Mental Health

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

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

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

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

Study 1 Overview (Oberhaus et al)

Objective: To compare the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) to the long-form Confusion Assessment Method (CAM) in detecting postoperative delirium.

Design: Prospective concurrent comparison of 3D-CAM and CAM evaluations in a cohort of postoperative geriatric patients.

Setting and participants: Eligible participants were patients aged 60 years or older undergoing major elective surgery at Barnes Jewish Hospital (St. Louis, Missouri) who were enrolled in ongoing clinical trials (PODCAST, ENGAGES, SATISFY-SOS) between 2015 and 2018. Surgeries were at least 2 hours in length and required general anesthesia, planned extubation, and a minimum 2-day hospital stay. Investigators were extensively trained in administering 3D-CAM and CAM instruments. Participants were evaluated 2 hours after the end of anesthesia care on the day of surgery, then daily until follow-up was completed per clinical trial protocol or until the participant was determined by CAM to be nondelirious for 3 consecutive days. For each evaluation, both 3D-CAM and CAM assessors approached the participant together, but the evaluation was conducted such that the 3D-CAM assessor was masked to the additional questions ascertained by the long-form CAM assessment. The 3D-CAM or CAM assessor independently scored their respective assessments blinded to the results of the other assessor.

Main outcome measures: Participants were concurrently evaluated for postoperative delirium by both 3D-CAM and long-form CAM assessments. Comparisons between 3D-CAM and CAM scores were made using Cohen κ with repeated measures, generalized linear mixed-effects model, and Bland-Altman analysis.

Main results: Sixteen raters performed 471 concurrent 3D-CAM and CAM assessments in 299 participants (mean [SD] age, 69 [6.5] years). Of these participants, 152 (50.8%) were men, 263 (88.0%) were White, and 211 (70.6%) underwent noncardiac surgery. Both instruments showed good intraclass correlation (0.98 for 3D-CAM, 0.84 for CAM) with good overall agreement (Cohen κ = 0.71; 95% CI, 0.58-0.83). The mixed-effects model indicated a significant disagreement between the 3D-CAM and CAM assessments (estimated difference in fixed effect, –0.68; 95% CI, –1.32 to –0.05; P = .04). The Bland-Altman analysis showed that the probability of a delirium diagnosis with the 3D-CAM was more than twice that with the CAM (probability ratio, 2.78; 95% CI, 2.44-3.23).

Conclusion: The high degree of agreement between 3D-CAM and long-form CAM assessments suggests that the former may be a pragmatic and easy-to-administer clinical tool to screen for postoperative delirium in vulnerable older surgical patients.

Study 2 Overview (Shenkin et al)

Objective: To assess the accuracy of the 4 ‘A’s Test (4AT) for delirium detection in the medical inpatient setting and to compare the 4AT to the CAM.

Design: Prospective randomized diagnostic test accuracy study.

Setting and participants: This study was conducted in emergency departments and acute medical wards at 3 UK sites (Edinburgh, Bradford, and Sheffield) and enrolled acute medical patients aged 70 years or older without acute life-threatening illnesses and/or coma. Assessors administering the delirium evaluation were nurses or graduate clinical research associates who underwent systematic training in delirium and delirium assessment. Additional training was provided to those administering the CAM but not to those administering the 4AT as the latter is designed to be administered without special training. First, all participants underwent a reference standard delirium assessment using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria to derive a final definitive diagnosis of delirium via expert consensus (1 psychiatrist and 2 geriatricians). Then, the participants were randomized to either the 4AT or the comparator CAM group using computer-generated pseudo-random numbers, stratified by study site, with block allocation. All assessments were performed by pairs of independent assessors blinded to the results of the other assessment.

Main outcome measures: All participants were evaluated by the reference standard (DSM-IV criteria for delirium) and by either 4AT or CAM instruments for delirium. The accuracy of the 4AT instrument was evaluated by comparing its positive and negative predictive values, sensitivity, and specificity to the reference standard and analyzed via the area under the receiver operating characteristic curve. The diagnostic accuracy of 4AT, compared to the CAM, was evaluated by comparing positive and negative predictive values, sensitivity, and specificity using Fisher’s exact test. The overall performance of 4AT and CAM was summarized using Youden’s Index and the diagnostic odds ratio of sensitivity to specificity.

Results: All 843 individuals enrolled in the study were randomized and 785 were included in the analysis (23 withdrew, 3 lost contact, 32 indeterminate diagnosis, 2 missing outcome). Of the participants analyzed, the mean age was 81.4 [6.4] years, and 12.1% (95/785) had delirium by reference standard assessment, 14.3% (56/392) by 4AT, and 4.7% (18/384) by CAM. The 4AT group had an area under the receiver operating characteristic curve of 0.90 (95% CI, 0.84-0.96), a sensitivity of 76% (95% CI, 61%-87%), and a specificity of 94% (95% CI, 92%-97%). In comparison, the CAM group had a sensitivity of 40% (95% CI, 26%-57%) and a specificity of 100% (95% CI, 98%-100%).

Conclusions: The 4AT is a pragmatic screening test for delirium in a medical space that does not require special training to administer. The use of this instrument may help to improve delirium detection as a part of routine clinical care in hospitalized older adults.

Delirium is an acute confusional state marked by fluctuating mental status, inattention, disorganized thinking, and altered level of consciousness. It is exceedingly common in older patients in both surgical and medical settings and is associated with increased morbidity, mortality, hospital length of stay, institutionalization, and health care costs. Delirium is frequently underdiagnosed in the hospitalized setting, perhaps due to a combination of its waxing and waning nature and a lack of pragmatic and easily implementable screening tools that can be readily administered by clinicians and nonclinicians alike.¹ While the CAM is a well-validated instrument to diagnose delirium, it requires specific training in the rating of each of the cardinal features ascertained through a brief cognitive assessment and takes 5 to 10 minutes to complete. Taken together, given the high patient load for clinicians in the hospital setting, the validation and application of brief delirium screening instruments that can be reliably administered by nonphysicians and nonclinicians may enhance delirium detection in vulnerable patients and consequently improve their outcomes.

In Study 1, Oberhaus et al approach the challenge of underdiagnosing delirium in the postoperative setting by investigating whether the widely accepted long-form CAM and an abbreviated 3-minute version, the 3D-CAM, provide similar delirium detection in older surgical patients. The authors found that both instruments were reliable tests individually (high interrater reliability) and had good overall agreement. However, the 3D-CAM was more likely to yield a positive diagnosis of delirium compared to the long-form CAM, consistent with its purpose as a screening tool with a high sensitivity. It is important to emphasize that the 3D-CAM takes less time to administer, but also requires less extensive training and clinical knowledge than the long-form CAM. Therefore, this instrument meets the prerequisite of a brief screening test that can be rapidly administered by nonclinicians, and if affirmative, followed by a more extensive confirmatory test performed by a clinician. Limitations of this study include a lack of a reference standard structured interview conducted by a physician-rater to better determine the true diagnostic accuracy of both 3D-CAM and CAM assessments, and the use of convenience sampling at a single center, which reduces the generalizability of its findings.

In a similar vein, Shenkin et al in Study 2 attempt to evaluate the utility of the 4AT instrument in diagnosing delirium in older medical inpatients by testing the diagnostic accuracy of the 4AT against a reference standard (ie, DSM-IV–based evaluation by physicians) as well as comparing it to CAM. The 4AT takes less time (~2 minutes) and requires less knowledge and training to administer as compared to the CAM. The study showed that the abbreviated 4AT, compared to CAM, had a higher sensitivity (76% vs 40%) and lower specificity (94% vs 100%) in delirium detection. Thus, akin to the application of 3D-CAM in the postoperative setting, 4AT possesses key characteristics of a brief delirium screening test for older patients in the acute medical setting. In contrast to the Oberhaus et al study, a major strength of this study was the utilization of a reference standard that was validated by expert consensus. This allowed the 4AT and CAM assessments to be compared to a more objective standard, thereby directly testing their diagnostic performance in detecting delirium.

