delivery. Instead, it’s about focusing on the repercussions for the child.

During her presentation, Dr. Franchitto also pointed out that it’s necessary to recognize that caregivers who work in maternity wards may also be negatively impacted, as they routinely see the complications that women have during pregnancy and delivery. These workers may also develop a PTSD state, requiring support so that they can properly carry out their duties.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), posttraumatic stress disorder arises after exposure to actual (or threatened) death, serious injury, or sexual violence. Individuals who have witnessed a traumatic event in person or who have experienced repeated (or extreme) exposure to aversive details of traumatic events may also develop PTSD.

Dr. Franchitto mentioned some of the criteria needed to make the diagnosis. “Intrusive distressing memories of the event, recurrent distressing dreams related to the event, persistent avoidance of stimuli associated with the traumatic event, or negative alterations in cognitions and mood associated with the traumatic event. And the duration of the disturbance is more than 1 month.” There may also be marked alterations in arousal and reactivity associated with the traumatic event (for example, irritable behavior, loss of awareness of present surroundings).
 

Prevalent in 18% of women in high-risk groups

According to the studies, there is a wide variability of PTSD rates. If referring only to traumatic symptoms (for example, depressive syndrome, suicidal ideation, hyperreactivity, and persistent avoidance), the rate could reach up to 40%. A 2016 meta-analysis of 59 studies found that the prevalence of childbirth-related PTSD was 5.9%.

The authors distinguished two groups of women: those without complications during pregnancy or during delivery and those with severe complications related to the pregnancy, a fear of giving birth, a difficult delivery, an emergency C-section, a baby born prematurely with birth defects, etc. Their analysis showed PTSD rates of 4% and 18.5%, respectively.

Surprisingly, the major risk factor for PTSD turned out to be uncontrollable vomiting during pregnancy (seen in 40% of postpartum PTSD cases). The birth of a baby with birth defects was the second risk factor (35%), and the third, a history of violence in the mother’s childhood (34%). Women who experienced depression during the delivery were also at higher risk.

Other risk factors identified were lack of communication with the health care team, lack of consent, lack of support from the medical staff, and a long labor. Conversely, a sense of control and the support of a partner play a protective role.
 

Early screening

“If the symptoms of posttraumatic stress disorder aren’t treated after delivery, they tend to get worse over the period of 1 to 6 months following the child’s birth,” Dr. Franchitto indicated. This is why it’s necessary to screen for it as early as possible – in particular, by having the women fill out the City Birth Trauma Scale questionnaire – and provide proper treatment accordingly. When seeking to limit the effects of stress, early intervention by a psychologist may be beneficial.

Psychotherapy is the recommended first-line treatment for PTSD, especially cognitive behavioral therapy and Eye Movement Desensitization and Reprocessing therapy. This approach aims to limit the mental and behavioral avoidance that prevents the traumatic memory from being integrated and processed as a regular memory.

The consequences that the mother’s PTSD state has on the child are well documented. “Children whose mothers had PTSD during pregnancy have a lower birth weight and a shorter breast-feeding duration,” Dr. Franchitto reported. With respect to the quality of the mother-child relationship and the long-term development of the child, “the studies have highly conflicting findings.”

At the end of the presentation, Professor Israël Nisand, MD, an ob.gyn. at the American Hospital of Paris and the former president of the National College of French Gynecologists and Obstetricians, made the following comment: “I often think that we underestimate the consequences that the mother’s posttraumatic stress has on the child postpartum.” He added, “Postpartum posttraumatic stress disorder is a reality. Yet it isn’t screened for, let alone treated, even though it has serious consequences for the child.”

Dr. Franchitto also brought up the impact on members of the health care staff, the “second victims” of the traumatic events that occur while caring for the women in the maternity ward. “The estimated prevalence of PTSD symptoms among midwives is 22.9%,” which could lead to “a loss of confidence and a desire to leave the profession.”
 

Providing psychoeducation to health care staff

Dr. Franchitto believes that it’s essential to also protect caregivers who work in maternity wards. “It’s important to have the support of colleagues” – in particular, of team leaders – “and to share one’s experiences,” as long as one knows how to recognize the symptoms of posttraumatic stress through one’s emotions and is able to verbalize them.

She went on to say that providing psychoeducation to health care staff is therefore to be encouraged, as is “simulation-based training, for learning how to manage problematic situations.”

This content was originally published on Medscape French edition. A translated version appeared on Medscape.com.

Roughly 7% of all adult Americans may currently have had long COVID, with symptoms that have lasted 3 months or longer, according to the latest U.S. government survey done in October. More than a quarter say their condition is severe enough to significantly limit their day-to-day activities – yet the problem is only barely starting to get the attention of employers, the health care system, and policymakers.

With no cure or treatment in sight, long COVID is already burdening not only the health care system, but also the economy – and that burden is set to grow. Many experts worry about the possible long-term ripple effects, from increased spending on medical care costs to lost wages due to not being able to work, as well as the policy implications that come with addressing these issues.

“At this point, anyone who’s looking at this seriously would say this is a huge deal,” says senior Brookings Institution fellow Katie Bach, the author of a study that analyzed long COVID’s impact on the labor market.

“We need a real concerted focus on treating these people, which means both research and the clinical side, and figuring out how to build a labor market that is more inclusive of people with disabilities,” she said.

It’s not only that many people are affected. It’s that they are often affected for months and possibly even years.

The U.S. government figures suggest more than 18 million people could have symptoms of long COVID right now. The latest Household Pulse Survey by the Census Bureau and the National Center for Health Statistics takes data from 41,415 people.

A preprint of a study by researchers from City University of New York, posted on medRxiv in September and based on a similar population survey done between June 30 and July 2, drew comparable results. The study has not been peer reviewed.

More than 7% of all those who answered said they had long COVID at the time of the survey, which the researchers said corresponded to approximately 18.5 million U.S. adults. The same study found that a quarter of those, or an estimated 4.7 million adults, said their daily activities were impacted “a lot.”

This can translate into pain not only for the patients, but for governments and employers, too.

In high-income countries around the world, government surveys and other studies are shedding light on the extent to which post-COVID-19 symptoms – commonly known as long COVID – are affecting populations. While results vary, they generally fall within similar ranges.

The World Health Organization estimates that between 10% and 20% of those with COVID-19 go on to have an array of medium- to long-term post-COVID-19 symptoms that range from mild to debilitating. The U.S. Government Accountability Office puts that estimate at 10% to 30%; one of the latest studies published at the end of October in The Journal of the American Medical Association found that 15% of U.S. adults who had tested positive for COVID-19 reported current long COVID symptoms. Elsewhere, a study from the Netherlands published in The Lancet in August found that one in eight COVID-19 cases, or 12.7%, were likely to become long COVID.

“It’s very clear that the condition is devastating people’s lives and livelihoods,” WHO Director-General Tedros Adhanom Ghebreyesus wrote in an article for The Guardian newspaper in October.

“The world has already lost a significant number of the workforce to illness, death, fatigue, unplanned retirement due to an increase in long-term disability, which not only impacts the health system, but is a hit to the overarching economy … the impact of long COVID for all countries is very serious and needs immediate and sustained action equivalent to its scale.”
 

Global snapshot: Lasting symptoms, impact on activities

Patients describe a spectrum of persistent issues, with extreme fatigue, brain fog or cognitive problems, and shortness of breath among the most common complaints. Many also have manageable symptoms that worsen significantly after even mild physical or mental exertion.

Women appear almost twice as likely as men to get long COVID. Many patients have other medical conditions and disabilities that make them more vulnerable to the condition. Those who face greater obstacles accessing health care due to discrimination or socioeconomic inequity are at higher risk as well. 

While many are older, a large number are also in their prime working age. The Census Bureau data show that people ages 40-49 are more likely than any other group to get long COVID, which has broader implications for labor markets and the global economy. Already, experts have estimated that long COVID is likely to cost the U.S. trillions of dollars and affect multiple industries.

“Whether they’re in the financial world, the medical system, lawyers, they’re telling me they’re sitting at the computer screen and they’re unable to process the data,” said Zachary Schwartz, MD, medical director for Vancouver General Hospital’s Post-COVID-19 Recovery Clinic.

“That is what’s most distressing for people, in that they’re not working, they’re not making money, and they don’t know when, or if, they’re going to get better.”

Nearly a third of respondents in the Census Bureau’s Household Pulse Survey who said they have had COVID-19 reported symptoms that lasted 3 months or longer. People between the ages of 30 and 59 were the most affected, with about 32% reporting symptoms. Across the entire adult U.S. population, the survey found that 1 in 7 adults have had long COVID at some point during the pandemic, with about 1 in 18 saying it limited their activity to some degree, and 1 in 50 saying they have faced “a lot” of limits on their activities. Any way these numbers are dissected, long COVID has impacted a large swath of the population.

Yet research into the causes and possible treatments of long COVID is just getting underway.

“The amount of energy and time devoted to it is way, way less than it should, given how many people are likely affected,” said David Cutler, PhD, professor of economics at Harvard University, Cambridge, Mass., who has written about the economic cost of long COVID. “We’re way, way underdoing it here. And I think that’s really a terrible thing.”

Population surveys and studies from around the world show that long COVID lives up to its name, with people reporting serious symptoms for months on end.

In October, Statistics Canada and the Public Health Agency of Canada published early results from a questionnaire done between spring and summer 2022 that found just under 15% of adults who had a confirmed or suspected case of COVID-19 went on to have new or continuing symptoms 3 or more months later. Nearly half, or 47.3%, dealt with symptoms that lasted a year or more. More than one in five said their symptoms “often or always” limited their day-to-day activities, which included routine tasks such as preparing meals, doing errands and chores, and basic functions such as personal care and moving around in their homes.

Nearly three-quarters of workers or students said they missed an average of 20 days of work or school. 

“We haven’t yet been able to determine exactly when symptoms resolve,” said Rainu Kaushal, MD, the senior associate dean for clinical research at Weill Cornell Medicine in New York. She is co-leading a national study on long COVID in adults and children, funded by the National Institutes of Health RECOVER Initiative.

“But there does seem to be, for many of the milder symptoms, resolution at about 4-6 weeks. There seems to be a second point of resolution around 6 months for certain symptoms, and then some symptoms do seem to be permanent, and those tend to be patients who have underlying conditions,” she said.
 

Reducing the risk

Given all the data so far, experts recommend urgent policy changes to help people with long COVID.

“The population needs to be prepared, that understanding long COVID is going to be a very long and difficult process,” said Alexander Charney, MD, PhD, associate professor and the lead principal investigator of the RECOVER adult cohort at Icahn School of Medicine at Mount Sinai in New York. He said the government can do a great deal to help, including setting up a network of connected clinics treating long COVID, standardizing best practices, and sharing information.

“That would go a long way towards making sure that every person feels like they’re not too far away from a clinic where they can get treated for this particular condition,” he said.

But the only known way to prevent long COVID is to prevent COVID-19 infections in the first place, experts say. That means equitable access to tests, therapeutics, and vaccines.

“I will say that avoiding COVID remains the best treatment in the arsenal right now,” said Dr. Kaushal. This means masking, avoiding crowded places with poor ventilation and high exposure risk, and being up to date on vaccinations, she said.

A number of papers – including a large U.K. study published in May 2022, another one from July, and the JAMA study from October – all suggest that vaccinations can help reduce the risk of long COVID.

“I am absolutely of the belief that vaccination has reduced the incidence and overall amount of long COVID … [and is] still by far the best thing the public can do,” said Dr. Schwartz.

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

Roughly 7% of all adult Americans may currently have had long COVID, with symptoms that have lasted 3 months or longer, according to the latest U.S. government survey done in October. More than a quarter say their condition is severe enough to significantly limit their day-to-day activities – yet the problem is only barely starting to get the attention of employers, the health care system, and policymakers.

With no cure or treatment in sight, long COVID is already burdening not only the health care system, but also the economy – and that burden is set to grow. Many experts worry about the possible long-term ripple effects, from increased spending on medical care costs to lost wages due to not being able to work, as well as the policy implications that come with addressing these issues.

“At this point, anyone who’s looking at this seriously would say this is a huge deal,” says senior Brookings Institution fellow Katie Bach, the author of a study that analyzed long COVID’s impact on the labor market.

“We need a real concerted focus on treating these people, which means both research and the clinical side, and figuring out how to build a labor market that is more inclusive of people with disabilities,” she said.

It’s not only that many people are affected. It’s that they are often affected for months and possibly even years.

The U.S. government figures suggest more than 18 million people could have symptoms of long COVID right now. The latest Household Pulse Survey by the Census Bureau and the National Center for Health Statistics takes data from 41,415 people.

A preprint of a study by researchers from City University of New York, posted on medRxiv in September and based on a similar population survey done between June 30 and July 2, drew comparable results. The study has not been peer reviewed.

More than 7% of all those who answered said they had long COVID at the time of the survey, which the researchers said corresponded to approximately 18.5 million U.S. adults. The same study found that a quarter of those, or an estimated 4.7 million adults, said their daily activities were impacted “a lot.”

This can translate into pain not only for the patients, but for governments and employers, too.

In high-income countries around the world, government surveys and other studies are shedding light on the extent to which post-COVID-19 symptoms – commonly known as long COVID – are affecting populations. While results vary, they generally fall within similar ranges.

The World Health Organization estimates that between 10% and 20% of those with COVID-19 go on to have an array of medium- to long-term post-COVID-19 symptoms that range from mild to debilitating. The U.S. Government Accountability Office puts that estimate at 10% to 30%; one of the latest studies published at the end of October in The Journal of the American Medical Association found that 15% of U.S. adults who had tested positive for COVID-19 reported current long COVID symptoms. Elsewhere, a study from the Netherlands published in The Lancet in August found that one in eight COVID-19 cases, or 12.7%, were likely to become long COVID.

“It’s very clear that the condition is devastating people’s lives and livelihoods,” WHO Director-General Tedros Adhanom Ghebreyesus wrote in an article for The Guardian newspaper in October.

“The world has already lost a significant number of the workforce to illness, death, fatigue, unplanned retirement due to an increase in long-term disability, which not only impacts the health system, but is a hit to the overarching economy … the impact of long COVID for all countries is very serious and needs immediate and sustained action equivalent to its scale.”
 

Global snapshot: Lasting symptoms, impact on activities

Patients describe a spectrum of persistent issues, with extreme fatigue, brain fog or cognitive problems, and shortness of breath among the most common complaints. Many also have manageable symptoms that worsen significantly after even mild physical or mental exertion.

Women appear almost twice as likely as men to get long COVID. Many patients have other medical conditions and disabilities that make them more vulnerable to the condition. Those who face greater obstacles accessing health care due to discrimination or socioeconomic inequity are at higher risk as well. 

While many are older, a large number are also in their prime working age. The Census Bureau data show that people ages 40-49 are more likely than any other group to get long COVID, which has broader implications for labor markets and the global economy. Already, experts have estimated that long COVID is likely to cost the U.S. trillions of dollars and affect multiple industries.

“Whether they’re in the financial world, the medical system, lawyers, they’re telling me they’re sitting at the computer screen and they’re unable to process the data,” said Zachary Schwartz, MD, medical director for Vancouver General Hospital’s Post-COVID-19 Recovery Clinic.

“That is what’s most distressing for people, in that they’re not working, they’re not making money, and they don’t know when, or if, they’re going to get better.”

Nearly a third of respondents in the Census Bureau’s Household Pulse Survey who said they have had COVID-19 reported symptoms that lasted 3 months or longer. People between the ages of 30 and 59 were the most affected, with about 32% reporting symptoms. Across the entire adult U.S. population, the survey found that 1 in 7 adults have had long COVID at some point during the pandemic, with about 1 in 18 saying it limited their activity to some degree, and 1 in 50 saying they have faced “a lot” of limits on their activities. Any way these numbers are dissected, long COVID has impacted a large swath of the population.

Yet research into the causes and possible treatments of long COVID is just getting underway.

“The amount of energy and time devoted to it is way, way less than it should, given how many people are likely affected,” said David Cutler, PhD, professor of economics at Harvard University, Cambridge, Mass., who has written about the economic cost of long COVID. “We’re way, way underdoing it here. And I think that’s really a terrible thing.”

Population surveys and studies from around the world show that long COVID lives up to its name, with people reporting serious symptoms for months on end.

In October, Statistics Canada and the Public Health Agency of Canada published early results from a questionnaire done between spring and summer 2022 that found just under 15% of adults who had a confirmed or suspected case of COVID-19 went on to have new or continuing symptoms 3 or more months later. Nearly half, or 47.3%, dealt with symptoms that lasted a year or more. More than one in five said their symptoms “often or always” limited their day-to-day activities, which included routine tasks such as preparing meals, doing errands and chores, and basic functions such as personal care and moving around in their homes.

Nearly three-quarters of workers or students said they missed an average of 20 days of work or school. 

“We haven’t yet been able to determine exactly when symptoms resolve,” said Rainu Kaushal, MD, the senior associate dean for clinical research at Weill Cornell Medicine in New York. She is co-leading a national study on long COVID in adults and children, funded by the National Institutes of Health RECOVER Initiative.

“But there does seem to be, for many of the milder symptoms, resolution at about 4-6 weeks. There seems to be a second point of resolution around 6 months for certain symptoms, and then some symptoms do seem to be permanent, and those tend to be patients who have underlying conditions,” she said.
 

Reducing the risk

Given all the data so far, experts recommend urgent policy changes to help people with long COVID.

“The population needs to be prepared, that understanding long COVID is going to be a very long and difficult process,” said Alexander Charney, MD, PhD, associate professor and the lead principal investigator of the RECOVER adult cohort at Icahn School of Medicine at Mount Sinai in New York. He said the government can do a great deal to help, including setting up a network of connected clinics treating long COVID, standardizing best practices, and sharing information.

“That would go a long way towards making sure that every person feels like they’re not too far away from a clinic where they can get treated for this particular condition,” he said.

But the only known way to prevent long COVID is to prevent COVID-19 infections in the first place, experts say. That means equitable access to tests, therapeutics, and vaccines.

“I will say that avoiding COVID remains the best treatment in the arsenal right now,” said Dr. Kaushal. This means masking, avoiding crowded places with poor ventilation and high exposure risk, and being up to date on vaccinations, she said.

A number of papers – including a large U.K. study published in May 2022, another one from July, and the JAMA study from October – all suggest that vaccinations can help reduce the risk of long COVID.

“I am absolutely of the belief that vaccination has reduced the incidence and overall amount of long COVID … [and is] still by far the best thing the public can do,” said Dr. Schwartz.

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

Roughly 7% of all adult Americans may currently have had long COVID, with symptoms that have lasted 3 months or longer, according to the latest U.S. government survey done in October. More than a quarter say their condition is severe enough to significantly limit their day-to-day activities – yet the problem is only barely starting to get the attention of employers, the health care system, and policymakers.

With no cure or treatment in sight, long COVID is already burdening not only the health care system, but also the economy – and that burden is set to grow. Many experts worry about the possible long-term ripple effects, from increased spending on medical care costs to lost wages due to not being able to work, as well as the policy implications that come with addressing these issues.

“At this point, anyone who’s looking at this seriously would say this is a huge deal,” says senior Brookings Institution fellow Katie Bach, the author of a study that analyzed long COVID’s impact on the labor market.

“We need a real concerted focus on treating these people, which means both research and the clinical side, and figuring out how to build a labor market that is more inclusive of people with disabilities,” she said.

It’s not only that many people are affected. It’s that they are often affected for months and possibly even years.

The U.S. government figures suggest more than 18 million people could have symptoms of long COVID right now. The latest Household Pulse Survey by the Census Bureau and the National Center for Health Statistics takes data from 41,415 people.

A preprint of a study by researchers from City University of New York, posted on medRxiv in September and based on a similar population survey done between June 30 and July 2, drew comparable results. The study has not been peer reviewed.

More than 7% of all those who answered said they had long COVID at the time of the survey, which the researchers said corresponded to approximately 18.5 million U.S. adults. The same study found that a quarter of those, or an estimated 4.7 million adults, said their daily activities were impacted “a lot.”

This can translate into pain not only for the patients, but for governments and employers, too.

In high-income countries around the world, government surveys and other studies are shedding light on the extent to which post-COVID-19 symptoms – commonly known as long COVID – are affecting populations. While results vary, they generally fall within similar ranges.

The World Health Organization estimates that between 10% and 20% of those with COVID-19 go on to have an array of medium- to long-term post-COVID-19 symptoms that range from mild to debilitating. The U.S. Government Accountability Office puts that estimate at 10% to 30%; one of the latest studies published at the end of October in The Journal of the American Medical Association found that 15% of U.S. adults who had tested positive for COVID-19 reported current long COVID symptoms. Elsewhere, a study from the Netherlands published in The Lancet in August found that one in eight COVID-19 cases, or 12.7%, were likely to become long COVID.

“It’s very clear that the condition is devastating people’s lives and livelihoods,” WHO Director-General Tedros Adhanom Ghebreyesus wrote in an article for The Guardian newspaper in October.

“The world has already lost a significant number of the workforce to illness, death, fatigue, unplanned retirement due to an increase in long-term disability, which not only impacts the health system, but is a hit to the overarching economy … the impact of long COVID for all countries is very serious and needs immediate and sustained action equivalent to its scale.”
 

Global snapshot: Lasting symptoms, impact on activities

Patients describe a spectrum of persistent issues, with extreme fatigue, brain fog or cognitive problems, and shortness of breath among the most common complaints. Many also have manageable symptoms that worsen significantly after even mild physical or mental exertion.

Women appear almost twice as likely as men to get long COVID. Many patients have other medical conditions and disabilities that make them more vulnerable to the condition. Those who face greater obstacles accessing health care due to discrimination or socioeconomic inequity are at higher risk as well. 

While many are older, a large number are also in their prime working age. The Census Bureau data show that people ages 40-49 are more likely than any other group to get long COVID, which has broader implications for labor markets and the global economy. Already, experts have estimated that long COVID is likely to cost the U.S. trillions of dollars and affect multiple industries.

“Whether they’re in the financial world, the medical system, lawyers, they’re telling me they’re sitting at the computer screen and they’re unable to process the data,” said Zachary Schwartz, MD, medical director for Vancouver General Hospital’s Post-COVID-19 Recovery Clinic.

“That is what’s most distressing for people, in that they’re not working, they’re not making money, and they don’t know when, or if, they’re going to get better.”

Nearly a third of respondents in the Census Bureau’s Household Pulse Survey who said they have had COVID-19 reported symptoms that lasted 3 months or longer. People between the ages of 30 and 59 were the most affected, with about 32% reporting symptoms. Across the entire adult U.S. population, the survey found that 1 in 7 adults have had long COVID at some point during the pandemic, with about 1 in 18 saying it limited their activity to some degree, and 1 in 50 saying they have faced “a lot” of limits on their activities. Any way these numbers are dissected, long COVID has impacted a large swath of the population.

Yet research into the causes and possible treatments of long COVID is just getting underway.

“The amount of energy and time devoted to it is way, way less than it should, given how many people are likely affected,” said David Cutler, PhD, professor of economics at Harvard University, Cambridge, Mass., who has written about the economic cost of long COVID. “We’re way, way underdoing it here. And I think that’s really a terrible thing.”

Population surveys and studies from around the world show that long COVID lives up to its name, with people reporting serious symptoms for months on end.

In October, Statistics Canada and the Public Health Agency of Canada published early results from a questionnaire done between spring and summer 2022 that found just under 15% of adults who had a confirmed or suspected case of COVID-19 went on to have new or continuing symptoms 3 or more months later. Nearly half, or 47.3%, dealt with symptoms that lasted a year or more. More than one in five said their symptoms “often or always” limited their day-to-day activities, which included routine tasks such as preparing meals, doing errands and chores, and basic functions such as personal care and moving around in their homes.

Nearly three-quarters of workers or students said they missed an average of 20 days of work or school. 

“We haven’t yet been able to determine exactly when symptoms resolve,” said Rainu Kaushal, MD, the senior associate dean for clinical research at Weill Cornell Medicine in New York. She is co-leading a national study on long COVID in adults and children, funded by the National Institutes of Health RECOVER Initiative.

“But there does seem to be, for many of the milder symptoms, resolution at about 4-6 weeks. There seems to be a second point of resolution around 6 months for certain symptoms, and then some symptoms do seem to be permanent, and those tend to be patients who have underlying conditions,” she said.
 

Reducing the risk

Given all the data so far, experts recommend urgent policy changes to help people with long COVID.

“The population needs to be prepared, that understanding long COVID is going to be a very long and difficult process,” said Alexander Charney, MD, PhD, associate professor and the lead principal investigator of the RECOVER adult cohort at Icahn School of Medicine at Mount Sinai in New York. He said the government can do a great deal to help, including setting up a network of connected clinics treating long COVID, standardizing best practices, and sharing information.

“That would go a long way towards making sure that every person feels like they’re not too far away from a clinic where they can get treated for this particular condition,” he said.

But the only known way to prevent long COVID is to prevent COVID-19 infections in the first place, experts say. That means equitable access to tests, therapeutics, and vaccines.

“I will say that avoiding COVID remains the best treatment in the arsenal right now,” said Dr. Kaushal. This means masking, avoiding crowded places with poor ventilation and high exposure risk, and being up to date on vaccinations, she said.

A number of papers – including a large U.K. study published in May 2022, another one from July, and the JAMA study from October – all suggest that vaccinations can help reduce the risk of long COVID.

“I am absolutely of the belief that vaccination has reduced the incidence and overall amount of long COVID … [and is] still by far the best thing the public can do,” said Dr. Schwartz.

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

Mindfulness-based stress reduction (MBSR) is as effective at reducing anxiety as the antidepressant escitalopram, a first-line pharmaceutical treatment, new research shows.

“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.

The findings were published online  in JAMA Psychiatry.
 

Screening recommended

Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.

Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.

Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.

The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.

Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.

The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.

Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.

The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.

Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).

The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
 

Remarkable results

“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”

The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.

Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”

Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.

The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”

Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.

MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.

But online classes might work if “the exact same class,” including all its components, is moved online, she said.

MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
 

A time-tested intervention

Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.

“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.

He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”

Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”

The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.

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

Mindfulness-based stress reduction (MBSR) is as effective at reducing anxiety as the antidepressant escitalopram, a first-line pharmaceutical treatment, new research shows.

“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.

The findings were published online  in JAMA Psychiatry.
 

Screening recommended

Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.

Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.

Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.

The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.

Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.

The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.

Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.

The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.

Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).

The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
 

Remarkable results

“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”

The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.

Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”

Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.

The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”

Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.

MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.

But online classes might work if “the exact same class,” including all its components, is moved online, she said.

MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
 

A time-tested intervention

Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.

“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.

He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”

Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”

The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.

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

Mindfulness-based stress reduction (MBSR) is as effective at reducing anxiety as the antidepressant escitalopram, a first-line pharmaceutical treatment, new research shows.

“I would encourage clinicians to list meditation training as one possible treatment option for patients who are diagnosed with anxiety disorders. Doctors should feel comfortable recommending in-person, group-based meditation classes,” study investigator Elizabeth A. Hoge, MD, director, Anxiety Disorders Research Program, Georgetown University Medical Center, Washington, told this news organization.

The findings were published online  in JAMA Psychiatry.
 

Screening recommended

Anxiety disorders, including generalized anxiety, social anxiety, panic disorder, and agoraphobia, are the most common type of mental disorder, affecting an estimated 301 million people worldwide. Owing to their high prevalence, the United States Preventive Services Task Force recommends screening for anxiety disorders.

Effective treatments for anxiety disorders include medications and cognitive-behavioral therapy. However, not all patients have access to these interventions, respond to them, or are comfortable seeking care in a psychiatric setting.

Mindfulness meditation, which has risen in popularity in recent years, may help people experiencing intrusive, anxious thoughts. “By practicing mindfulness meditation, people learn not to be overwhelmed by those thoughts,” said Dr. Hoge.

The study included 276 adult patients with an anxiety disorder, mostly generalized anxiety or social anxiety. The mean age of the study population was 33 years; 75% were women, 59% were White, 15% were Black, and 20% were Asian.

Researchers randomly assigned 136 patients to receive MBSR and 140 to receive the selective serotonin reuptake inhibitor escitalopram, a first-line medication for treating anxiety disorders.

The MBSR intervention included a weekly 2.5-hour class and a day-long weekend class. Participants also completed daily 45-minute guided meditation sessions at home. They learned mindfulness meditation exercises, including breath awareness, body scanning, and mindful movement.

Those in the escitalopram group initially received 10 mg of the oral drug daily. The dose was increased to 20 mg daily at week 2 if well tolerated.

The primary outcome was the score on the Clinical Global Impression of Severity (CGI-S) scale for anxiety, assessed by clinicians blinded to treatment allocation. This instrument measures overall symptom severity on a scale from 1 (not at all ill) to 7 (most extremely ill) and can be used to assess different types of anxiety disorders, said Dr. Hoge.