Application for Clinical Practice and System Implementation

The findings from both Study 1 and 2 suggest that using an abbreviated delirium instrument in both surgical and acute medical settings may provide a pragmatic and sensitive method to detect delirium in older patients. The brevity of administration of 3D-CAM (~3 minutes) and 4AT (~2 minutes), combined with their higher sensitivity for detecting delirium compared to CAM, make these instruments potentially effective rapid screening tests for delirium in hospitalized older patients. Importantly, the utilization of such instruments might be a feasible way to mitigate the issue of underdiagnosing delirium in the hospital.

Several additional aspects of these abbreviated delirium instruments increase their suitability for clinical application. Specifically, the 3D-CAM and 4AT require less extensive training and clinical knowledge to both administer and interpret the results than the CAM.² For instance, a multistage, multiday training for CAM is a key factor in maintaining its diagnostic accuracy.^3,4 In contrast, the 3D-CAM requires only a 1- to 2-hour training session, and the 4AT can be administered by a nonclinician without the need for instrument-specific training. Thus, implementation of these instruments can be particularly pragmatic in clinical settings in which the staff involved in delirium screening cannot undergo the substantial training required to administer CAM. Moreover, these abbreviated tests enable nonphysician care team members to assume the role of delirium screener in the hospital. Taken together, the adoption of these abbreviated instruments may facilitate brief screenings of delirium in older patients by caregivers who see them most often—nurses and certified nursing assistants—thereby improving early detection and prevention of delirium-related complications in the hospital.

The feasibility of using abbreviated delirium screening instruments in the hospital setting raises a system implementation question—if these instruments are designed to be administered by those with limited to no training, could nonclinicians, such as hospital volunteers, effectively take on delirium screening roles in the hospital? If volunteers are able to take on this role, the integration of hospital volunteers into the clinical team can greatly expand the capacity for delirium screening in the hospital setting. Further research is warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

Practice Points

• Abbreviated delirium screening tools such as 3D-CAM and 4AT may be pragmatic instruments to improve delirium detection in surgical and hospitalized older patients, respectively.
• Further studies are warranted to validate the diagnostic accuracy of 3D-CAM and 4AT by nonclinician administrators in order to more broadly adopt this approach to delirium screening.

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

After 15 years as a high school teacher at urban schools, I realized adults widely misunderstand that teenagers do not want to talk to them. In fact, most crave finding an adult they can trust and have serious conversations about issues like sex, drugs, and death. G was a sophomore who was going blind from a rare degenerative disease and one day sought my guidance about a sexual orgy he accidentally got in involved in. Was it wrong? Would God send him to hell? Why was he now so anxious after?

Because I was an openly gay teacher, students every semester would come out to me, asking what the “gay scene” was like, or how to deal with a homophobic family. Sometimes, students would seek counsel about an unplanned pregnancy, about abortion. In one instance, a student sought counsel about her violent thoughts, and eventually checked herself into a psychiatric ward. Five separate times, students in my class were murdered and I accompanied my classes through mourning.

Unlike many pediatricians, a teacher has a lot of time with these young adults: daily, sometimes over years. Students often admit they spend more time with their teachers than their parents. I can’t give you that time, but here are some general tips.
 

Attitude promoting trust

My guiding attitude toward teens was that they were my equals. I would “do unto them as I would have them do unto me.” Not less, but also not more – because sometimes “more” can cloak condescension. When I was a student, I trusted teachers who shared their fears and mistakes, not performing under a confessional spotlight, but to establish commonality, to flatten hierarchy. I also trusted those who could set boundaries and wield authority compassionately. Because sometimes I needed a firm hand. And so, as an adult I tried to give this to my students as well.

Although my students and I were equals, our situations are different. That is true with gender, race, and class, and it is also true with adults versus teens. The first step toward treating someone authentically as an equal when in a position of authority is to understand the unique stressors of their life. That means asking questions and listening to what they need.
 

Stressors in a teen’s life

A typical high school junior or senior goes to work 8-10 hours a day. Unpaid. They sit for hours at a small desk in a small room with sometimes 34 others. Most of the time they cannot eat or use their phone. If they need to pee, they need to ask permission. They have to ask permission to speak. And then when they go home, they sit at a small desk again for homework. They often do not even have their own room. They also have to ask for permission to buy something for themselves, for money, for a ride anywhere. Their values are often compromised so they won’t get kicked out of a house or a class. The life of a teen is not at all “carefree” but largely prescribed and with little control.

When I think about my youth and how little freedom, privacy, and control I had compared with now, it softens my attitude to even the rudest student. (Isn’t rudeness often a sign of resistance against an oppressive system?) But, some may say, these teens do not have to worry about bills. But if I think back honestly to my teen years, would I trade the responsibilities I have now for those supposed carefree years? Carefree is not how most teens describe their lives but a nostalgic rosy retrospection adults assign. Almost all teens I taught would rather work to gain some control over their lives. Which is why so many work 4-5 hours after school on top of homework, giving up their weekends, and binding themselves to a “carefree” 60- to 80-hour work week.
 

Talking about drugs, sex, and mental health

Drugs

It’s a good idea to first disarm teens of their fear of judgment or punishment, saying things like: “It’s normal to experiment with drugs, even hard ones.” The most successful, respected adults you see now have, so it’s not a reflection of who you are. Tell me what you’re worried about and it’ll be just between us.

After rapport is established, follow-up questions that elicit and affirm their feelings and thoughts can encourage more revelations: Do you think you have a problem? Why? How do you get your drugs and I’m curious only because finding that out can help us understand risks and solutions. What made you start? And keep on using?
 

Sex

Again, first disarm their fears: You can talk to me freely and confidently about sex: What you do, who you do it with, how you do it, and how often – I know that people are very different in their sexual interests and activities.

It is also good to set up clear boundaries. I had instances where students had romantic interest in me and would use these conversations as overtures. If you feel like your patient may be interested in you, then be explicit about boundaries: I’m a doctor who can point you to resources or offer treatments related to any sexual practice and its consequences, but that is all I am. Anything else is illegal and would end our patient-doctor relationship. (I would also immediately document the interaction and tell it to a witness.)

I never escalated incidences like this because I understood that most teens are naturally curious and often not taught about sexual boundaries, so I tried to make these encounters “teachable moments,” not punitive ones. Many teens are more aware of health consequences, like STDs or pregnancy, than psychological ones. So, it’s useful to ask: When you have sex outside your relationship, how does that make you feel? Does sex with multiple partners make you anxious or guilty afterwards? I like to use straightforward language and normalize taboo sexual practices with an even tone to allow teens to speak truthfully.
 

Suicide/depression

First, disarm and normalize: It is very common for people to have depression or thoughts of suicide. Most of the adults around you probably have and so have I (if that is true). Have you experienced this? Older teens often crave an intelligent open discussion about depression and suicide. If they look particularly distressed, I also tell them that I, and countless others, found strategies to deal with these thoughts. For most older teens, talking about causes of mental health issues and treatments is a breath of fresh air. This is especially true for teens from urban communities who have dealt precociously with death and violence, minority communities where mental health is often stigmatized, and young males whose machismo code can prevent them from acknowledging their feelings.

Some follow-up questions: Where do you think these thoughts come from? And if they don’t know: It’s perfectly normal for there to be no reason. The important thing is that they don’t last too long and that you know that. And if they do, then I can provide you resources and potential treatments.
 

Summary

Treating teens as equals by understanding their situation allows understanding and compassion for their stressors. This motivates an inquisitive and collaborative patient-centric approach that allows a sharing of sensitive topics like drugs, sex, and mental health.

Dr. Nguyen is a resident in psychiatry at the University of California, San Francisco.

*This story was updated on Nov. 3, 2022.

After 15 years as a high school teacher at urban schools, I realized adults widely misunderstand that teenagers do not want to talk to them. In fact, most crave finding an adult they can trust and have serious conversations about issues like sex, drugs, and death. G was a sophomore who was going blind from a rare degenerative disease and one day sought my guidance about a sexual orgy he accidentally got in involved in. Was it wrong? Would God send him to hell? Why was he now so anxious after?

Because I was an openly gay teacher, students every semester would come out to me, asking what the “gay scene” was like, or how to deal with a homophobic family. Sometimes, students would seek counsel about an unplanned pregnancy, about abortion. In one instance, a student sought counsel about her violent thoughts, and eventually checked herself into a psychiatric ward. Five separate times, students in my class were murdered and I accompanied my classes through mourning.

Unlike many pediatricians, a teacher has a lot of time with these young adults: daily, sometimes over years. Students often admit they spend more time with their teachers than their parents. I can’t give you that time, but here are some general tips.
 

Attitude promoting trust

My guiding attitude toward teens was that they were my equals. I would “do unto them as I would have them do unto me.” Not less, but also not more – because sometimes “more” can cloak condescension. When I was a student, I trusted teachers who shared their fears and mistakes, not performing under a confessional spotlight, but to establish commonality, to flatten hierarchy. I also trusted those who could set boundaries and wield authority compassionately. Because sometimes I needed a firm hand. And so, as an adult I tried to give this to my students as well.

Although my students and I were equals, our situations are different. That is true with gender, race, and class, and it is also true with adults versus teens. The first step toward treating someone authentically as an equal when in a position of authority is to understand the unique stressors of their life. That means asking questions and listening to what they need.
 

Stressors in a teen’s life

A typical high school junior or senior goes to work 8-10 hours a day. Unpaid. They sit for hours at a small desk in a small room with sometimes 34 others. Most of the time they cannot eat or use their phone. If they need to pee, they need to ask permission. They have to ask permission to speak. And then when they go home, they sit at a small desk again for homework. They often do not even have their own room. They also have to ask for permission to buy something for themselves, for money, for a ride anywhere. Their values are often compromised so they won’t get kicked out of a house or a class. The life of a teen is not at all “carefree” but largely prescribed and with little control.

When I think about my youth and how little freedom, privacy, and control I had compared with now, it softens my attitude to even the rudest student. (Isn’t rudeness often a sign of resistance against an oppressive system?) But, some may say, these teens do not have to worry about bills. But if I think back honestly to my teen years, would I trade the responsibilities I have now for those supposed carefree years? Carefree is not how most teens describe their lives but a nostalgic rosy retrospection adults assign. Almost all teens I taught would rather work to gain some control over their lives. Which is why so many work 4-5 hours after school on top of homework, giving up their weekends, and binding themselves to a “carefree” 60- to 80-hour work week.
 

Talking about drugs, sex, and mental health

Drugs

It’s a good idea to first disarm teens of their fear of judgment or punishment, saying things like: “It’s normal to experiment with drugs, even hard ones.” The most successful, respected adults you see now have, so it’s not a reflection of who you are. Tell me what you’re worried about and it’ll be just between us.

After rapport is established, follow-up questions that elicit and affirm their feelings and thoughts can encourage more revelations: Do you think you have a problem? Why? How do you get your drugs and I’m curious only because finding that out can help us understand risks and solutions. What made you start? And keep on using?
 

Sex

Again, first disarm their fears: You can talk to me freely and confidently about sex: What you do, who you do it with, how you do it, and how often – I know that people are very different in their sexual interests and activities.

It is also good to set up clear boundaries. I had instances where students had romantic interest in me and would use these conversations as overtures. If you feel like your patient may be interested in you, then be explicit about boundaries: I’m a doctor who can point you to resources or offer treatments related to any sexual practice and its consequences, but that is all I am. Anything else is illegal and would end our patient-doctor relationship. (I would also immediately document the interaction and tell it to a witness.)

I never escalated incidences like this because I understood that most teens are naturally curious and often not taught about sexual boundaries, so I tried to make these encounters “teachable moments,” not punitive ones. Many teens are more aware of health consequences, like STDs or pregnancy, than psychological ones. So, it’s useful to ask: When you have sex outside your relationship, how does that make you feel? Does sex with multiple partners make you anxious or guilty afterwards? I like to use straightforward language and normalize taboo sexual practices with an even tone to allow teens to speak truthfully.
 

Suicide/depression

First, disarm and normalize: It is very common for people to have depression or thoughts of suicide. Most of the adults around you probably have and so have I (if that is true). Have you experienced this? Older teens often crave an intelligent open discussion about depression and suicide. If they look particularly distressed, I also tell them that I, and countless others, found strategies to deal with these thoughts. For most older teens, talking about causes of mental health issues and treatments is a breath of fresh air. This is especially true for teens from urban communities who have dealt precociously with death and violence, minority communities where mental health is often stigmatized, and young males whose machismo code can prevent them from acknowledging their feelings.

Some follow-up questions: Where do you think these thoughts come from? And if they don’t know: It’s perfectly normal for there to be no reason. The important thing is that they don’t last too long and that you know that. And if they do, then I can provide you resources and potential treatments.
 

Summary

Treating teens as equals by understanding their situation allows understanding and compassion for their stressors. This motivates an inquisitive and collaborative patient-centric approach that allows a sharing of sensitive topics like drugs, sex, and mental health.

Dr. Nguyen is a resident in psychiatry at the University of California, San Francisco.

*This story was updated on Nov. 3, 2022.

After 15 years as a high school teacher at urban schools, I realized adults widely misunderstand that teenagers do not want to talk to them. In fact, most crave finding an adult they can trust and have serious conversations about issues like sex, drugs, and death. G was a sophomore who was going blind from a rare degenerative disease and one day sought my guidance about a sexual orgy he accidentally got in involved in. Was it wrong? Would God send him to hell? Why was he now so anxious after?

Because I was an openly gay teacher, students every semester would come out to me, asking what the “gay scene” was like, or how to deal with a homophobic family. Sometimes, students would seek counsel about an unplanned pregnancy, about abortion. In one instance, a student sought counsel about her violent thoughts, and eventually checked herself into a psychiatric ward. Five separate times, students in my class were murdered and I accompanied my classes through mourning.

Unlike many pediatricians, a teacher has a lot of time with these young adults: daily, sometimes over years. Students often admit they spend more time with their teachers than their parents. I can’t give you that time, but here are some general tips.
 

Attitude promoting trust

My guiding attitude toward teens was that they were my equals. I would “do unto them as I would have them do unto me.” Not less, but also not more – because sometimes “more” can cloak condescension. When I was a student, I trusted teachers who shared their fears and mistakes, not performing under a confessional spotlight, but to establish commonality, to flatten hierarchy. I also trusted those who could set boundaries and wield authority compassionately. Because sometimes I needed a firm hand. And so, as an adult I tried to give this to my students as well.

Although my students and I were equals, our situations are different. That is true with gender, race, and class, and it is also true with adults versus teens. The first step toward treating someone authentically as an equal when in a position of authority is to understand the unique stressors of their life. That means asking questions and listening to what they need.
 

Stressors in a teen’s life

A typical high school junior or senior goes to work 8-10 hours a day. Unpaid. They sit for hours at a small desk in a small room with sometimes 34 others. Most of the time they cannot eat or use their phone. If they need to pee, they need to ask permission. They have to ask permission to speak. And then when they go home, they sit at a small desk again for homework. They often do not even have their own room. They also have to ask for permission to buy something for themselves, for money, for a ride anywhere. Their values are often compromised so they won’t get kicked out of a house or a class. The life of a teen is not at all “carefree” but largely prescribed and with little control.

When I think about my youth and how little freedom, privacy, and control I had compared with now, it softens my attitude to even the rudest student. (Isn’t rudeness often a sign of resistance against an oppressive system?) But, some may say, these teens do not have to worry about bills. But if I think back honestly to my teen years, would I trade the responsibilities I have now for those supposed carefree years? Carefree is not how most teens describe their lives but a nostalgic rosy retrospection adults assign. Almost all teens I taught would rather work to gain some control over their lives. Which is why so many work 4-5 hours after school on top of homework, giving up their weekends, and binding themselves to a “carefree” 60- to 80-hour work week.
 