Among the 208 participants who completed the study, the baseline mean CGI-S score was 4.44 for MBSR and 4.51 for escitalopram. At week 8, on the CGI-S scale, the MBSR group’s score improved by a mean of 1.35 points, and the escitalopram group’s score improved by 1.43 points (difference of –0.07; 95% CI, –0.38 to 0.23; P = .65).

The lower end of the confidence interval (–0.38) was smaller than the prespecified noninferiority margin of –0.495, indicating noninferiority of MBSR, compared with escitalopram.
 

Remarkable results

“What was remarkable was that the medication worked great, like it always does, but the meditation also worked great; we saw about a 30% drop in symptoms for both groups,” said Dr. Hoge. “That helps us know that meditation, and in particular mindfulness meditation, could be useful as a first-line treatment for patients with anxiety disorders.”

The patient-reported outcome of the Overall Anxiety Severity and Impairment Scale also showed no significant group differences. “It’s important to have the self-reports, because that gives us two ways to look at the information,” said Dr. Hoge.

Anecdotally, participants noted that the meditation helped with their personal relationships and with being “kinder to themselves,” said Dr. Hoge. “In meditation, there’s an implicit teaching to be accepting and nonjudgmental towards your own thoughts, and that teaches people to be more self-compassionate.”

Just over 78% of patients in the escitalopram group had at least one treatment-related adverse event (AE), which included sleep disturbances, nausea, fatigue, and headache, compared with 15.4% in the MBSR group.

The most common AE in the meditation group was anxiety, which is “counterintuitive” but represents “a momentary anxiety,” said Dr. Hoge. “People who are meditating have feelings come up that maybe they didn’t pay attention to before. This gives them an opportunity to process through those emotions.”

Fatigue was the next most common AE for meditators, which “makes sense,” since they’re putting away their phones and not being stimulated, said Dr. Hoge.

MBSR was delivered in person, which limits extrapolation to mindfulness apps or programs delivered over the internet. Dr. Hoge believes apps would likely be less effective because they don’t have the face-to-face component, instructors available for consultation, or fellow participants contributing group support.

But online classes might work if “the exact same class,” including all its components, is moved online, she said.

MBSR is available in all major U.S. cities, doesn’t require finding a therapist, and is available outside a mental health environment – for example, at yoga centers and some places of employment. Anyone can learn MBSR, although it takes time and commitment, said Dr. Hoge.
 

A time-tested intervention

Commenting on the study, psychiatrist Gregory Scott Brown, MD, affiliate faculty, University of Texas Dell Medical School, and author of “The Self-Healing Mind: An Essential Five-Step Practice for Overcoming Anxiety and Depression and Revitalizing Your Life,” said the results aren’t surprising inasmuch as mindfulness, including spirituality, breath work, and meditation, is a “time-tested and evidence-based” intervention.

“I’m encouraged by the fact studies like this are now being conducted and there’s more evidence that supports these mindfulness-based interventions, so they can start to make their way into standard-of-care treatments.” he said.

He noted that mindfulness can produce “long-term, sustainable improvements” and that the 45-minute daily home exercise included in the study “is not a huge time commitment when you talk about benefits you can potentially glean from incorporating that time.”

Because most study participants were women and “men are anxious too,” Dr. Brown said he would like to see the study replicated “with a more diverse pool of participants.”

The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Hoge and Dr. Brown have reported no relevant financial relationships.

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

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

A new study sheds light on the escalating youth suicide crisis, revealing that emergency room visits for suicidal thoughts among kids and teens steeply increased even before the  start of the  COVID-19 pandemic.

Emergency room visits for “suicidal ideation” (or suicidal thoughts) among 5- to 19-year-olds increased 59% from 2016 to 2021, and hospitalizations rose 57% from fall 2019 to the fall of 2020, according to the study published in Pediatrics.

“A lot of people have talked about mental health problems in youth during the pandemic, but it was happening before the pandemic,” said author Audrey Brewer, MD, MPH, in a news release from the Ann and Robert H. Lurie Children’s Hospital of Chicago. “This has been an issue for so long, and it’s getting worse.”

Researchers looked at data for 81,105 emergency room visits across 205 Illinois hospitals from 2016 to 2021 for kids between the ages of 5 and 19. 

The researchers found “there was a very sharp spike in fall 2019, followed by a similar spike during the pandemic fall of 2020, with the highest number of monthly visits during October 2020,” the authors said. “Youth aged 14-17 years had the highest frequency of [suicidal ideation emergency room] monthly visits, with visits in this group greater than the other age groups combined.”

Last year, the Centers for Disease Control and Prevention announced that suicide is the second leading cause of death among 10- to 19-year-olds. 

The new research is being called a benchmark because it evaluates emergency room data for suicidal thoughts – a critical point of care for serving youths’ mental health needs. The data showed that providers were increasingly likely to list suicidal thoughts as the main diagnosis.

“Suicidal ideation can be thought about as two types: actively thinking about suicide or having thoughts, but not having a plan,” Dr. Brewer said in the news release. “That could be the difference in why someone might get admitted to the hospital.”

The researchers hypothesize that care in 2019 (when the initial spike occurred) was delayed in the early days of the pandemic, and that delay possibly contributed to the increase in providers identifying suicidal ideation as the main diagnosis. 

“The early pandemic period coincided with constrained access to pediatric mental health services through schools, pediatric primary care homes, and mental health clinics for many children and their families,” the authors wrote. “The proportion of child mental health visits increased relative to other types as patients avoided ED visits during the early wave of the COVID-19 pandemic. Thus, the increase in hospitalizations during fall 2020 may reflect patients’ deferring care until symptoms became even more severe.”

Other health care scholars agreed the study spurred questions about whether the pandemic was truly the source of the crisis.

“Was it the pandemic that exacerbated the increase or is this a growing trend?” wrote Lisa M. Horowitz, PhD, MPH, and Jeffrey A. Bridge, PhD, in a commentary published along with the study. “These rising rates underscore the worsening mental health crisis for youth, as noted by the 2022 Surgeon General report and several youth mental health organizations.”

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

A new study sheds light on the escalating youth suicide crisis, revealing that emergency room visits for suicidal thoughts among kids and teens steeply increased even before the  start of the  COVID-19 pandemic.

Emergency room visits for “suicidal ideation” (or suicidal thoughts) among 5- to 19-year-olds increased 59% from 2016 to 2021, and hospitalizations rose 57% from fall 2019 to the fall of 2020, according to the study published in Pediatrics.

“A lot of people have talked about mental health problems in youth during the pandemic, but it was happening before the pandemic,” said author Audrey Brewer, MD, MPH, in a news release from the Ann and Robert H. Lurie Children’s Hospital of Chicago. “This has been an issue for so long, and it’s getting worse.”

Researchers looked at data for 81,105 emergency room visits across 205 Illinois hospitals from 2016 to 2021 for kids between the ages of 5 and 19. 

The researchers found “there was a very sharp spike in fall 2019, followed by a similar spike during the pandemic fall of 2020, with the highest number of monthly visits during October 2020,” the authors said. “Youth aged 14-17 years had the highest frequency of [suicidal ideation emergency room] monthly visits, with visits in this group greater than the other age groups combined.”

Last year, the Centers for Disease Control and Prevention announced that suicide is the second leading cause of death among 10- to 19-year-olds. 

The new research is being called a benchmark because it evaluates emergency room data for suicidal thoughts – a critical point of care for serving youths’ mental health needs. The data showed that providers were increasingly likely to list suicidal thoughts as the main diagnosis.

“Suicidal ideation can be thought about as two types: actively thinking about suicide or having thoughts, but not having a plan,” Dr. Brewer said in the news release. “That could be the difference in why someone might get admitted to the hospital.”

The researchers hypothesize that care in 2019 (when the initial spike occurred) was delayed in the early days of the pandemic, and that delay possibly contributed to the increase in providers identifying suicidal ideation as the main diagnosis. 

“The early pandemic period coincided with constrained access to pediatric mental health services through schools, pediatric primary care homes, and mental health clinics for many children and their families,” the authors wrote. “The proportion of child mental health visits increased relative to other types as patients avoided ED visits during the early wave of the COVID-19 pandemic. Thus, the increase in hospitalizations during fall 2020 may reflect patients’ deferring care until symptoms became even more severe.”

Other health care scholars agreed the study spurred questions about whether the pandemic was truly the source of the crisis.

“Was it the pandemic that exacerbated the increase or is this a growing trend?” wrote Lisa M. Horowitz, PhD, MPH, and Jeffrey A. Bridge, PhD, in a commentary published along with the study. “These rising rates underscore the worsening mental health crisis for youth, as noted by the 2022 Surgeon General report and several youth mental health organizations.”

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

A new study sheds light on the escalating youth suicide crisis, revealing that emergency room visits for suicidal thoughts among kids and teens steeply increased even before the  start of the  COVID-19 pandemic.

Emergency room visits for “suicidal ideation” (or suicidal thoughts) among 5- to 19-year-olds increased 59% from 2016 to 2021, and hospitalizations rose 57% from fall 2019 to the fall of 2020, according to the study published in Pediatrics.

“A lot of people have talked about mental health problems in youth during the pandemic, but it was happening before the pandemic,” said author Audrey Brewer, MD, MPH, in a news release from the Ann and Robert H. Lurie Children’s Hospital of Chicago. “This has been an issue for so long, and it’s getting worse.”

Researchers looked at data for 81,105 emergency room visits across 205 Illinois hospitals from 2016 to 2021 for kids between the ages of 5 and 19. 

The researchers found “there was a very sharp spike in fall 2019, followed by a similar spike during the pandemic fall of 2020, with the highest number of monthly visits during October 2020,” the authors said. “Youth aged 14-17 years had the highest frequency of [suicidal ideation emergency room] monthly visits, with visits in this group greater than the other age groups combined.”

Last year, the Centers for Disease Control and Prevention announced that suicide is the second leading cause of death among 10- to 19-year-olds. 

The new research is being called a benchmark because it evaluates emergency room data for suicidal thoughts – a critical point of care for serving youths’ mental health needs. The data showed that providers were increasingly likely to list suicidal thoughts as the main diagnosis.

“Suicidal ideation can be thought about as two types: actively thinking about suicide or having thoughts, but not having a plan,” Dr. Brewer said in the news release. “That could be the difference in why someone might get admitted to the hospital.”

The researchers hypothesize that care in 2019 (when the initial spike occurred) was delayed in the early days of the pandemic, and that delay possibly contributed to the increase in providers identifying suicidal ideation as the main diagnosis. 

“The early pandemic period coincided with constrained access to pediatric mental health services through schools, pediatric primary care homes, and mental health clinics for many children and their families,” the authors wrote. “The proportion of child mental health visits increased relative to other types as patients avoided ED visits during the early wave of the COVID-19 pandemic. Thus, the increase in hospitalizations during fall 2020 may reflect patients’ deferring care until symptoms became even more severe.”

Other health care scholars agreed the study spurred questions about whether the pandemic was truly the source of the crisis.

“Was it the pandemic that exacerbated the increase or is this a growing trend?” wrote Lisa M. Horowitz, PhD, MPH, and Jeffrey A. Bridge, PhD, in a commentary published along with the study. “These rising rates underscore the worsening mental health crisis for youth, as noted by the 2022 Surgeon General report and several youth mental health organizations.”

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

Preschoolers who watch violent television are more likely to have emotional and behavioral issues at the age of 12, according to investigators.

These findings align with previous studies that have shown the negative effects of watching violent content, reinforcing the importance of restricting childhood screen time, lead author Linda S. Pagani, PhD, of Université de Montréal and colleagues reported.

Past research measured the immediate or short-term effects of seeing violent media. This study examined how TV violence could be leading to issues almost a decade later, the investigators wrote in the Journal of Developmental & Behavioral Pediatrics.

Their study looked at 1,976 children from the Quebec Longitudinal Study of Child Development, a random representative cohort of boys and girls followed since their births in 1997 and 1998.

At the cohort study follow-ups at ages 3.5 and 4.5 years, the parents of these children reported if their kids watched violent TV, showing that about half of them were exposed. At age 12, the same children were scored by their teachers on a range of psychosocial outcomes, including emotional distress, inattentive behavior, disorderly behavior, social withdrawal, classroom engagement, and overall academic achievement. At this second time point, the children also scored themselves on their own academic motivation and confidence in writing.

To adjust for other factors that could be playing a role, the investigators accounted for participant characteristics at various ages between 5 months and 12 years, as well as differences in parenting styles, home environment, and socioeconomic status.

Dr. Pagani noted that these were not “garden-variety” statistical techniques.

“We did them in such a way that we set ourselves up for not finding results,” Dr. Pagani said in an interview. “That’s why this is really interesting.”

She and her colleagues found that watching TV violence during preschool was significantly associated with multiple negative outcomes at age 12.

For girls, negative outcomes included greater emotional distress, less classroom engagement, lower academic achievement, and less academic motivation. Boys showed greater emotional distress, decreased attention, disorderly behavior, social withdrawal, less classroom engagement, lower academic achievement, and less academic motivation.

“As expected, early screen violence exposure seems to come at a cost,” the investigators wrote.
 

Seeing TV through a child’s eyes

According to Dr. Pagani, many parents think that TV shows watched by preschoolers – like cartoons – are harmless, but these parents need to understand that the brains of children are not yet fully developed.

“The kid has an interpretation that’s very concrete,” Dr. Pagani said. “They don’t have abstract thinking.”

Because of this, kids who see “good guys” beating up “bad guys” don’t understand that the violence is comical and justified; they just see violence being used to address social disagreement, Dr. Pagani said. This leads children to believe that violence is an acceptable way to solve problems in daily life. Children are also more likely to see hostility in others when it isn’t present, leading to conflict.

Although the natural response to these findings is to restrict childhood exposure to violent content, this may be easier said than done, the investigators noted, particularly because TV is no longer the only screen in the home, as it was when this study began. Nowadays, parents need to monitor multiple devices, including smartphones, tablets, and computers, all of which may negatively impact normal brain development.

“People think this technology is innocuous,” Dr. Pagani said. “We are asleep at the wheel.”

She advised parents to wake up and follow the World Health Organization guidelines for sedentary screen time. The guidelines call for no screen time at all until a child is at least 2 years old, and then less than 1 hour per day until age 5.

“It’s the parents who should be in charge,” she said. “They’re the ones who have the cognitive ability to make decisions for their children.”
 

Choosing quality time over screen time

Loredana Marchica, PhD, of Montreal Children’s Hospital and McGill University, also in Montreal, expressed confidence in the study findings, because the results line up with past research, and because the investigators accounted for other explanations.

There is a “very strong probability” that watching violent TV in preschool leads to psychological issues down the line, Dr. Marchica said.

If a child is exposed to violent content, then parents should help children understand the difference between what happens in TV shows and real life, she added, as this can reduce negative effects on behavior.

“Parents need to explain that it’s a TV show,” Dr. Marchica said. “It’s not real, and if [that violent act] happened in real life, it would actually hurt a person.”

In addition to limiting screen time and explaining any violent content, she encouraged parents to spend quality time with their children, especially during the preschool years.

“Those are the years to fortify the attachment you have with that child,” Dr. Marchica said. “Even 15 minutes a day of quality, interactive play time can make such a difference in their development, their imagination, and their social engagement and abilities.”

Parents should also try to have conversations with their young children, she said, noting that it’s okay to share personal feelings, as this teaches kids how to manage their own emotions.

“Not everything is wonderful in life, and we’re allowed to talk about that,” Dr. Marchica said. “[Parents can say,] ‘Mommy had a bad day today. This bad thing happened. But here’s what I did to make myself feel better.’ ”

Dr. Pagani and coauthors termed their findings “robust,” but also cautioned that, in their correlational study, TV violence cannot be interpreted as causal. In other limitations, they noted that the study relies on a single parent-reported item that yielded a low rate of reported exposure. Or the findings could result from other things, such as family chaos or parenting style or something else.

The longitudinal study was supported by Fondation Lucie et André Chagnon, the Institut de la Statistique du Québec, the Ministère de l’Éducation et de l’Enseignement supérieur, and others. The investigators and Dr. Marchica reported no relevant conflicts of interest.

Preschoolers who watch violent television are more likely to have emotional and behavioral issues at the age of 12, according to investigators.

These findings align with previous studies that have shown the negative effects of watching violent content, reinforcing the importance of restricting childhood screen time, lead author Linda S. Pagani, PhD, of Université de Montréal and colleagues reported.

Past research measured the immediate or short-term effects of seeing violent media. This study examined how TV violence could be leading to issues almost a decade later, the investigators wrote in the Journal of Developmental & Behavioral Pediatrics.

Their study looked at 1,976 children from the Quebec Longitudinal Study of Child Development, a random representative cohort of boys and girls followed since their births in 1997 and 1998.

At the cohort study follow-ups at ages 3.5 and 4.5 years, the parents of these children reported if their kids watched violent TV, showing that about half of them were exposed. At age 12, the same children were scored by their teachers on a range of psychosocial outcomes, including emotional distress, inattentive behavior, disorderly behavior, social withdrawal, classroom engagement, and overall academic achievement. At this second time point, the children also scored themselves on their own academic motivation and confidence in writing.

To adjust for other factors that could be playing a role, the investigators accounted for participant characteristics at various ages between 5 months and 12 years, as well as differences in parenting styles, home environment, and socioeconomic status.

Dr. Pagani noted that these were not “garden-variety” statistical techniques.

“We did them in such a way that we set ourselves up for not finding results,” Dr. Pagani said in an interview. “That’s why this is really interesting.”

She and her colleagues found that watching TV violence during preschool was significantly associated with multiple negative outcomes at age 12.

For girls, negative outcomes included greater emotional distress, less classroom engagement, lower academic achievement, and less academic motivation. Boys showed greater emotional distress, decreased attention, disorderly behavior, social withdrawal, less classroom engagement, lower academic achievement, and less academic motivation.

“As expected, early screen violence exposure seems to come at a cost,” the investigators wrote.
 

Seeing TV through a child’s eyes

According to Dr. Pagani, many parents think that TV shows watched by preschoolers – like cartoons – are harmless, but these parents need to understand that the brains of children are not yet fully developed.

“The kid has an interpretation that’s very concrete,” Dr. Pagani said. “They don’t have abstract thinking.”

Because of this, kids who see “good guys” beating up “bad guys” don’t understand that the violence is comical and justified; they just see violence being used to address social disagreement, Dr. Pagani said. This leads children to believe that violence is an acceptable way to solve problems in daily life. Children are also more likely to see hostility in others when it isn’t present, leading to conflict.

Although the natural response to these findings is to restrict childhood exposure to violent content, this may be easier said than done, the investigators noted, particularly because TV is no longer the only screen in the home, as it was when this study began. Nowadays, parents need to monitor multiple devices, including smartphones, tablets, and computers, all of which may negatively impact normal brain development.

“People think this technology is innocuous,” Dr. Pagani said. “We are asleep at the wheel.”

She advised parents to wake up and follow the World Health Organization guidelines for sedentary screen time. The guidelines call for no screen time at all until a child is at least 2 years old, and then less than 1 hour per day until age 5.

“It’s the parents who should be in charge,” she said. “They’re the ones who have the cognitive ability to make decisions for their children.”
 

Choosing quality time over screen time

Loredana Marchica, PhD, of Montreal Children’s Hospital and McGill University, also in Montreal, expressed confidence in the study findings, because the results line up with past research, and because the investigators accounted for other explanations.

There is a “very strong probability” that watching violent TV in preschool leads to psychological issues down the line, Dr. Marchica said.

If a child is exposed to violent content, then parents should help children understand the difference between what happens in TV shows and real life, she added, as this can reduce negative effects on behavior.

“Parents need to explain that it’s a TV show,” Dr. Marchica said. “It’s not real, and if [that violent act] happened in real life, it would actually hurt a person.”

In addition to limiting screen time and explaining any violent content, she encouraged parents to spend quality time with their children, especially during the preschool years.

“Those are the years to fortify the attachment you have with that child,” Dr. Marchica said. “Even 15 minutes a day of quality, interactive play time can make such a difference in their development, their imagination, and their social engagement and abilities.”

Parents should also try to have conversations with their young children, she said, noting that it’s okay to share personal feelings, as this teaches kids how to manage their own emotions.

“Not everything is wonderful in life, and we’re allowed to talk about that,” Dr. Marchica said. “[Parents can say,] ‘Mommy had a bad day today. This bad thing happened. But here’s what I did to make myself feel better.’ ”

Dr. Pagani and coauthors termed their findings “robust,” but also cautioned that, in their correlational study, TV violence cannot be interpreted as causal. In other limitations, they noted that the study relies on a single parent-reported item that yielded a low rate of reported exposure. Or the findings could result from other things, such as family chaos or parenting style or something else.

The longitudinal study was supported by Fondation Lucie et André Chagnon, the Institut de la Statistique du Québec, the Ministère de l’Éducation et de l’Enseignement supérieur, and others. The investigators and Dr. Marchica reported no relevant conflicts of interest.

Preschoolers who watch violent television are more likely to have emotional and behavioral issues at the age of 12, according to investigators.

These findings align with previous studies that have shown the negative effects of watching violent content, reinforcing the importance of restricting childhood screen time, lead author Linda S. Pagani, PhD, of Université de Montréal and colleagues reported.

Past research measured the immediate or short-term effects of seeing violent media. This study examined how TV violence could be leading to issues almost a decade later, the investigators wrote in the Journal of Developmental & Behavioral Pediatrics.

Their study looked at 1,976 children from the Quebec Longitudinal Study of Child Development, a random representative cohort of boys and girls followed since their births in 1997 and 1998.

At the cohort study follow-ups at ages 3.5 and 4.5 years, the parents of these children reported if their kids watched violent TV, showing that about half of them were exposed. At age 12, the same children were scored by their teachers on a range of psychosocial outcomes, including emotional distress, inattentive behavior, disorderly behavior, social withdrawal, classroom engagement, and overall academic achievement. At this second time point, the children also scored themselves on their own academic motivation and confidence in writing.

To adjust for other factors that could be playing a role, the investigators accounted for participant characteristics at various ages between 5 months and 12 years, as well as differences in parenting styles, home environment, and socioeconomic status.

Dr. Pagani noted that these were not “garden-variety” statistical techniques.

“We did them in such a way that we set ourselves up for not finding results,” Dr. Pagani said in an interview. “That’s why this is really interesting.”

She and her colleagues found that watching TV violence during preschool was significantly associated with multiple negative outcomes at age 12.

For girls, negative outcomes included greater emotional distress, less classroom engagement, lower academic achievement, and less academic motivation. Boys showed greater emotional distress, decreased attention, disorderly behavior, social withdrawal, less classroom engagement, lower academic achievement, and less academic motivation.

“As expected, early screen violence exposure seems to come at a cost,” the investigators wrote.
 

Seeing TV through a child’s eyes

According to Dr. Pagani, many parents think that TV shows watched by preschoolers – like cartoons – are harmless, but these parents need to understand that the brains of children are not yet fully developed.

“The kid has an interpretation that’s very concrete,” Dr. Pagani said. “They don’t have abstract thinking.”

Because of this, kids who see “good guys” beating up “bad guys” don’t understand that the violence is comical and justified; they just see violence being used to address social disagreement, Dr. Pagani said. This leads children to believe that violence is an acceptable way to solve problems in daily life. Children are also more likely to see hostility in others when it isn’t present, leading to conflict.

Although the natural response to these findings is to restrict childhood exposure to violent content, this may be easier said than done, the investigators noted, particularly because TV is no longer the only screen in the home, as it was when this study began. Nowadays, parents need to monitor multiple devices, including smartphones, tablets, and computers, all of which may negatively impact normal brain development.

“People think this technology is innocuous,” Dr. Pagani said. “We are asleep at the wheel.”

She advised parents to wake up and follow the World Health Organization guidelines for sedentary screen time. The guidelines call for no screen time at all until a child is at least 2 years old, and then less than 1 hour per day until age 5.

“It’s the parents who should be in charge,” she said. “They’re the ones who have the cognitive ability to make decisions for their children.”
 

Choosing quality time over screen time

Loredana Marchica, PhD, of Montreal Children’s Hospital and McGill University, also in Montreal, expressed confidence in the study findings, because the results line up with past research, and because the investigators accounted for other explanations.

There is a “very strong probability” that watching violent TV in preschool leads to psychological issues down the line, Dr. Marchica said.

If a child is exposed to violent content, then parents should help children understand the difference between what happens in TV shows and real life, she added, as this can reduce negative effects on behavior.

“Parents need to explain that it’s a TV show,” Dr. Marchica said. “It’s not real, and if [that violent act] happened in real life, it would actually hurt a person.”

In addition to limiting screen time and explaining any violent content, she encouraged parents to spend quality time with their children, especially during the preschool years.

“Those are the years to fortify the attachment you have with that child,” Dr. Marchica said. “Even 15 minutes a day of quality, interactive play time can make such a difference in their development, their imagination, and their social engagement and abilities.”

Parents should also try to have conversations with their young children, she said, noting that it’s okay to share personal feelings, as this teaches kids how to manage their own emotions.

“Not everything is wonderful in life, and we’re allowed to talk about that,” Dr. Marchica said. “[Parents can say,] ‘Mommy had a bad day today. This bad thing happened. But here’s what I did to make myself feel better.’ ”

Dr. Pagani and coauthors termed their findings “robust,” but also cautioned that, in their correlational study, TV violence cannot be interpreted as causal. In other limitations, they noted that the study relies on a single parent-reported item that yielded a low rate of reported exposure. Or the findings could result from other things, such as family chaos or parenting style or something else.

The longitudinal study was supported by Fondation Lucie et André Chagnon, the Institut de la Statistique du Québec, the Ministère de l’Éducation et de l’Enseignement supérieur, and others. The investigators and Dr. Marchica reported no relevant conflicts of interest.

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

Patients who presented to a laser and cosmetic dermatology clinic were significantly more likely to be on a psychiatric medication and/or carry a psychiatric diagnosis, compared with those who presented to a medical dermatology clinic, results from a large retrospective analysis showed.

“As the rate of cosmetic procedures continues to increase, it is crucial that physicians understand that many patients with a psychiatric disorder require clear communication and appropriate consultation visits,” lead study author Patricia Richey, MD, told this news organization.

While studies have displayed links between the desire for a cosmetic procedure and psychiatric stressors and disorders – most commonly mood disorders, personality disorders, body dysmorphic disorder, and addiction-like behavior – the scarce literature on the subject mostly comes from the realm of plastic surgery.

“The relationship between psychiatric disease and the motivation for dermatologic cosmetic procedures has never been fully elucidated,” said Dr. Richey, who practices Mohs surgery and cosmetic dermatology in Washington, D.C., and conducts research for the Wellman Center for Photomedicine and the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital, Boston. “A possible association between psychiatric disorder and the motivation for cosmetic procedures is critical to understand given increasing procedure rates and the need for clear communication and appropriate consultation visits with these patients.”

For the retrospective cohort study, which was published online in the Journal of the American Academy of Dermatology, Dr. Richey; Mathew Avram, MD, JD, director of the Dermatology Laser and Cosmetic Center at MGH; and Ryan W. Chapin, PharmD, of Beth Israel Deaconess Medical Center, Boston, reviewed the medical records of 1,000 patients from a cosmetic dermatology clinic and 1,000 patients from a medical dermatology clinic, both at MGH. Those who crossed over between the two clinics were excluded from the analysis.

Patients in the cosmetic group were significantly younger than those in the medical group (a mean of 48 vs. 56 years, respectively; P < .0001), and there was a higher percentage of women than men in both groups (78.5% vs. 21.5% in the cosmetic group and 61.4% vs. 38.6% in the medical group; P < .00001).

The researchers found that 49% of patients in the cosmetic group had been diagnosed with at least one psychiatric disorder, compared with 33% in the medical group (P < .00001), most commonly anxiety, depression, ADHD, and insomnia. In addition, 39 patients in the cosmetic group had 2 or more psychiatric disorders, compared with 22 of those in the medical group.

Similarly, 44% of patients in the cosmetic group were on a psychiatric medication, compared with 28% in the medical group (P < .00001). The average number of medications among those on more than one psychiatric medication was 1.67 among those in the cosmetic dermatology group versus 1.48 among those in the medical dermatology group (P = .020).

By drug class, a higher percentage of patients in the cosmetic group, compared with those in the medical group, were taking antidepressants (33% vs. 21%, respectively; P < .00001), anxiolytics (26% vs. 13%; P < .00001), mood stabilizers (2.80% vs. 1.10%; P = .006), and stimulants (15.2% vs. 7.20%; P < .00001). The proportion of those taking antipsychotics was essentially even in the two groups (2.50% vs. 2.70%; P = .779).