Talking about drugs, sex, and mental health

Drugs

It’s a good idea to first disarm teens of their fear of judgment or punishment, saying things like: “It’s normal to experiment with drugs, even hard ones.” The most successful, respected adults you see now have, so it’s not a reflection of who you are. Tell me what you’re worried about and it’ll be just between us.

After rapport is established, follow-up questions that elicit and affirm their feelings and thoughts can encourage more revelations: Do you think you have a problem? Why? How do you get your drugs and I’m curious only because finding that out can help us understand risks and solutions. What made you start? And keep on using?
 

Sex

Again, first disarm their fears: You can talk to me freely and confidently about sex: What you do, who you do it with, how you do it, and how often – I know that people are very different in their sexual interests and activities.

It is also good to set up clear boundaries. I had instances where students had romantic interest in me and would use these conversations as overtures. If you feel like your patient may be interested in you, then be explicit about boundaries: I’m a doctor who can point you to resources or offer treatments related to any sexual practice and its consequences, but that is all I am. Anything else is illegal and would end our patient-doctor relationship. (I would also immediately document the interaction and tell it to a witness.)

I never escalated incidences like this because I understood that most teens are naturally curious and often not taught about sexual boundaries, so I tried to make these encounters “teachable moments,” not punitive ones. Many teens are more aware of health consequences, like STDs or pregnancy, than psychological ones. So, it’s useful to ask: When you have sex outside your relationship, how does that make you feel? Does sex with multiple partners make you anxious or guilty afterwards? I like to use straightforward language and normalize taboo sexual practices with an even tone to allow teens to speak truthfully.
 

Suicide/depression

First, disarm and normalize: It is very common for people to have depression or thoughts of suicide. Most of the adults around you probably have and so have I (if that is true). Have you experienced this? Older teens often crave an intelligent open discussion about depression and suicide. If they look particularly distressed, I also tell them that I, and countless others, found strategies to deal with these thoughts. For most older teens, talking about causes of mental health issues and treatments is a breath of fresh air. This is especially true for teens from urban communities who have dealt precociously with death and violence, minority communities where mental health is often stigmatized, and young males whose machismo code can prevent them from acknowledging their feelings.

Some follow-up questions: Where do you think these thoughts come from? And if they don’t know: It’s perfectly normal for there to be no reason. The important thing is that they don’t last too long and that you know that. And if they do, then I can provide you resources and potential treatments.
 

Summary

Treating teens as equals by understanding their situation allows understanding and compassion for their stressors. This motivates an inquisitive and collaborative patient-centric approach that allows a sharing of sensitive topics like drugs, sex, and mental health.

Dr. Nguyen is a resident in psychiatry at the University of California, San Francisco.

*This story was updated on Nov. 3, 2022.

A new report shines a light on the toll the pandemic and other stressors have taken on the mental health of U.S. children and adolescents over the last 6 years.

The report shows a dramatic increase in use of acute care services for depression, anxiety, and other mental health conditions, especially among teens and preteens.

The report – The Kids Are Not Alright: Pediatric Mental Health Care Utilization from 2016-2021 – is the work of researchers at the Clarify Health Institute, the research arm of Clarify Health.

The results are “deeply concerning” and should “spark a conversation” around the need to improve access, utilization, and quality of pediatric behavioral health services, Niall Brennan, chief analytics and privacy officer for the Clarify Health Institute, told this news organization.
 

‘Startling’ trends

Leveraging an observational, national sample of insurance claims from more than 20 million children aged 1-19 years annually, the researchers observed several disturbing trends in mental health care.

From 2016 to 2021, inpatient (IP) admissions rose 61% (from 30 to 48 visits annually per 1,000) and emergency department visits rose 20% (from 55 to 66 visits annually per 1,000).

Mental health IP admissions ranged from a low of 27% in the West North Central region to a high of 137% in the Middle Atlantic region.

There were substantial increases from 2016 to 2021 in mental health IP admissions among children of all age groups, but particularly among adolescents 12 to 15 years old, increasing 84% among girls and 83% among boys in this age group.

There was also a sharp increase in mental health ED visits among girls and boys aged 12-15 years, increasing 20% overall during the study period. 

Mental health IP use grew faster from 2016 to 2021 among children with commercial insurance than among those with Medicaid (103% vs. 40%).

In contrast, mental health–specific ED visits declined 10% among children with commercial insurance and increased by 20% among those with Medicaid.

ED utilization rates in 2021 were nearly twice as high in the Medicaid population, compared with those for children with commercial insurance.

These are “startling” increases, Mr. Brennan said in an interview.

These trends “reinforce health care leaders’ responsibility to address children’s mental health, especially when considering that half of all mental health conditions onset during adolescence and carry into adulthood,” Jean Drouin, MD, Clarify Health’s chief executive office and cofounder, adds in a news release.

“With a growing consensus that mental, behavioral, and physical health intersect, this research report aims to spark a conversation about the overall wellbeing of America’s next generation,” Dr. Drouin says.
 

Concern for the future

Commenting on the new report, Anish Dube, MD, chair of the American Psychiatric Association’s Council on Children, Adolescents, and their Families, said the findings are “concerning, though unsurprising.”

“They confirm what those of us in clinical practice have experienced in the last several years. The need for mental health services continues to rise every year, while access to adequate help remains lacking,” Dr. Dube said.

“With the recent COVID-19 pandemic, concerns about the effects of climate change, global political uncertainty, and a rapidly changing employment landscape, young people in particular are vulnerable to worries about their future and feelings of helplessness and hopelessness,” he added.

Dr. Dube said there is no one right solution, and addressing this problem must consider individual and local factors.

However, some of the broader interventions needed to tackle the problem include increasing access to care by enforcing mental health parity and increasing the number of trained and qualified mental health professionals, such as child and adolescent psychiatrists, who can assess and treat these conditions in young people before they become major crises and lead to acute interventions like inpatient hospitalization.

“Public health interventions aimed at schools and families in raising awareness of mental health and well-being, and simple, cost-effective interventions to practice mental wellness will also help reduce the burden of mental illness in young people,” Dr. Dube added.

“The APA continues to fight for mental health parity enforcement and for meaningful access to mental health care for children, adolescents, and their families,” Dr. Dube said.

This research was conducted by the Clarify Health Institute. Mr. Brennan and Dr. Dube report no relevant financial relationships.

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

A new report shines a light on the toll the pandemic and other stressors have taken on the mental health of U.S. children and adolescents over the last 6 years.

The report shows a dramatic increase in use of acute care services for depression, anxiety, and other mental health conditions, especially among teens and preteens.

The report – The Kids Are Not Alright: Pediatric Mental Health Care Utilization from 2016-2021 – is the work of researchers at the Clarify Health Institute, the research arm of Clarify Health.

The results are “deeply concerning” and should “spark a conversation” around the need to improve access, utilization, and quality of pediatric behavioral health services, Niall Brennan, chief analytics and privacy officer for the Clarify Health Institute, told this news organization.
 

‘Startling’ trends

Leveraging an observational, national sample of insurance claims from more than 20 million children aged 1-19 years annually, the researchers observed several disturbing trends in mental health care.

From 2016 to 2021, inpatient (IP) admissions rose 61% (from 30 to 48 visits annually per 1,000) and emergency department visits rose 20% (from 55 to 66 visits annually per 1,000).

Mental health IP admissions ranged from a low of 27% in the West North Central region to a high of 137% in the Middle Atlantic region.

There were substantial increases from 2016 to 2021 in mental health IP admissions among children of all age groups, but particularly among adolescents 12 to 15 years old, increasing 84% among girls and 83% among boys in this age group.

There was also a sharp increase in mental health ED visits among girls and boys aged 12-15 years, increasing 20% overall during the study period. 