Dr. Richey and colleagues also observed that patients in the cosmetic group had significantly higher rates of obsessive-compulsive disorder (OCD) and ADHD than those in the medical group. “This finding did not particularly surprise me,” she said, since she and her colleagues recently published a study on the association of stimulant use with psychocutaneous disease.

“Stimulants are used to treat ADHD and are also known to trigger OCD-like symptoms,” she said. “I was surprised that no patients had been diagnosed with body dysmorphic disorder, but we know that with increased patient access to medical records, physicians are often cautious in their documentation.”

She added that the overall results of the new study underscore the importance of consultation visits with cosmetic patients, including obtaining a full medication list and accurate medical history, if possible. “One could also consider well-studied screening tools mostly from the mood disorder realm, such as the Patient Health Questionnaire–2,” Dr. Richey said. “Much can be gained from simply talking to the patient and trying to understand him/her and underlying motivations prior to performing a procedure.”

Evan Rieder, MD, a New York City–based dermatologist and psychiatrist who was asked to comment on the study, characterized the analysis as demonstrating what medical and cosmetic dermatologists have been seeing in their practices for years. “While this study is limited by its single-center retrospective nature in an academic center that may not be representative of the general population, it does demonstrate a high burden of psychopathology and psychopharmacologic treatments in aesthetic patients,” Dr. Rieder said in an interview.

“While psychiatric illness is not a contraindication to cosmetic treatment, a high percentage of patients with ADHD, OCD, and likely [body dysmorphic disorder] in cosmetic dermatology practices should give us pause.” The nature of these diseases may indicate that some people are seeking aesthetic treatments for reasons yet to be elucidated, he added.

“It certainly indicates that dermatologists should be equipped to screen for, identify, and provide such patients with the appropriate resources for psychological treatment, regardless if they are deemed appropriate candidates for cosmetic intervention,” he said.

In an interview, Pooja Sodha, MD, director of the Center for Laser and Cosmetic Dermatology at George Washington University, Washington, noted that previous studies have demonstrated the interplay between mood disorders and dermatologic conditions for years, namely in acne, atopic dermatitis, psoriasis, and immune mediated disorders.

“In these conditions, the psychiatric stressors can worsen the skin condition and impede treatment,” Dr. Sodha said. “This study is an important segue into further elucidating our cosmetic patient population, and we should try to ask the next important question: how do we as physicians build a better rapport with these patients, understand their motivations for care, and effectively guide the patient through the consultation process to realistically address their concerns? It might help us both.”

Neither the researchers nor Dr. Sodha reported having financial disclosures. Dr. Rieder disclosed that he is a consultant for Allergan, Almirall, Bristol-Myers Squibb, Dr. Brandt, L’Oreal, Procter & Gamble, and Unilever.






 

The US Department of Veterans Affairs (VA) is the largest integrated health care system in the United States, providing care for more than 9 million veterans.¹ With veterans experiencing mental health conditions like posttraumatic stress disorder (PTSD), substance use disorders, and other serious mental illnesses (SMI) at higher rates compared with the general population, the VA plays an important role in the provision of mental health services.^2-5 Since the implementation of its Mental Health Strategic Plan in 2004, the VA has overseen the development of a wide array of mental health programs geared toward the complex needs of veterans. Research has demonstrated VA care outperforming Medicaid-reimbursed services in terms of the percentage of veterans filling antidepressants for at least 12 weeks after initiation of treatment for major depressive disorder (MDD), as well as posthospitalization follow-up.⁶

Eligible veterans enrolled in the VA often also seek non-VA care. Medicaid covers nearly 10% of all nonelderly veterans, and of these veterans, 39% rely solely on Medicaid for health care access.⁷ Today, Medicaid is the largest payer for mental health services in the US, providing coverage for approximately 27% of Americans who have SMI and helping fulfill unmet mental health needs.^8,9 Understanding which of these systems veterans choose to use, and under which circumstances, is essential in guiding the allocation of limited health care resources.¹⁰

Beyond Medicaid, alternatives to VA care may include TRICARE, Medicare, Indian Health Services, and employer-based or self-purchased private insurance. While these options potentially increase convenience, choice, and access to health care practitioners (HCPs) and services not available at local VA systems, cross-system utilization with poor integration may cause care coordination and continuity problems, such as medication mismanagement and opioid overdose, unnecessary duplicate utilization, and possible increased mortality.^11-15 As recent national legislative changes, such as the Patient Protection and Affordable Care Act (ACA), Veterans Access, Choice and Accountability Act, and the VA MISSION Act, continue to shift the health care landscape for veterans, questions surrounding how veterans are changing their health care use become significant.^16,17

Here, we approach the impacts of Medicaid expansion on veterans’ reliance on the VA for mental health services with a unique lens. We leverage a difference-in-difference design to study 2 historical Medicaid expansions in Arizona (AZ) and New York (NY), which extended eligibility to childless adults in 2001. Prior Medicaid dual-eligible mental health research investigated reliance shifts during the immediate postenrollment year in a subset of veterans newly enrolled in Medicaid.¹⁸ However, this study took place in a period of relative policy stability. In contrast, we investigate the potential effects of a broad policy shift by analyzing state-level changes in veterans’ reliance over 6 years after a statewide Medicaid expansion. We match expansion states with demographically similar nonexpansion states to account for unobserved trends and confounding effects. Prior studies have used this method to evaluate post-Medicaid expansion mortality changes and changes in veteran dual enrollment and hospitalizations.^10,19 While a study of ACA Medicaid expansion states would be ideal, Medicaid data from most states were only available through 2014 at the time of this analysis. Our study offers a quasi-experimental framework leveraging longitudinal data that can be applied as more post-ACA data become available.

Given the rising incidence of suicide among veterans, understanding care-seeking behaviors for depression among veterans is important as it is the most common psychiatric condition found in those who died by suicide.^20,21 Furthermore, depression may be useful as a clinical proxy for mental health policy impacts, given that the Patient Health Questionnaire-9 (PHQ-9) screening tool is well validated and increasingly research accessible, and it is a chronic condition responsive to both well-managed pharmacologic treatment and psychotherapeutic interventions.^22,23

In this study, we quantify the change in care-seeking behavior for depression among veterans after Medicaid expansion, using a quasi-experimental design. We hypothesize that new access to Medicaid would be associated with a shift away from using VA services for depression. Given the income-dependent eligibility requirements of Medicaid, we also hypothesize that veterans who qualified for VA coverage due to low income, determined by a regional means test (Priority group 5, “income-eligible”), would be more likely to shift care compared with those whose serviced-connected conditions related to their military service (Priority groups 1-4, “service-connected”) provide VA access.

Methods

To investigate the relative changes in veterans’ reliance on the VA for depression care after the 2001 NY and AZ Medicaid expansions We used a retrospective, difference-in-difference analysis. Our comparison pairings, based on prior demographic analyses were as follows: NY with Pennsylvania(PA); AZ with New Mexico and Nevada (NM/NV).¹⁹ The time frame of our analysis was 1999 to 2006, with pre- and postexpansion periods defined as 1999 to 2000 and 2001 to 2006, respectively.

Data

We included veterans aged 18 to 64 years, seeking care for depression from 1999 to 2006, who were also VA-enrolled and residing in our states of interest. We counted veterans as enrolled in Medicaid if they were enrolled at least 1 month in a given year.

Using similar methods like those used in prior studies, we selected patients with encounters documenting depression as the primary outpatient or inpatient diagnosis using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 296.2x for a single episode of major depressive disorder, 296.3x for a recurrent episode of MDD, 300.4 for dysthymia, and 311.0 for depression not otherwise specified.^18,24 We used data from the Medicaid Analytic eXtract files (MAX) for Medicaid data and the VA Corporate Data Warehouse (CDW) for VA data. We chose 1999 as the first study year because it was the earliest year MAX data were available.

Our final sample included 1833 person-years pre-expansion and 7157 postexpansion in our inpatient analysis, as well as 31,767 person-years pre-expansion and 130,382 postexpansion in our outpatient analysis.

Outcomes and Variables

Our primary outcomes were comparative shifts in VA reliance between expansion and nonexpansion states after Medicaid expansion for both inpatient and outpatient depression care. For each year of study, we calculated a veteran’s VA reliance by aggregating the number of days with depression-related encounters at the VA and dividing by the total number of days with a VA or Medicaid depression-related encounters for the year. To provide context to these shifts in VA reliance, we further analyzed the changes in the proportion of annual VA-Medicaid dual users and annual per capita utilization of depression care across the VA and Medicaid. Changes in the proportion would indicate a relative shift in usage between the VA and Medicaid. Annual per capita changes demonstrate changes in the volume of usage. Understanding how proportion and volume interact is critical to understanding likely ramifications for resource management and cost. For example, a relative shift in the proportion of care toward Medicaid might be explained by a substitution effect of increased Medicaid usage and lower VA per capita usage, or an additive (or complementary) effect, with more Medicaid services coming on top of the current VA services.

We conducted subanalyses by income-eligible and service-connected veterans and adjusted our models for age, non-White race, sex, distances to the nearest inpatient and outpatient VA facilities, and VA Relative Risk Score, which is a measure of disease burden and clinical complexity validated specifically for veterans.²⁵

Statistical Analysis

We used fractional logistic regression to model the adjusted effect of Medicaid expansion on VA reliance for depression care. In parallel, we leveraged ordered logit regression and negative binomial regression models to examine the proportion of VA-Medicaid dual users and the per capita utilization of Medicaid and VA depression care, respectively. To estimate the difference-in-difference effects, we used the interaction term of 2 categorical variables—expansion vs nonexpansion states and pre- vs postexpansion status—as the independent variable. We then calculated the average marginal effects with 95% CIs to estimate the differences in outcomes between expansion and nonexpansion states from pre- to postexpansion periods, as well as year-by-year shifts as a robustness check. We conducted these analyses using Stata MP, version 15.

This project was approved by the Baylor College of Medicine Institutional Review Board (IRB # H-40441) and the Michael E. Debakey Veterans Affairs Medical Center Research and Development Committee.

Results

Baseline and postexpansion characteristics

VA Reliance

Overall, we observed postexpansion decreases in VA reliance for depression care

At the state level, reliance on the VA for inpatient depression care in NY decreased by 13.53 pp (95% CI, -22.58 to -4.49) for income-eligible veterans and 16.67 pp (95% CI, -24.53 to -8.80) for service-connected veterans. No relative differences were observed in the outpatient comparisons for both income-eligible (-0.58 pp; 95% CI, -2.13 to 0.98) and service-connected (0.05 pp; 95% CI, -1.00 to 1.10) veterans. In AZ, Medicaid expansion was associated with decreased VA reliance for outpatient depression care among income-eligible veterans (-8.60 pp; 95% CI, -10.60 to -6.61), greater than that for service-connected veterans (-2.89 pp; 95% CI, -4.02 to -1.77). This decrease in VA reliance was significant in the inpatient context only for service-connected veterans (-4.55 pp; 95% CI, -8.14 to -0.97), not income-eligible veterans (-8.38 pp; 95% CI, -17.91 to 1.16).

By applying the aggregate pp changes toward the postexpansion number of visits across both expansion and nonexpansion states, we found that expansion of Medicaid across all our study states would have resulted in 996 fewer hospitalizations and 10,109 fewer outpatient visits for depression at VA in the postexpansion period vs if no states had chosen to expand Medicaid.

Dual Use/Per Capita Utilization

Overall, Medicaid expansion was associated with greater dual use for inpatient depression care—a 0.97-pp (95% CI, 0.46 to 1.48) increase among service-connected veterans and a 0.64-pp (95% CI, 0.35 to 0.94) increase among income-eligible veterans.
At the state level, NY similarly showed increases in dual use among both service-connected (1.48 pp; 95% CI, 0.80 to 2.16) and income-eligible veterans (0.73 pp; 95% CI, 0.39 to 1.07) after Medicaid expansion. However, dual use in AZ increased significantly only among service-connected veterans (0.70 pp; 95% CI, 0.03 to 1.38), not income-eligible veterans (0.31 pp; 95% CI, -0.17 to 0.78).

Among outpatient visits, Medicaid expansion was associated with increased dual use only for income-eligible veterans (0.16 pp; 95% CI, 0.03-0.29), and not service-connected veterans (0.09 pp; 95% CI, -0.04 to 0.21). State-level analyses showed that Medicaid expansion in NY was not associated with changes in dual use for either service-connected (0.01 pp; 95% CI, -0.16 to 0.17) or income-eligible veterans (0.03 pp; 95% CI, -0.12 to 0.18), while expansion in AZ was associated with increases in dual use among both service-connected (0.42 pp; 95% CI, 0.23 to 0.61) and income-eligible veterans (0.83 pp; 95% CI, 0.59 to 1.07).

Concerning per capita utilization of depression care after Medicaid expansion, analyses showed no detectable changes for either inpatient or outpatient services, among both service-connected and income-eligible veterans. However, while this pattern held at the state level among hospitalizations, outpatient visit results showed divergent trends between AZ and NY. In NY, Medicaid expansion was associated with decreased per capita utilization of outpatient depression care among both service-connected (-0.25 visits annually; 95% CI, -0.48 to -0.01) and income-eligible veterans (-0.64 visits annually; 95% CI, -0.93 to -0.35). In AZ, Medicaid expansion was associated with increased per capita utilization of outpatient depression care among both service-connected (0.62 visits annually; 95% CI, 0.32-0.91) and income-eligible veterans (2.32 visits annually; 95% CI, 1.99-2.65).

Discussion

Our study quantified changes in depression-related health care utilization after Medicaid expansions in NY and AZ in 2001. Overall, the balance of evidence indicated that Medicaid expansion was associated with decreased reliance on the VA for depression-related services. There was an exception: income-eligible veterans in AZ did not shift their hospital care away from the VA in a statistically discernible way, although the point estimate was lower. More broadly, these findings concerning veterans’ reliance varied not only in inpatient vs outpatient services and income- vs service-connected eligibility, but also in the state-level contexts of veteran dual users and per capita utilization.

Given that the overall per capita utilization of depression care was unchanged from pre- to postexpansion periods, one might interpret the decreases in VA reliance and increases in Medicaid-VA dual users as a substitution effect from VA care to non-VA care. This could be plausible for hospitalizations where state-level analyses showed similarly stable levels of per capita utilization. However, state-level trends in our outpatient utilization analysis, especially with a substantial 2.32 pp increase in annual per capita visits among income-eligible veterans in AZ, leave open the possibility that in some cases veterans may be complementing VA care with Medicaid-reimbursed services.

The causes underlying these differences in reliance shifts between NY and AZ are likely also influenced by the policy contexts of their respective Medicaid expansions. For example, in 1999, NY passed Kendra’s Law, which established a procedure for obtaining court orders for assisted outpatient mental health treatment for individuals deemed unlikely to survive safely in the community.²⁶ A reasonable inference is that there was less unfulfilled outpatient mental health need in NY under the existing accessibility provisioned by Kendra’s Law. In addition, while both states extended coverage to childless adults under 100% of the Federal Poverty level (FPL), the AZ Medicaid expansion was via a voters’ initiative and extended family coverage to 200% FPL vs 150% FPL for families in NY. Given that the AZ Medicaid expansion enjoyed both broader public participation and generosity in terms of eligibility, its uptake and therefore effect size may have been larger than in NY for nonacute outpatient care.

Our findings contribute to the growing body of literature surrounding the changes in health care utilization after Medicaid expansion, specifically for a newly dual-eligible population of veterans seeking mental health services for depression. While prior research concerning Medicare dual-enrolled veterans has shown high reliance on the VA for both mental health diagnoses and services, scholars have established the association of Medicaid enrollment with decreased VA reliance.^27-29 Our analysis is the first to investigate state-level effects of Medicaid expansion on VA reliance for a single mental health condition using a natural experimental framework. We focus on a population that includes a large portion of veterans who are newly Medicaid-eligible due to a sweeping policy change and use demographically matched nonexpansion states to draw comparisons in VA reliance for depression care. Our findings of Medicaid expansion–associated decreases in VA reliance for depression care complement prior literature that describe Medicaid enrollment–associated decreases in VA reliance for overall mental health care.

Implications

From a systems-level perspective, the implications of shifting services away from the VA are complex and incompletely understood. The VA lacks interoperability with the electronic health records (EHRs) used by Medicaid clinicians. Consequently, significant issues of service duplication and incomplete clinical data exist for veterans seeking treatment outside of the VA system, posing health care quality and safety concerns.³⁰ On one hand, Medicaid access is associated with increased health care utilization attributed to filling unmet needs for Medicare dual enrollees, as well as increased prescription filling for psychiatric medications.^31,32 Furthermore, the only randomized control trial of Medicaid expansion to date was associated with a 9-pp decrease in positive screening rates for depression among those who received access at around 2 years postexpansion.³³ On the other hand, the VA has developed a mental health system tailored to the particular needs of veterans, and health care practitioners at the VA have significantly greater rates of military cultural competency compared to those in nonmilitary settings (70% vs 24% in the TRICARE network and 8% among those with no military or TRICARE affiliation).³⁴ Compared to individuals seeking mental health services with private insurance plans, veterans were about twice as likely to receive appropriate treatment for schizophrenia and depression at the VA.³⁵ These documented strengths of VA mental health care may together help explain the small absolute number of visits that were associated with shifts away from VA overall after Medicaid expansion.

Finally, it is worth considering extrinsic factors that influence utilization among newly dual-eligible veterans. For example, hospitalizations are less likely to be planned than outpatient services, translating to a greater importance of proximity to a nearby medical facility than a veteran’s preference of where to seek care. In the same vein, major VA medical centers are fewer and more distant on average than VA outpatient clinics, therefore reducing the advantage of a Medicaid-reimbursed outpatient clinic in terms of distance.³⁶ These realities may partially explain the proportionally larger shifts away from the VA for hospitalizations compared to outpatient care for depression.

These shifts in utilization after Medicaid expansion may have important implications for VA policymakers. First, more study is needed to know which types of veterans are more likely to use Medicaid instead of VA services—or use both Medicaid and VA services. Our research indicates unsurprisingly that veterans without service-connected disability ratings and eligible for VA services due to low income are more likely to use at least some Medicaid services. Further understanding of who switches will be useful for the VA both tailoring its services to those who prefer VA and for reaching out to specific types of patients who might be better served by staying within the VA system. Finally, VA clinicians and administrators can prioritize improving care coordination for those who chose to use both Medicaid and VA services.

Limitations and Future Directions

Our results should be interpreted within methodological and data limitations. With only 2 states in our sample, NY demonstrably skewed overall results, contributing 1.7 to 3 times more observations than AZ across subanalyses—a challenge also cited by Sommers and colleagues.¹⁹ Our veteran groupings were also unable to distinguish those veterans classified as service-connected who may also have qualified by income-eligible criteria (which would tend to understate the size of results) and those veterans who gained and then lost Medicaid coverage in a given year. Our study also faces limitations in generalizability and establishing causality. First, we included only 2 historical state Medicaid expansions, compared with the 38 states and Washington, DC, that have now expanded Medicaid to date under the ACA. Just in the 2 states from our study, we noted significant heterogeneity in the shifts associated with Medicaid expansion, which makes extrapolating specific trends difficult. Differences in underlying health care resources, legislation, and other external factors may limit the applicability of Medicaid expansion in the era of the ACA, as well as the Veterans Choice and MISSION acts. Second, while we leveraged a difference-in-difference analysis using demographically matched, neighboring comparison states, our findings are nevertheless drawn from observational data obviating causality. VA data for other sources of coverage such as private insurance are limited and not included in our study, and MAX datasets vary by quality across states, translating to potential gaps in our study cohort.²⁸Finally, as in any study using diagnoses, visits addressing care for depression may have been missed if other diagnoses were noted as primary (eg, VA clinicians carrying forward old diagnoses, like PTSD, on the problem list) or nondepression care visits may have been captured if a depression diagnosis was used by default.

Moving forward, our study demonstrates the potential for applying a natural experimental approach to studying dual-eligible veterans at the interface of Medicaid expansion. We focused on changes in VA reliance for the specific condition of depression and, in doing so, invite further inquiry into the impact of state mental health policy on outcomes more proximate to veterans’ outcomes. Clinical indicators, such as rates of antidepressant filling, utilization and duration of psychotherapy, and PHQ-9 scores, can similarly be investigated by natural experimental design. While current limits of administrative data and the siloing of EHRs may pose barriers to some of these avenues of research, multidisciplinary methodologies and data querying innovations such as natural language processing algorithms for clinical notes hold exciting opportunities to bridge the gap between policy and clinical efficacy.

Conclusions

This study applied a difference-in-difference analysis and found that Medicaid expansion is associated with decreases in VA reliance for both inpatient and outpatient services for depression. As additional data are generated from the Medicaid expansions of the ACA, similarly robust methods should be applied to further explore the impacts associated with such policy shifts and open the door to a better understanding of implications at the clinical level.

Acknowledgments

We acknowledge the efforts of Janine Wong, who proofread and formatted the manuscript.

The US Department of Veterans Affairs (VA) is the largest integrated health care system in the United States, providing care for more than 9 million veterans.¹ With veterans experiencing mental health conditions like posttraumatic stress disorder (PTSD), substance use disorders, and other serious mental illnesses (SMI) at higher rates compared with the general population, the VA plays an important role in the provision of mental health services.^2-5 Since the implementation of its Mental Health Strategic Plan in 2004, the VA has overseen the development of a wide array of mental health programs geared toward the complex needs of veterans. Research has demonstrated VA care outperforming Medicaid-reimbursed services in terms of the percentage of veterans filling antidepressants for at least 12 weeks after initiation of treatment for major depressive disorder (MDD), as well as posthospitalization follow-up.⁶

Eligible veterans enrolled in the VA often also seek non-VA care. Medicaid covers nearly 10% of all nonelderly veterans, and of these veterans, 39% rely solely on Medicaid for health care access.⁷ Today, Medicaid is the largest payer for mental health services in the US, providing coverage for approximately 27% of Americans who have SMI and helping fulfill unmet mental health needs.^8,9 Understanding which of these systems veterans choose to use, and under which circumstances, is essential in guiding the allocation of limited health care resources.¹⁰

Beyond Medicaid, alternatives to VA care may include TRICARE, Medicare, Indian Health Services, and employer-based or self-purchased private insurance. While these options potentially increase convenience, choice, and access to health care practitioners (HCPs) and services not available at local VA systems, cross-system utilization with poor integration may cause care coordination and continuity problems, such as medication mismanagement and opioid overdose, unnecessary duplicate utilization, and possible increased mortality.^11-15 As recent national legislative changes, such as the Patient Protection and Affordable Care Act (ACA), Veterans Access, Choice and Accountability Act, and the VA MISSION Act, continue to shift the health care landscape for veterans, questions surrounding how veterans are changing their health care use become significant.^16,17

Here, we approach the impacts of Medicaid expansion on veterans’ reliance on the VA for mental health services with a unique lens. We leverage a difference-in-difference design to study 2 historical Medicaid expansions in Arizona (AZ) and New York (NY), which extended eligibility to childless adults in 2001. Prior Medicaid dual-eligible mental health research investigated reliance shifts during the immediate postenrollment year in a subset of veterans newly enrolled in Medicaid.¹⁸ However, this study took place in a period of relative policy stability. In contrast, we investigate the potential effects of a broad policy shift by analyzing state-level changes in veterans’ reliance over 6 years after a statewide Medicaid expansion. We match expansion states with demographically similar nonexpansion states to account for unobserved trends and confounding effects. Prior studies have used this method to evaluate post-Medicaid expansion mortality changes and changes in veteran dual enrollment and hospitalizations.^10,19 While a study of ACA Medicaid expansion states would be ideal, Medicaid data from most states were only available through 2014 at the time of this analysis. Our study offers a quasi-experimental framework leveraging longitudinal data that can be applied as more post-ACA data become available.

Given the rising incidence of suicide among veterans, understanding care-seeking behaviors for depression among veterans is important as it is the most common psychiatric condition found in those who died by suicide.^20,21 Furthermore, depression may be useful as a clinical proxy for mental health policy impacts, given that the Patient Health Questionnaire-9 (PHQ-9) screening tool is well validated and increasingly research accessible, and it is a chronic condition responsive to both well-managed pharmacologic treatment and psychotherapeutic interventions.^22,23

In this study, we quantify the change in care-seeking behavior for depression among veterans after Medicaid expansion, using a quasi-experimental design. We hypothesize that new access to Medicaid would be associated with a shift away from using VA services for depression. Given the income-dependent eligibility requirements of Medicaid, we also hypothesize that veterans who qualified for VA coverage due to low income, determined by a regional means test (Priority group 5, “income-eligible”), would be more likely to shift care compared with those whose serviced-connected conditions related to their military service (Priority groups 1-4, “service-connected”) provide VA access.

Methods

To investigate the relative changes in veterans’ reliance on the VA for depression care after the 2001 NY and AZ Medicaid expansions We used a retrospective, difference-in-difference analysis. Our comparison pairings, based on prior demographic analyses were as follows: NY with Pennsylvania(PA); AZ with New Mexico and Nevada (NM/NV).¹⁹ The time frame of our analysis was 1999 to 2006, with pre- and postexpansion periods defined as 1999 to 2000 and 2001 to 2006, respectively.

Data

We included veterans aged 18 to 64 years, seeking care for depression from 1999 to 2006, who were also VA-enrolled and residing in our states of interest. We counted veterans as enrolled in Medicaid if they were enrolled at least 1 month in a given year.

Using similar methods like those used in prior studies, we selected patients with encounters documenting depression as the primary outpatient or inpatient diagnosis using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 296.2x for a single episode of major depressive disorder, 296.3x for a recurrent episode of MDD, 300.4 for dysthymia, and 311.0 for depression not otherwise specified.^18,24 We used data from the Medicaid Analytic eXtract files (MAX) for Medicaid data and the VA Corporate Data Warehouse (CDW) for VA data. We chose 1999 as the first study year because it was the earliest year MAX data were available.

Our final sample included 1833 person-years pre-expansion and 7157 postexpansion in our inpatient analysis, as well as 31,767 person-years pre-expansion and 130,382 postexpansion in our outpatient analysis.

Outcomes and Variables

Our primary outcomes were comparative shifts in VA reliance between expansion and nonexpansion states after Medicaid expansion for both inpatient and outpatient depression care. For each year of study, we calculated a veteran’s VA reliance by aggregating the number of days with depression-related encounters at the VA and dividing by the total number of days with a VA or Medicaid depression-related encounters for the year. To provide context to these shifts in VA reliance, we further analyzed the changes in the proportion of annual VA-Medicaid dual users and annual per capita utilization of depression care across the VA and Medicaid. Changes in the proportion would indicate a relative shift in usage between the VA and Medicaid. Annual per capita changes demonstrate changes in the volume of usage. Understanding how proportion and volume interact is critical to understanding likely ramifications for resource management and cost. For example, a relative shift in the proportion of care toward Medicaid might be explained by a substitution effect of increased Medicaid usage and lower VA per capita usage, or an additive (or complementary) effect, with more Medicaid services coming on top of the current VA services.

We conducted subanalyses by income-eligible and service-connected veterans and adjusted our models for age, non-White race, sex, distances to the nearest inpatient and outpatient VA facilities, and VA Relative Risk Score, which is a measure of disease burden and clinical complexity validated specifically for veterans.²⁵

Statistical Analysis

We used fractional logistic regression to model the adjusted effect of Medicaid expansion on VA reliance for depression care. In parallel, we leveraged ordered logit regression and negative binomial regression models to examine the proportion of VA-Medicaid dual users and the per capita utilization of Medicaid and VA depression care, respectively. To estimate the difference-in-difference effects, we used the interaction term of 2 categorical variables—expansion vs nonexpansion states and pre- vs postexpansion status—as the independent variable. We then calculated the average marginal effects with 95% CIs to estimate the differences in outcomes between expansion and nonexpansion states from pre- to postexpansion periods, as well as year-by-year shifts as a robustness check. We conducted these analyses using Stata MP, version 15.

This project was approved by the Baylor College of Medicine Institutional Review Board (IRB # H-40441) and the Michael E. Debakey Veterans Affairs Medical Center Research and Development Committee.

Results

Baseline and postexpansion characteristics

VA Reliance

Overall, we observed postexpansion decreases in VA reliance for depression care

At the state level, reliance on the VA for inpatient depression care in NY decreased by 13.53 pp (95% CI, -22.58 to -4.49) for income-eligible veterans and 16.67 pp (95% CI, -24.53 to -8.80) for service-connected veterans. No relative differences were observed in the outpatient comparisons for both income-eligible (-0.58 pp; 95% CI, -2.13 to 0.98) and service-connected (0.05 pp; 95% CI, -1.00 to 1.10) veterans. In AZ, Medicaid expansion was associated with decreased VA reliance for outpatient depression care among income-eligible veterans (-8.60 pp; 95% CI, -10.60 to -6.61), greater than that for service-connected veterans (-2.89 pp; 95% CI, -4.02 to -1.77). This decrease in VA reliance was significant in the inpatient context only for service-connected veterans (-4.55 pp; 95% CI, -8.14 to -0.97), not income-eligible veterans (-8.38 pp; 95% CI, -17.91 to 1.16).