Mental health IP use grew faster from 2016 to 2021 among children with commercial insurance than among those with Medicaid (103% vs. 40%).

In contrast, mental health–specific ED visits declined 10% among children with commercial insurance and increased by 20% among those with Medicaid.

ED utilization rates in 2021 were nearly twice as high in the Medicaid population, compared with those for children with commercial insurance.

These are “startling” increases, Mr. Brennan said in an interview.

These trends “reinforce health care leaders’ responsibility to address children’s mental health, especially when considering that half of all mental health conditions onset during adolescence and carry into adulthood,” Jean Drouin, MD, Clarify Health’s chief executive office and cofounder, adds in a news release.

“With a growing consensus that mental, behavioral, and physical health intersect, this research report aims to spark a conversation about the overall wellbeing of America’s next generation,” Dr. Drouin says.
 

Concern for the future

Commenting on the new report, Anish Dube, MD, chair of the American Psychiatric Association’s Council on Children, Adolescents, and their Families, said the findings are “concerning, though unsurprising.”

“They confirm what those of us in clinical practice have experienced in the last several years. The need for mental health services continues to rise every year, while access to adequate help remains lacking,” Dr. Dube said.

“With the recent COVID-19 pandemic, concerns about the effects of climate change, global political uncertainty, and a rapidly changing employment landscape, young people in particular are vulnerable to worries about their future and feelings of helplessness and hopelessness,” he added.

Dr. Dube said there is no one right solution, and addressing this problem must consider individual and local factors.

However, some of the broader interventions needed to tackle the problem include increasing access to care by enforcing mental health parity and increasing the number of trained and qualified mental health professionals, such as child and adolescent psychiatrists, who can assess and treat these conditions in young people before they become major crises and lead to acute interventions like inpatient hospitalization.

“Public health interventions aimed at schools and families in raising awareness of mental health and well-being, and simple, cost-effective interventions to practice mental wellness will also help reduce the burden of mental illness in young people,” Dr. Dube added.

“The APA continues to fight for mental health parity enforcement and for meaningful access to mental health care for children, adolescents, and their families,” Dr. Dube said.

This research was conducted by the Clarify Health Institute. Mr. Brennan and Dr. Dube report no relevant financial relationships.

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

A new report shines a light on the toll the pandemic and other stressors have taken on the mental health of U.S. children and adolescents over the last 6 years.

The report shows a dramatic increase in use of acute care services for depression, anxiety, and other mental health conditions, especially among teens and preteens.

The report – The Kids Are Not Alright: Pediatric Mental Health Care Utilization from 2016-2021 – is the work of researchers at the Clarify Health Institute, the research arm of Clarify Health.

The results are “deeply concerning” and should “spark a conversation” around the need to improve access, utilization, and quality of pediatric behavioral health services, Niall Brennan, chief analytics and privacy officer for the Clarify Health Institute, told this news organization.
 

‘Startling’ trends

Leveraging an observational, national sample of insurance claims from more than 20 million children aged 1-19 years annually, the researchers observed several disturbing trends in mental health care.

From 2016 to 2021, inpatient (IP) admissions rose 61% (from 30 to 48 visits annually per 1,000) and emergency department visits rose 20% (from 55 to 66 visits annually per 1,000).

Mental health IP admissions ranged from a low of 27% in the West North Central region to a high of 137% in the Middle Atlantic region.

There were substantial increases from 2016 to 2021 in mental health IP admissions among children of all age groups, but particularly among adolescents 12 to 15 years old, increasing 84% among girls and 83% among boys in this age group.

There was also a sharp increase in mental health ED visits among girls and boys aged 12-15 years, increasing 20% overall during the study period. 

Mental health IP use grew faster from 2016 to 2021 among children with commercial insurance than among those with Medicaid (103% vs. 40%).

In contrast, mental health–specific ED visits declined 10% among children with commercial insurance and increased by 20% among those with Medicaid.

ED utilization rates in 2021 were nearly twice as high in the Medicaid population, compared with those for children with commercial insurance.

These are “startling” increases, Mr. Brennan said in an interview.

These trends “reinforce health care leaders’ responsibility to address children’s mental health, especially when considering that half of all mental health conditions onset during adolescence and carry into adulthood,” Jean Drouin, MD, Clarify Health’s chief executive office and cofounder, adds in a news release.

“With a growing consensus that mental, behavioral, and physical health intersect, this research report aims to spark a conversation about the overall wellbeing of America’s next generation,” Dr. Drouin says.
 

Concern for the future

Commenting on the new report, Anish Dube, MD, chair of the American Psychiatric Association’s Council on Children, Adolescents, and their Families, said the findings are “concerning, though unsurprising.”

“They confirm what those of us in clinical practice have experienced in the last several years. The need for mental health services continues to rise every year, while access to adequate help remains lacking,” Dr. Dube said.

“With the recent COVID-19 pandemic, concerns about the effects of climate change, global political uncertainty, and a rapidly changing employment landscape, young people in particular are vulnerable to worries about their future and feelings of helplessness and hopelessness,” he added.

Dr. Dube said there is no one right solution, and addressing this problem must consider individual and local factors.

However, some of the broader interventions needed to tackle the problem include increasing access to care by enforcing mental health parity and increasing the number of trained and qualified mental health professionals, such as child and adolescent psychiatrists, who can assess and treat these conditions in young people before they become major crises and lead to acute interventions like inpatient hospitalization.

“Public health interventions aimed at schools and families in raising awareness of mental health and well-being, and simple, cost-effective interventions to practice mental wellness will also help reduce the burden of mental illness in young people,” Dr. Dube added.

“The APA continues to fight for mental health parity enforcement and for meaningful access to mental health care for children, adolescents, and their families,” Dr. Dube said.

This research was conducted by the Clarify Health Institute. Mr. Brennan and Dr. Dube report no relevant financial relationships.

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

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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].

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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].

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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].

Clozapine or antipsychotic polytherapy appear to be the best approach in reducing the risk for a substance use disorder (SUD) in adults with schizophrenia and for preventing relapse in patients with both diagnoses, results of a real-world study show.

“Our findings are in line with a recent meta-analysis showing superior efficacy of clozapine in schizophrenia and comorbid SUD and other studies pointing toward clozapine’s superiority over other antipsychotics in the treatment of individuals with schizophrenia and comorbid SUD,” the investigators, led by Jari Tiihonen MD, PhD, department of clinical neuroscience, Karolinska Institutet, Stockholm, write.

Karolinska Institute

Research gap

Research on the effectiveness of pharmacotherapies for schizophrenia and comorbid SUD is “very sparse, and more importantly, non-existent on the prevention of the development of SUDs in patients with schizophrenia,” the researchers note.

To investigate, they analyzed data on more than 45,000 patients with schizophrenia from Finnish and Swedish national registries, with follow-up lasting 22 years in Finland and 11 years in Sweden.

In patients with schizophrenia without SUD, treatment with clozapine was associated with lowest risk for an initial SUD in both Finland (adjusted hazard ratio, 0.20; 95% confidence interval, 0.16-0.24) and Sweden (aHR, 0.35; 95% CI, 0.24-0.50), compared with no use or use of other antipsychotics.

In Finland, aripiprazole was associated with the second lowest risk for an initial SUD (aHR, 0.36; 95% CI, 0.24-0.55) and antipsychotic polytherapy the third lowest risk (aHR, 0.47; 95% CI, 0.42-0.53).

In Sweden, antipsychotic polytherapy was associated with second lowest risk for an initial SUD (aHR, 0.54; 95% CI, 0.44-0.66) and olanzapine the third lowest risk (aHR, 0.67; 95% CI, 0.53-0.84).

In both countries, the risk for relapse as indicated by psychiatric hospital admission and SUD-related hospital admission were lowest for clozapine, antipsychotic polytherapy and long-acting injectables, the investigators report.
 

Interpret with caution

Reached for comment, Christoph U. Correll, MD, professor of psychiatry and molecular medicine, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, urged caution in interpreting the results.