By applying the aggregate pp changes toward the postexpansion number of visits across both expansion and nonexpansion states, we found that expansion of Medicaid across all our study states would have resulted in 996 fewer hospitalizations and 10,109 fewer outpatient visits for depression at VA in the postexpansion period vs if no states had chosen to expand Medicaid.

Dual Use/Per Capita Utilization

Overall, Medicaid expansion was associated with greater dual use for inpatient depression care—a 0.97-pp (95% CI, 0.46 to 1.48) increase among service-connected veterans and a 0.64-pp (95% CI, 0.35 to 0.94) increase among income-eligible veterans.
At the state level, NY similarly showed increases in dual use among both service-connected (1.48 pp; 95% CI, 0.80 to 2.16) and income-eligible veterans (0.73 pp; 95% CI, 0.39 to 1.07) after Medicaid expansion. However, dual use in AZ increased significantly only among service-connected veterans (0.70 pp; 95% CI, 0.03 to 1.38), not income-eligible veterans (0.31 pp; 95% CI, -0.17 to 0.78).

Among outpatient visits, Medicaid expansion was associated with increased dual use only for income-eligible veterans (0.16 pp; 95% CI, 0.03-0.29), and not service-connected veterans (0.09 pp; 95% CI, -0.04 to 0.21). State-level analyses showed that Medicaid expansion in NY was not associated with changes in dual use for either service-connected (0.01 pp; 95% CI, -0.16 to 0.17) or income-eligible veterans (0.03 pp; 95% CI, -0.12 to 0.18), while expansion in AZ was associated with increases in dual use among both service-connected (0.42 pp; 95% CI, 0.23 to 0.61) and income-eligible veterans (0.83 pp; 95% CI, 0.59 to 1.07).

Concerning per capita utilization of depression care after Medicaid expansion, analyses showed no detectable changes for either inpatient or outpatient services, among both service-connected and income-eligible veterans. However, while this pattern held at the state level among hospitalizations, outpatient visit results showed divergent trends between AZ and NY. In NY, Medicaid expansion was associated with decreased per capita utilization of outpatient depression care among both service-connected (-0.25 visits annually; 95% CI, -0.48 to -0.01) and income-eligible veterans (-0.64 visits annually; 95% CI, -0.93 to -0.35). In AZ, Medicaid expansion was associated with increased per capita utilization of outpatient depression care among both service-connected (0.62 visits annually; 95% CI, 0.32-0.91) and income-eligible veterans (2.32 visits annually; 95% CI, 1.99-2.65).

Discussion

Our study quantified changes in depression-related health care utilization after Medicaid expansions in NY and AZ in 2001. Overall, the balance of evidence indicated that Medicaid expansion was associated with decreased reliance on the VA for depression-related services. There was an exception: income-eligible veterans in AZ did not shift their hospital care away from the VA in a statistically discernible way, although the point estimate was lower. More broadly, these findings concerning veterans’ reliance varied not only in inpatient vs outpatient services and income- vs service-connected eligibility, but also in the state-level contexts of veteran dual users and per capita utilization.

Given that the overall per capita utilization of depression care was unchanged from pre- to postexpansion periods, one might interpret the decreases in VA reliance and increases in Medicaid-VA dual users as a substitution effect from VA care to non-VA care. This could be plausible for hospitalizations where state-level analyses showed similarly stable levels of per capita utilization. However, state-level trends in our outpatient utilization analysis, especially with a substantial 2.32 pp increase in annual per capita visits among income-eligible veterans in AZ, leave open the possibility that in some cases veterans may be complementing VA care with Medicaid-reimbursed services.

The causes underlying these differences in reliance shifts between NY and AZ are likely also influenced by the policy contexts of their respective Medicaid expansions. For example, in 1999, NY passed Kendra’s Law, which established a procedure for obtaining court orders for assisted outpatient mental health treatment for individuals deemed unlikely to survive safely in the community.²⁶ A reasonable inference is that there was less unfulfilled outpatient mental health need in NY under the existing accessibility provisioned by Kendra’s Law. In addition, while both states extended coverage to childless adults under 100% of the Federal Poverty level (FPL), the AZ Medicaid expansion was via a voters’ initiative and extended family coverage to 200% FPL vs 150% FPL for families in NY. Given that the AZ Medicaid expansion enjoyed both broader public participation and generosity in terms of eligibility, its uptake and therefore effect size may have been larger than in NY for nonacute outpatient care.

Our findings contribute to the growing body of literature surrounding the changes in health care utilization after Medicaid expansion, specifically for a newly dual-eligible population of veterans seeking mental health services for depression. While prior research concerning Medicare dual-enrolled veterans has shown high reliance on the VA for both mental health diagnoses and services, scholars have established the association of Medicaid enrollment with decreased VA reliance.^27-29 Our analysis is the first to investigate state-level effects of Medicaid expansion on VA reliance for a single mental health condition using a natural experimental framework. We focus on a population that includes a large portion of veterans who are newly Medicaid-eligible due to a sweeping policy change and use demographically matched nonexpansion states to draw comparisons in VA reliance for depression care. Our findings of Medicaid expansion–associated decreases in VA reliance for depression care complement prior literature that describe Medicaid enrollment–associated decreases in VA reliance for overall mental health care.

Implications

From a systems-level perspective, the implications of shifting services away from the VA are complex and incompletely understood. The VA lacks interoperability with the electronic health records (EHRs) used by Medicaid clinicians. Consequently, significant issues of service duplication and incomplete clinical data exist for veterans seeking treatment outside of the VA system, posing health care quality and safety concerns.³⁰ On one hand, Medicaid access is associated with increased health care utilization attributed to filling unmet needs for Medicare dual enrollees, as well as increased prescription filling for psychiatric medications.^31,32 Furthermore, the only randomized control trial of Medicaid expansion to date was associated with a 9-pp decrease in positive screening rates for depression among those who received access at around 2 years postexpansion.³³ On the other hand, the VA has developed a mental health system tailored to the particular needs of veterans, and health care practitioners at the VA have significantly greater rates of military cultural competency compared to those in nonmilitary settings (70% vs 24% in the TRICARE network and 8% among those with no military or TRICARE affiliation).³⁴ Compared to individuals seeking mental health services with private insurance plans, veterans were about twice as likely to receive appropriate treatment for schizophrenia and depression at the VA.³⁵ These documented strengths of VA mental health care may together help explain the small absolute number of visits that were associated with shifts away from VA overall after Medicaid expansion.

Finally, it is worth considering extrinsic factors that influence utilization among newly dual-eligible veterans. For example, hospitalizations are less likely to be planned than outpatient services, translating to a greater importance of proximity to a nearby medical facility than a veteran’s preference of where to seek care. In the same vein, major VA medical centers are fewer and more distant on average than VA outpatient clinics, therefore reducing the advantage of a Medicaid-reimbursed outpatient clinic in terms of distance.³⁶ These realities may partially explain the proportionally larger shifts away from the VA for hospitalizations compared to outpatient care for depression.

These shifts in utilization after Medicaid expansion may have important implications for VA policymakers. First, more study is needed to know which types of veterans are more likely to use Medicaid instead of VA services—or use both Medicaid and VA services. Our research indicates unsurprisingly that veterans without service-connected disability ratings and eligible for VA services due to low income are more likely to use at least some Medicaid services. Further understanding of who switches will be useful for the VA both tailoring its services to those who prefer VA and for reaching out to specific types of patients who might be better served by staying within the VA system. Finally, VA clinicians and administrators can prioritize improving care coordination for those who chose to use both Medicaid and VA services.

Limitations and Future Directions

Our results should be interpreted within methodological and data limitations. With only 2 states in our sample, NY demonstrably skewed overall results, contributing 1.7 to 3 times more observations than AZ across subanalyses—a challenge also cited by Sommers and colleagues.¹⁹ Our veteran groupings were also unable to distinguish those veterans classified as service-connected who may also have qualified by income-eligible criteria (which would tend to understate the size of results) and those veterans who gained and then lost Medicaid coverage in a given year. Our study also faces limitations in generalizability and establishing causality. First, we included only 2 historical state Medicaid expansions, compared with the 38 states and Washington, DC, that have now expanded Medicaid to date under the ACA. Just in the 2 states from our study, we noted significant heterogeneity in the shifts associated with Medicaid expansion, which makes extrapolating specific trends difficult. Differences in underlying health care resources, legislation, and other external factors may limit the applicability of Medicaid expansion in the era of the ACA, as well as the Veterans Choice and MISSION acts. Second, while we leveraged a difference-in-difference analysis using demographically matched, neighboring comparison states, our findings are nevertheless drawn from observational data obviating causality. VA data for other sources of coverage such as private insurance are limited and not included in our study, and MAX datasets vary by quality across states, translating to potential gaps in our study cohort.²⁸Finally, as in any study using diagnoses, visits addressing care for depression may have been missed if other diagnoses were noted as primary (eg, VA clinicians carrying forward old diagnoses, like PTSD, on the problem list) or nondepression care visits may have been captured if a depression diagnosis was used by default.

Moving forward, our study demonstrates the potential for applying a natural experimental approach to studying dual-eligible veterans at the interface of Medicaid expansion. We focused on changes in VA reliance for the specific condition of depression and, in doing so, invite further inquiry into the impact of state mental health policy on outcomes more proximate to veterans’ outcomes. Clinical indicators, such as rates of antidepressant filling, utilization and duration of psychotherapy, and PHQ-9 scores, can similarly be investigated by natural experimental design. While current limits of administrative data and the siloing of EHRs may pose barriers to some of these avenues of research, multidisciplinary methodologies and data querying innovations such as natural language processing algorithms for clinical notes hold exciting opportunities to bridge the gap between policy and clinical efficacy.

Conclusions

This study applied a difference-in-difference analysis and found that Medicaid expansion is associated with decreases in VA reliance for both inpatient and outpatient services for depression. As additional data are generated from the Medicaid expansions of the ACA, similarly robust methods should be applied to further explore the impacts associated with such policy shifts and open the door to a better understanding of implications at the clinical level.

Acknowledgments

We acknowledge the efforts of Janine Wong, who proofread and formatted the manuscript.

The US Department of Veterans Affairs (VA) is the largest integrated health care system in the United States, providing care for more than 9 million veterans.¹ With veterans experiencing mental health conditions like posttraumatic stress disorder (PTSD), substance use disorders, and other serious mental illnesses (SMI) at higher rates compared with the general population, the VA plays an important role in the provision of mental health services.^2-5 Since the implementation of its Mental Health Strategic Plan in 2004, the VA has overseen the development of a wide array of mental health programs geared toward the complex needs of veterans. Research has demonstrated VA care outperforming Medicaid-reimbursed services in terms of the percentage of veterans filling antidepressants for at least 12 weeks after initiation of treatment for major depressive disorder (MDD), as well as posthospitalization follow-up.⁶

Eligible veterans enrolled in the VA often also seek non-VA care. Medicaid covers nearly 10% of all nonelderly veterans, and of these veterans, 39% rely solely on Medicaid for health care access.⁷ Today, Medicaid is the largest payer for mental health services in the US, providing coverage for approximately 27% of Americans who have SMI and helping fulfill unmet mental health needs.^8,9 Understanding which of these systems veterans choose to use, and under which circumstances, is essential in guiding the allocation of limited health care resources.¹⁰

Beyond Medicaid, alternatives to VA care may include TRICARE, Medicare, Indian Health Services, and employer-based or self-purchased private insurance. While these options potentially increase convenience, choice, and access to health care practitioners (HCPs) and services not available at local VA systems, cross-system utilization with poor integration may cause care coordination and continuity problems, such as medication mismanagement and opioid overdose, unnecessary duplicate utilization, and possible increased mortality.^11-15 As recent national legislative changes, such as the Patient Protection and Affordable Care Act (ACA), Veterans Access, Choice and Accountability Act, and the VA MISSION Act, continue to shift the health care landscape for veterans, questions surrounding how veterans are changing their health care use become significant.^16,17

Here, we approach the impacts of Medicaid expansion on veterans’ reliance on the VA for mental health services with a unique lens. We leverage a difference-in-difference design to study 2 historical Medicaid expansions in Arizona (AZ) and New York (NY), which extended eligibility to childless adults in 2001. Prior Medicaid dual-eligible mental health research investigated reliance shifts during the immediate postenrollment year in a subset of veterans newly enrolled in Medicaid.¹⁸ However, this study took place in a period of relative policy stability. In contrast, we investigate the potential effects of a broad policy shift by analyzing state-level changes in veterans’ reliance over 6 years after a statewide Medicaid expansion. We match expansion states with demographically similar nonexpansion states to account for unobserved trends and confounding effects. Prior studies have used this method to evaluate post-Medicaid expansion mortality changes and changes in veteran dual enrollment and hospitalizations.^10,19 While a study of ACA Medicaid expansion states would be ideal, Medicaid data from most states were only available through 2014 at the time of this analysis. Our study offers a quasi-experimental framework leveraging longitudinal data that can be applied as more post-ACA data become available.

Given the rising incidence of suicide among veterans, understanding care-seeking behaviors for depression among veterans is important as it is the most common psychiatric condition found in those who died by suicide.^20,21 Furthermore, depression may be useful as a clinical proxy for mental health policy impacts, given that the Patient Health Questionnaire-9 (PHQ-9) screening tool is well validated and increasingly research accessible, and it is a chronic condition responsive to both well-managed pharmacologic treatment and psychotherapeutic interventions.^22,23

In this study, we quantify the change in care-seeking behavior for depression among veterans after Medicaid expansion, using a quasi-experimental design. We hypothesize that new access to Medicaid would be associated with a shift away from using VA services for depression. Given the income-dependent eligibility requirements of Medicaid, we also hypothesize that veterans who qualified for VA coverage due to low income, determined by a regional means test (Priority group 5, “income-eligible”), would be more likely to shift care compared with those whose serviced-connected conditions related to their military service (Priority groups 1-4, “service-connected”) provide VA access.

Methods

To investigate the relative changes in veterans’ reliance on the VA for depression care after the 2001 NY and AZ Medicaid expansions We used a retrospective, difference-in-difference analysis. Our comparison pairings, based on prior demographic analyses were as follows: NY with Pennsylvania(PA); AZ with New Mexico and Nevada (NM/NV).¹⁹ The time frame of our analysis was 1999 to 2006, with pre- and postexpansion periods defined as 1999 to 2000 and 2001 to 2006, respectively.

Data

We included veterans aged 18 to 64 years, seeking care for depression from 1999 to 2006, who were also VA-enrolled and residing in our states of interest. We counted veterans as enrolled in Medicaid if they were enrolled at least 1 month in a given year.

Using similar methods like those used in prior studies, we selected patients with encounters documenting depression as the primary outpatient or inpatient diagnosis using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes: 296.2x for a single episode of major depressive disorder, 296.3x for a recurrent episode of MDD, 300.4 for dysthymia, and 311.0 for depression not otherwise specified.^18,24 We used data from the Medicaid Analytic eXtract files (MAX) for Medicaid data and the VA Corporate Data Warehouse (CDW) for VA data. We chose 1999 as the first study year because it was the earliest year MAX data were available.

Our final sample included 1833 person-years pre-expansion and 7157 postexpansion in our inpatient analysis, as well as 31,767 person-years pre-expansion and 130,382 postexpansion in our outpatient analysis.

Outcomes and Variables

Our primary outcomes were comparative shifts in VA reliance between expansion and nonexpansion states after Medicaid expansion for both inpatient and outpatient depression care. For each year of study, we calculated a veteran’s VA reliance by aggregating the number of days with depression-related encounters at the VA and dividing by the total number of days with a VA or Medicaid depression-related encounters for the year. To provide context to these shifts in VA reliance, we further analyzed the changes in the proportion of annual VA-Medicaid dual users and annual per capita utilization of depression care across the VA and Medicaid. Changes in the proportion would indicate a relative shift in usage between the VA and Medicaid. Annual per capita changes demonstrate changes in the volume of usage. Understanding how proportion and volume interact is critical to understanding likely ramifications for resource management and cost. For example, a relative shift in the proportion of care toward Medicaid might be explained by a substitution effect of increased Medicaid usage and lower VA per capita usage, or an additive (or complementary) effect, with more Medicaid services coming on top of the current VA services.

We conducted subanalyses by income-eligible and service-connected veterans and adjusted our models for age, non-White race, sex, distances to the nearest inpatient and outpatient VA facilities, and VA Relative Risk Score, which is a measure of disease burden and clinical complexity validated specifically for veterans.²⁵

Statistical Analysis

We used fractional logistic regression to model the adjusted effect of Medicaid expansion on VA reliance for depression care. In parallel, we leveraged ordered logit regression and negative binomial regression models to examine the proportion of VA-Medicaid dual users and the per capita utilization of Medicaid and VA depression care, respectively. To estimate the difference-in-difference effects, we used the interaction term of 2 categorical variables—expansion vs nonexpansion states and pre- vs postexpansion status—as the independent variable. We then calculated the average marginal effects with 95% CIs to estimate the differences in outcomes between expansion and nonexpansion states from pre- to postexpansion periods, as well as year-by-year shifts as a robustness check. We conducted these analyses using Stata MP, version 15.

This project was approved by the Baylor College of Medicine Institutional Review Board (IRB # H-40441) and the Michael E. Debakey Veterans Affairs Medical Center Research and Development Committee.

Results

Baseline and postexpansion characteristics

VA Reliance

Overall, we observed postexpansion decreases in VA reliance for depression care

At the state level, reliance on the VA for inpatient depression care in NY decreased by 13.53 pp (95% CI, -22.58 to -4.49) for income-eligible veterans and 16.67 pp (95% CI, -24.53 to -8.80) for service-connected veterans. No relative differences were observed in the outpatient comparisons for both income-eligible (-0.58 pp; 95% CI, -2.13 to 0.98) and service-connected (0.05 pp; 95% CI, -1.00 to 1.10) veterans. In AZ, Medicaid expansion was associated with decreased VA reliance for outpatient depression care among income-eligible veterans (-8.60 pp; 95% CI, -10.60 to -6.61), greater than that for service-connected veterans (-2.89 pp; 95% CI, -4.02 to -1.77). This decrease in VA reliance was significant in the inpatient context only for service-connected veterans (-4.55 pp; 95% CI, -8.14 to -0.97), not income-eligible veterans (-8.38 pp; 95% CI, -17.91 to 1.16).

By applying the aggregate pp changes toward the postexpansion number of visits across both expansion and nonexpansion states, we found that expansion of Medicaid across all our study states would have resulted in 996 fewer hospitalizations and 10,109 fewer outpatient visits for depression at VA in the postexpansion period vs if no states had chosen to expand Medicaid.

Dual Use/Per Capita Utilization

Overall, Medicaid expansion was associated with greater dual use for inpatient depression care—a 0.97-pp (95% CI, 0.46 to 1.48) increase among service-connected veterans and a 0.64-pp (95% CI, 0.35 to 0.94) increase among income-eligible veterans.
At the state level, NY similarly showed increases in dual use among both service-connected (1.48 pp; 95% CI, 0.80 to 2.16) and income-eligible veterans (0.73 pp; 95% CI, 0.39 to 1.07) after Medicaid expansion. However, dual use in AZ increased significantly only among service-connected veterans (0.70 pp; 95% CI, 0.03 to 1.38), not income-eligible veterans (0.31 pp; 95% CI, -0.17 to 0.78).

Among outpatient visits, Medicaid expansion was associated with increased dual use only for income-eligible veterans (0.16 pp; 95% CI, 0.03-0.29), and not service-connected veterans (0.09 pp; 95% CI, -0.04 to 0.21). State-level analyses showed that Medicaid expansion in NY was not associated with changes in dual use for either service-connected (0.01 pp; 95% CI, -0.16 to 0.17) or income-eligible veterans (0.03 pp; 95% CI, -0.12 to 0.18), while expansion in AZ was associated with increases in dual use among both service-connected (0.42 pp; 95% CI, 0.23 to 0.61) and income-eligible veterans (0.83 pp; 95% CI, 0.59 to 1.07).

Concerning per capita utilization of depression care after Medicaid expansion, analyses showed no detectable changes for either inpatient or outpatient services, among both service-connected and income-eligible veterans. However, while this pattern held at the state level among hospitalizations, outpatient visit results showed divergent trends between AZ and NY. In NY, Medicaid expansion was associated with decreased per capita utilization of outpatient depression care among both service-connected (-0.25 visits annually; 95% CI, -0.48 to -0.01) and income-eligible veterans (-0.64 visits annually; 95% CI, -0.93 to -0.35). In AZ, Medicaid expansion was associated with increased per capita utilization of outpatient depression care among both service-connected (0.62 visits annually; 95% CI, 0.32-0.91) and income-eligible veterans (2.32 visits annually; 95% CI, 1.99-2.65).

Discussion

Our study quantified changes in depression-related health care utilization after Medicaid expansions in NY and AZ in 2001. Overall, the balance of evidence indicated that Medicaid expansion was associated with decreased reliance on the VA for depression-related services. There was an exception: income-eligible veterans in AZ did not shift their hospital care away from the VA in a statistically discernible way, although the point estimate was lower. More broadly, these findings concerning veterans’ reliance varied not only in inpatient vs outpatient services and income- vs service-connected eligibility, but also in the state-level contexts of veteran dual users and per capita utilization.

Given that the overall per capita utilization of depression care was unchanged from pre- to postexpansion periods, one might interpret the decreases in VA reliance and increases in Medicaid-VA dual users as a substitution effect from VA care to non-VA care. This could be plausible for hospitalizations where state-level analyses showed similarly stable levels of per capita utilization. However, state-level trends in our outpatient utilization analysis, especially with a substantial 2.32 pp increase in annual per capita visits among income-eligible veterans in AZ, leave open the possibility that in some cases veterans may be complementing VA care with Medicaid-reimbursed services.

The causes underlying these differences in reliance shifts between NY and AZ are likely also influenced by the policy contexts of their respective Medicaid expansions. For example, in 1999, NY passed Kendra’s Law, which established a procedure for obtaining court orders for assisted outpatient mental health treatment for individuals deemed unlikely to survive safely in the community.²⁶ A reasonable inference is that there was less unfulfilled outpatient mental health need in NY under the existing accessibility provisioned by Kendra’s Law. In addition, while both states extended coverage to childless adults under 100% of the Federal Poverty level (FPL), the AZ Medicaid expansion was via a voters’ initiative and extended family coverage to 200% FPL vs 150% FPL for families in NY. Given that the AZ Medicaid expansion enjoyed both broader public participation and generosity in terms of eligibility, its uptake and therefore effect size may have been larger than in NY for nonacute outpatient care.

Our findings contribute to the growing body of literature surrounding the changes in health care utilization after Medicaid expansion, specifically for a newly dual-eligible population of veterans seeking mental health services for depression. While prior research concerning Medicare dual-enrolled veterans has shown high reliance on the VA for both mental health diagnoses and services, scholars have established the association of Medicaid enrollment with decreased VA reliance.^27-29 Our analysis is the first to investigate state-level effects of Medicaid expansion on VA reliance for a single mental health condition using a natural experimental framework. We focus on a population that includes a large portion of veterans who are newly Medicaid-eligible due to a sweeping policy change and use demographically matched nonexpansion states to draw comparisons in VA reliance for depression care. Our findings of Medicaid expansion–associated decreases in VA reliance for depression care complement prior literature that describe Medicaid enrollment–associated decreases in VA reliance for overall mental health care.

Implications

From a systems-level perspective, the implications of shifting services away from the VA are complex and incompletely understood. The VA lacks interoperability with the electronic health records (EHRs) used by Medicaid clinicians. Consequently, significant issues of service duplication and incomplete clinical data exist for veterans seeking treatment outside of the VA system, posing health care quality and safety concerns.³⁰ On one hand, Medicaid access is associated with increased health care utilization attributed to filling unmet needs for Medicare dual enrollees, as well as increased prescription filling for psychiatric medications.^31,32 Furthermore, the only randomized control trial of Medicaid expansion to date was associated with a 9-pp decrease in positive screening rates for depression among those who received access at around 2 years postexpansion.³³ On the other hand, the VA has developed a mental health system tailored to the particular needs of veterans, and health care practitioners at the VA have significantly greater rates of military cultural competency compared to those in nonmilitary settings (70% vs 24% in the TRICARE network and 8% among those with no military or TRICARE affiliation).³⁴ Compared to individuals seeking mental health services with private insurance plans, veterans were about twice as likely to receive appropriate treatment for schizophrenia and depression at the VA.³⁵ These documented strengths of VA mental health care may together help explain the small absolute number of visits that were associated with shifts away from VA overall after Medicaid expansion.

Finally, it is worth considering extrinsic factors that influence utilization among newly dual-eligible veterans. For example, hospitalizations are less likely to be planned than outpatient services, translating to a greater importance of proximity to a nearby medical facility than a veteran’s preference of where to seek care. In the same vein, major VA medical centers are fewer and more distant on average than VA outpatient clinics, therefore reducing the advantage of a Medicaid-reimbursed outpatient clinic in terms of distance.³⁶ These realities may partially explain the proportionally larger shifts away from the VA for hospitalizations compared to outpatient care for depression.

These shifts in utilization after Medicaid expansion may have important implications for VA policymakers. First, more study is needed to know which types of veterans are more likely to use Medicaid instead of VA services—or use both Medicaid and VA services. Our research indicates unsurprisingly that veterans without service-connected disability ratings and eligible for VA services due to low income are more likely to use at least some Medicaid services. Further understanding of who switches will be useful for the VA both tailoring its services to those who prefer VA and for reaching out to specific types of patients who might be better served by staying within the VA system. Finally, VA clinicians and administrators can prioritize improving care coordination for those who chose to use both Medicaid and VA services.

Limitations and Future Directions

Our results should be interpreted within methodological and data limitations. With only 2 states in our sample, NY demonstrably skewed overall results, contributing 1.7 to 3 times more observations than AZ across subanalyses—a challenge also cited by Sommers and colleagues.¹⁹ Our veteran groupings were also unable to distinguish those veterans classified as service-connected who may also have qualified by income-eligible criteria (which would tend to understate the size of results) and those veterans who gained and then lost Medicaid coverage in a given year. Our study also faces limitations in generalizability and establishing causality. First, we included only 2 historical state Medicaid expansions, compared with the 38 states and Washington, DC, that have now expanded Medicaid to date under the ACA. Just in the 2 states from our study, we noted significant heterogeneity in the shifts associated with Medicaid expansion, which makes extrapolating specific trends difficult. Differences in underlying health care resources, legislation, and other external factors may limit the applicability of Medicaid expansion in the era of the ACA, as well as the Veterans Choice and MISSION acts. Second, while we leveraged a difference-in-difference analysis using demographically matched, neighboring comparison states, our findings are nevertheless drawn from observational data obviating causality. VA data for other sources of coverage such as private insurance are limited and not included in our study, and MAX datasets vary by quality across states, translating to potential gaps in our study cohort.²⁸Finally, as in any study using diagnoses, visits addressing care for depression may have been missed if other diagnoses were noted as primary (eg, VA clinicians carrying forward old diagnoses, like PTSD, on the problem list) or nondepression care visits may have been captured if a depression diagnosis was used by default.

Moving forward, our study demonstrates the potential for applying a natural experimental approach to studying dual-eligible veterans at the interface of Medicaid expansion. We focused on changes in VA reliance for the specific condition of depression and, in doing so, invite further inquiry into the impact of state mental health policy on outcomes more proximate to veterans’ outcomes. Clinical indicators, such as rates of antidepressant filling, utilization and duration of psychotherapy, and PHQ-9 scores, can similarly be investigated by natural experimental design. While current limits of administrative data and the siloing of EHRs may pose barriers to some of these avenues of research, multidisciplinary methodologies and data querying innovations such as natural language processing algorithms for clinical notes hold exciting opportunities to bridge the gap between policy and clinical efficacy.

Conclusions

This study applied a difference-in-difference analysis and found that Medicaid expansion is associated with decreases in VA reliance for both inpatient and outpatient services for depression. As additional data are generated from the Medicaid expansions of the ACA, similarly robust methods should be applied to further explore the impacts associated with such policy shifts and open the door to a better understanding of implications at the clinical level.

Acknowledgments

We acknowledge the efforts of Janine Wong, who proofread and formatted the manuscript.