“While the authors are experts in national database analyses and the study was conducted with state-of-the-art methodology, the onset of SUD analyses favoring clozapine are subject to survival bias and order effects,” Dr. Correll said.

“Since clozapine is generally used later in the illness and treatment course, after multiple other antipsychotics have been used, and since SUDs generally occur early in the illness course, most SUDs will already have arisen by the time that clozapine is considered and used,” Dr. Correll said.

“A similar potential bias exists for long-acting injectables (LAIs), as these have generally also been used late in the treatment algorithm,” he noted.

In terms of the significant reduction of SUD-related hospitalizations observed with clozapine, the “order effect” could also be relevant, Dr. Correll said, because over time, patients are less likely to be nonadherent and hospitalized and clozapine is systematically used later in life than other antipsychotics.

“Why antipsychotic polytherapy came out as the second-best treatment is much less clear. Clearly head-to-head randomized trials are needed to follow up on these interesting and intriguing naturalistic database study data,” said Dr. Correll.

This study was funded by the Finnish Ministry of Social Affairs and Health through the developmental fund for Niuvanniemi Hospital. Dr. Tiihonen and three co-authors have participated in research projects funded by grants from Janssen-Cilag and Eli Lilly to their institution. Dr. Correll reports having been a consultant and/or advisor to or receiving honoraria from many companies. He has also provided expert testimony for Janssen and Otsuka; served on a Data Safety Monitoring Board for Lundbeck, Relmada, Reviva, Rovi, Supernus, and Teva; received royalties from UpToDate; and is a stock option holder of Cardio Diagnostics, Mindpax, LB Pharma, and Quantic.

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

Clozapine or antipsychotic polytherapy appear to be the best approach in reducing the risk for a substance use disorder (SUD) in adults with schizophrenia and for preventing relapse in patients with both diagnoses, results of a real-world study show.

“Our findings are in line with a recent meta-analysis showing superior efficacy of clozapine in schizophrenia and comorbid SUD and other studies pointing toward clozapine’s superiority over other antipsychotics in the treatment of individuals with schizophrenia and comorbid SUD,” the investigators, led by Jari Tiihonen MD, PhD, department of clinical neuroscience, Karolinska Institutet, Stockholm, write.

Karolinska Institute

Research gap

Research on the effectiveness of pharmacotherapies for schizophrenia and comorbid SUD is “very sparse, and more importantly, non-existent on the prevention of the development of SUDs in patients with schizophrenia,” the researchers note.

To investigate, they analyzed data on more than 45,000 patients with schizophrenia from Finnish and Swedish national registries, with follow-up lasting 22 years in Finland and 11 years in Sweden.

In patients with schizophrenia without SUD, treatment with clozapine was associated with lowest risk for an initial SUD in both Finland (adjusted hazard ratio, 0.20; 95% confidence interval, 0.16-0.24) and Sweden (aHR, 0.35; 95% CI, 0.24-0.50), compared with no use or use of other antipsychotics.

In Finland, aripiprazole was associated with the second lowest risk for an initial SUD (aHR, 0.36; 95% CI, 0.24-0.55) and antipsychotic polytherapy the third lowest risk (aHR, 0.47; 95% CI, 0.42-0.53).

In Sweden, antipsychotic polytherapy was associated with second lowest risk for an initial SUD (aHR, 0.54; 95% CI, 0.44-0.66) and olanzapine the third lowest risk (aHR, 0.67; 95% CI, 0.53-0.84).

In both countries, the risk for relapse as indicated by psychiatric hospital admission and SUD-related hospital admission were lowest for clozapine, antipsychotic polytherapy and long-acting injectables, the investigators report.
 

Interpret with caution

Reached for comment, Christoph U. Correll, MD, professor of psychiatry and molecular medicine, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, urged caution in interpreting the results.

“While the authors are experts in national database analyses and the study was conducted with state-of-the-art methodology, the onset of SUD analyses favoring clozapine are subject to survival bias and order effects,” Dr. Correll said.

“Since clozapine is generally used later in the illness and treatment course, after multiple other antipsychotics have been used, and since SUDs generally occur early in the illness course, most SUDs will already have arisen by the time that clozapine is considered and used,” Dr. Correll said.

“A similar potential bias exists for long-acting injectables (LAIs), as these have generally also been used late in the treatment algorithm,” he noted.

In terms of the significant reduction of SUD-related hospitalizations observed with clozapine, the “order effect” could also be relevant, Dr. Correll said, because over time, patients are less likely to be nonadherent and hospitalized and clozapine is systematically used later in life than other antipsychotics.

“Why antipsychotic polytherapy came out as the second-best treatment is much less clear. Clearly head-to-head randomized trials are needed to follow up on these interesting and intriguing naturalistic database study data,” said Dr. Correll.

This study was funded by the Finnish Ministry of Social Affairs and Health through the developmental fund for Niuvanniemi Hospital. Dr. Tiihonen and three co-authors have participated in research projects funded by grants from Janssen-Cilag and Eli Lilly to their institution. Dr. Correll reports having been a consultant and/or advisor to or receiving honoraria from many companies. He has also provided expert testimony for Janssen and Otsuka; served on a Data Safety Monitoring Board for Lundbeck, Relmada, Reviva, Rovi, Supernus, and Teva; received royalties from UpToDate; and is a stock option holder of Cardio Diagnostics, Mindpax, LB Pharma, and Quantic.

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

Clozapine or antipsychotic polytherapy appear to be the best approach in reducing the risk for a substance use disorder (SUD) in adults with schizophrenia and for preventing relapse in patients with both diagnoses, results of a real-world study show.

“Our findings are in line with a recent meta-analysis showing superior efficacy of clozapine in schizophrenia and comorbid SUD and other studies pointing toward clozapine’s superiority over other antipsychotics in the treatment of individuals with schizophrenia and comorbid SUD,” the investigators, led by Jari Tiihonen MD, PhD, department of clinical neuroscience, Karolinska Institutet, Stockholm, write.

Karolinska Institute

Research gap

Research on the effectiveness of pharmacotherapies for schizophrenia and comorbid SUD is “very sparse, and more importantly, non-existent on the prevention of the development of SUDs in patients with schizophrenia,” the researchers note.

To investigate, they analyzed data on more than 45,000 patients with schizophrenia from Finnish and Swedish national registries, with follow-up lasting 22 years in Finland and 11 years in Sweden.

In patients with schizophrenia without SUD, treatment with clozapine was associated with lowest risk for an initial SUD in both Finland (adjusted hazard ratio, 0.20; 95% confidence interval, 0.16-0.24) and Sweden (aHR, 0.35; 95% CI, 0.24-0.50), compared with no use or use of other antipsychotics.

In Finland, aripiprazole was associated with the second lowest risk for an initial SUD (aHR, 0.36; 95% CI, 0.24-0.55) and antipsychotic polytherapy the third lowest risk (aHR, 0.47; 95% CI, 0.42-0.53).

In Sweden, antipsychotic polytherapy was associated with second lowest risk for an initial SUD (aHR, 0.54; 95% CI, 0.44-0.66) and olanzapine the third lowest risk (aHR, 0.67; 95% CI, 0.53-0.84).

In both countries, the risk for relapse as indicated by psychiatric hospital admission and SUD-related hospital admission were lowest for clozapine, antipsychotic polytherapy and long-acting injectables, the investigators report.
 

Interpret with caution

Reached for comment, Christoph U. Correll, MD, professor of psychiatry and molecular medicine, the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, urged caution in interpreting the results.

“While the authors are experts in national database analyses and the study was conducted with state-of-the-art methodology, the onset of SUD analyses favoring clozapine are subject to survival bias and order effects,” Dr. Correll said.

“Since clozapine is generally used later in the illness and treatment course, after multiple other antipsychotics have been used, and since SUDs generally occur early in the illness course, most SUDs will already have arisen by the time that clozapine is considered and used,” Dr. Correll said.

“A similar potential bias exists for long-acting injectables (LAIs), as these have generally also been used late in the treatment algorithm,” he noted.

In terms of the significant reduction of SUD-related hospitalizations observed with clozapine, the “order effect” could also be relevant, Dr. Correll said, because over time, patients are less likely to be nonadherent and hospitalized and clozapine is systematically used later in life than other antipsychotics.

“Why antipsychotic polytherapy came out as the second-best treatment is much less clear. Clearly head-to-head randomized trials are needed to follow up on these interesting and intriguing naturalistic database study data,” said Dr. Correll.

This study was funded by the Finnish Ministry of Social Affairs and Health through the developmental fund for Niuvanniemi Hospital. Dr. Tiihonen and three co-authors have participated in research projects funded by grants from Janssen-Cilag and Eli Lilly to their institution. Dr. Correll reports having been a consultant and/or advisor to or receiving honoraria from many companies. He has also provided expert testimony for Janssen and Otsuka; served on a Data Safety Monitoring Board for Lundbeck, Relmada, Reviva, Rovi, Supernus, and Teva; received royalties from UpToDate; and is a stock option holder of Cardio Diagnostics, Mindpax, LB Pharma, and Quantic.

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

THE CASE

Louise T* is a 42-year-old woman who presented to her family medicine office for a routine annual visit. During the exam, her physician noticed bruises on Ms. T’s arms and back. Upon further inquiry, Ms. T reported that she and her husband had argued the night before the appointment. With some hesitancy, she went on to say that this was not the first time this had happened. She said that she and her husband had been arguing frequently for several years and that 6 months earlier, when he lost his job, he began hitting and pushing her.

● How would you proceed with this patient?

*The patient’s name has been changed to protect her identity.

Intimate partner violence (IPV) includes physical, sexual, or psychological aggression or stalking perpetrated by a current or former relationship partner.¹ IPV affects more than 12 million men and women living in the United States each year.² According to a national survey of IPV, approximately one-third (35.6%) of women and one-quarter (28.5%) of men living in the United States experience rape, physical violence, or stalking by an intimate partner during their lifetime.² Lifetime exposure to psychological IPV is even more prevalent, affecting nearly half of women and men (48.4% and 48.8%, respectively).²

Lifetime prevalence of any form of IPV is higher among women who identify as bisexual (59.8%) and lesbian (46.3%) compared with those who identify as heterosexual (37.2%); rates are comparable among men who identify as heterosexual (31.9%), bisexual (35.3%), and gay (35.1%).³ Preliminary data suggest that IPV may have increased in frequency and severity during the COVID-19 pandemic, particularly in the context of mandated shelter-in-place and stay-at-home orders.^4-6

IPV is associated with numerous negative health consequences. They include fear and concern for safety, mental health disorders such as posttraumatic stress disorder (PTSD), and physical health problems including physical injury, chronic pain, sleep disturbance, and frequent headaches.² IPV is also associated with a greater number of missed days from school and work and increased utilization of legal, health care, and housing services.^2,7 The overall annual cost of IPV against women is estimated at $5.8 billion, with health care costs accounting for approximately $4.1 billion.⁷ Family physicians can play an important role in curbing the devastating effects of IPV by screening patients and providing resources when needed.

Facilitate disclosure using screening tools and protocol

In Ms. T’s case, evidence of violence was clearly visible. However, not all instances of IPV leave physical marks. The US Preventive Services Task Force (USPSTF) recommends that all women of childbearing age be screened for IPV, whether or not they exhibit signs of violence.⁸ While the USPSTF has only published recommendations regarding screening women for IPV, there has been a recent push to screen all patients given that men also experience high rates of IPV.⁹

It’s helpful to ask questions such as: “Do arguments [with your partner] ever result in hitting, kicking, or pushing?” and “How often does your partner scream or curse at you?”

Utilize a brief screening tool. Directly ask patients about IPV; this can help reduce stigma, facilitate disclosure, and initiate the process of connecting patients to potentially lifesaving resources. The USPSTF lists several brief screening measures that can be used in primary care settings to assess exposure to IPV (TABLE 1^8,10-17). The brevity of these screening tools makes them well suited for busy physicians; cutoff scores facilitate the rapid identification of positive screens. While the USPSTF has not made specific recommendations regarding a screening interval, many studies examining the utility of these measures have reported on annual screenings.⁸ While there is limited evidence that brief screening alone leads to reductions in IPV,⁸ discussing IPV in a supportive and empathic manner and connecting patients to resources, such as supportive counseling, does have an important benefit: It can reduce symptoms of depression.¹⁸

Continue to: Screen patients in private; this protocol can help

Screen patients in private; this protocol can help. Given the sensitive nature of IPV and the potential danger some patients may be facing, it is important to screen patients in a safe and supportive environment.^19,20 Screening should be conducted by the primary care clinician, ideally when a trusting relationship already has been formed. Screen patients only when they are alone in a private room; avoid screening in public spaces such as clinic waiting rooms or in the vicinity of the patient’s partner or children older than age 2 years.^19,20

To provide all patients with an opportunity for private and safe IPV screening, clinics are encouraged to develop a clinic-wide policy whereby patients are routinely escorted to the exam room alone for the first portion of their visit, after which any accompanying individuals may be invited to join.²¹ Clinic staff can inform patients and accompanying individuals of this policy when they first arrive. Once in the exam room, and before the screening process begins, clearly state reporting requirements to ensure that patients can make an informed decision about whether to disclose IPV.¹⁹

Set a receptive tone. The manner in which clinicians discuss IPV with their patients is just as important as the setting. Demonstrating sensitivity and genuine concern for the patient’s safety and well-being may increase the patient’s comfort level throughout the screening process and may facilitate disclosures of IPV.^19,22 When screening patients for IPV, sit face to face rather than standing over them, maintain warm and open body language, and speak in a soft tone of voice.²²

Patients may feel more comfortable if you ask screening questions in a straightforward, nonjudgmental manner, as this helps to normalize the screening experience. We also recommend using behaviorally specific language (eg, “Do arguments [with your partner] ever result in hitting, kicking, or pushing?”¹⁶ or “How often does your partner scream or curse at you?”),¹³ as some patients who have experienced IPV will not label their experiences as “abuse” or “violence.” Not every patient who experiences IPV will be ready to disclose these events; however, maintaining a positive and supportive relationship during routine IPV screening and throughout the remainder of the medical visit may help facilitate future disclosures if, and when, a patient is ready to seek support.¹⁹

CRITICAL INTERVENTION ELEMENTS: EMPATHY AND SAFETY

A physician’s response to an IPV disclosure can have a lasting impact on the patient. We encourage family physicians to respond to IPV disclosures with empathy. Maintain eye contact and warm body language, validate the patient’s experiences (“I am sorry this happened to you,” “that must have been terrifying”), tell the patient that the violence was not their fault, and thank the patient for disclosing.²³

Continue to: Assess patient safety

Assess patient safety. Another critical component of intervention is to assess the patient’s safety and engage in safety planning. If the patient agrees to this next step, you may wish to provide a warm handoff to a trained social worker, nurse, or psychologist in the clinic who can spend more time covering this information with the patient. Some key components of a safety assessment include determining whether the violence or threat of violence is ongoing and identifying who lives in the home (eg, the partner, children, and any pets). You and the patient can also discuss red flags that would indicate elevated risk. You should discuss red flags that are unique to the patient’s relationship as well as common factors that have been found to heighten risk for IPV (eg, partner engaging in heavy alcohol use).¹

With the patient’s permission, collaboratively construct a safety plan that details how the patient can stay safe on a daily basis and how to safely leave should a dangerous situation arise (TABLE 2^9,24). The interactive safety planning tool available on the National Domestic Violence Hotline’s website can be a valuable resource (www.thehotline.org/plan-for-safety/).²⁴ Finally, if a patient is experiencing mental health concerns associated with IPV (eg, PTSD, depression, substance misuse, suicidal ideation), consider a referral to a domestic violence counseling center or mental health provider.

Move at the patient’s pace. Even if patients are willing to disclose IPV, they will differ in their readiness to discuss psychoeducation, safety planning, and referrals. Similarly, even if a patient is experiencing severe violence, they may not be ready to leave the relationship. Thus, it’s important to ask the patient for permission before initiating each successive step of the follow-up intervention. You and the patient may wish to schedule additional appointments to discuss this information at a pace the patient finds appropriate.

You may need to spend some time helping the patient recognize the severity of their situation and to feel empowered to take action. In addition, offer information and resources to all patients, even those who do not disclose IPV. Some patients may want to receive this information even if they do not feel comfortable sharing their experiences during the appointment.²⁰ You can also inform patients that they are welcome to bring up issues related to IPV at any future appointments in order to leave the door open to future disclosures.

THE CASE

The physician determined that Ms. T had been experiencing physical and psychological IPV in her current relationship. After responding empathically and obtaining the patient’s consent, the physician provided a warm handoff to the psychologist in the clinic. With Ms. T’s permission, the psychologist provided psychoeducation about IPV, and they discussed Ms. T’s current situation and risk level. They determined that Ms. T was at risk for subsequent episodes of IPV and they collaborated on a safety plan, making sure to discuss contact information for local and national crisis resources.

Continue to: Ms. T saved the phone number...

Ms. T saved the phone number for her local domestic violence shelter in her phone under a false name in case her husband looked through her phone. She said she planned to work on several safety plan items when her husband was away from the house and it was safe to do so. For example, she planned to identify additional ways to exit the house in an emergency and she was going to put together a bag with a change of clothes and some money and drop it off at a trusted friend’s house.

Ms. T and the psychologist agreed to follow up with an office visit in 1 week to discuss any additional safety concerns and to determine whether Ms. T could benefit from a referral to domestic violence counseling services or mental health treatment. The psychologist provided a summary of the topics she and Ms. T had discussed to the physician. The physician scheduled a follow-up appointment with Ms. T in 3 weeks to assess her current safety, troubleshoot any difficulties in implementing her safety plan, and offer additional resources, as needed.

CORRESPONDENCE
Andrea Massa, PhD, 125 Doughty Street, Suite 300, Charleston, SC 29403; [email protected]

THE CASE

Louise T* is a 42-year-old woman who presented to her family medicine office for a routine annual visit. During the exam, her physician noticed bruises on Ms. T’s arms and back. Upon further inquiry, Ms. T reported that she and her husband had argued the night before the appointment. With some hesitancy, she went on to say that this was not the first time this had happened. She said that she and her husband had been arguing frequently for several years and that 6 months earlier, when he lost his job, he began hitting and pushing her.

● How would you proceed with this patient?

*The patient’s name has been changed to protect her identity.

Intimate partner violence (IPV) includes physical, sexual, or psychological aggression or stalking perpetrated by a current or former relationship partner.¹ IPV affects more than 12 million men and women living in the United States each year.² According to a national survey of IPV, approximately one-third (35.6%) of women and one-quarter (28.5%) of men living in the United States experience rape, physical violence, or stalking by an intimate partner during their lifetime.² Lifetime exposure to psychological IPV is even more prevalent, affecting nearly half of women and men (48.4% and 48.8%, respectively).²

Lifetime prevalence of any form of IPV is higher among women who identify as bisexual (59.8%) and lesbian (46.3%) compared with those who identify as heterosexual (37.2%); rates are comparable among men who identify as heterosexual (31.9%), bisexual (35.3%), and gay (35.1%).³ Preliminary data suggest that IPV may have increased in frequency and severity during the COVID-19 pandemic, particularly in the context of mandated shelter-in-place and stay-at-home orders.^4-6

IPV is associated with numerous negative health consequences. They include fear and concern for safety, mental health disorders such as posttraumatic stress disorder (PTSD), and physical health problems including physical injury, chronic pain, sleep disturbance, and frequent headaches.² IPV is also associated with a greater number of missed days from school and work and increased utilization of legal, health care, and housing services.^2,7 The overall annual cost of IPV against women is estimated at $5.8 billion, with health care costs accounting for approximately $4.1 billion.⁷ Family physicians can play an important role in curbing the devastating effects of IPV by screening patients and providing resources when needed.

Facilitate disclosure using screening tools and protocol

In Ms. T’s case, evidence of violence was clearly visible. However, not all instances of IPV leave physical marks. The US Preventive Services Task Force (USPSTF) recommends that all women of childbearing age be screened for IPV, whether or not they exhibit signs of violence.⁸ While the USPSTF has only published recommendations regarding screening women for IPV, there has been a recent push to screen all patients given that men also experience high rates of IPV.⁹

It’s helpful to ask questions such as: “Do arguments [with your partner] ever result in hitting, kicking, or pushing?” and “How often does your partner scream or curse at you?”

Utilize a brief screening tool. Directly ask patients about IPV; this can help reduce stigma, facilitate disclosure, and initiate the process of connecting patients to potentially lifesaving resources. The USPSTF lists several brief screening measures that can be used in primary care settings to assess exposure to IPV (TABLE 1^8,10-17). The brevity of these screening tools makes them well suited for busy physicians; cutoff scores facilitate the rapid identification of positive screens. While the USPSTF has not made specific recommendations regarding a screening interval, many studies examining the utility of these measures have reported on annual screenings.⁸ While there is limited evidence that brief screening alone leads to reductions in IPV,⁸ discussing IPV in a supportive and empathic manner and connecting patients to resources, such as supportive counseling, does have an important benefit: It can reduce symptoms of depression.¹⁸

Continue to: Screen patients in private; this protocol can help

Screen patients in private; this protocol can help. Given the sensitive nature of IPV and the potential danger some patients may be facing, it is important to screen patients in a safe and supportive environment.^19,20 Screening should be conducted by the primary care clinician, ideally when a trusting relationship already has been formed. Screen patients only when they are alone in a private room; avoid screening in public spaces such as clinic waiting rooms or in the vicinity of the patient’s partner or children older than age 2 years.^19,20

To provide all patients with an opportunity for private and safe IPV screening, clinics are encouraged to develop a clinic-wide policy whereby patients are routinely escorted to the exam room alone for the first portion of their visit, after which any accompanying individuals may be invited to join.²¹ Clinic staff can inform patients and accompanying individuals of this policy when they first arrive. Once in the exam room, and before the screening process begins, clearly state reporting requirements to ensure that patients can make an informed decision about whether to disclose IPV.¹⁹

Set a receptive tone. The manner in which clinicians discuss IPV with their patients is just as important as the setting. Demonstrating sensitivity and genuine concern for the patient’s safety and well-being may increase the patient’s comfort level throughout the screening process and may facilitate disclosures of IPV.^19,22 When screening patients for IPV, sit face to face rather than standing over them, maintain warm and open body language, and speak in a soft tone of voice.²²

Patients may feel more comfortable if you ask screening questions in a straightforward, nonjudgmental manner, as this helps to normalize the screening experience. We also recommend using behaviorally specific language (eg, “Do arguments [with your partner] ever result in hitting, kicking, or pushing?”¹⁶ or “How often does your partner scream or curse at you?”),¹³ as some patients who have experienced IPV will not label their experiences as “abuse” or “violence.” Not every patient who experiences IPV will be ready to disclose these events; however, maintaining a positive and supportive relationship during routine IPV screening and throughout the remainder of the medical visit may help facilitate future disclosures if, and when, a patient is ready to seek support.¹⁹

CRITICAL INTERVENTION ELEMENTS: EMPATHY AND SAFETY

A physician’s response to an IPV disclosure can have a lasting impact on the patient. We encourage family physicians to respond to IPV disclosures with empathy. Maintain eye contact and warm body language, validate the patient’s experiences (“I am sorry this happened to you,” “that must have been terrifying”), tell the patient that the violence was not their fault, and thank the patient for disclosing.²³

Continue to: Assess patient safety

Assess patient safety. Another critical component of intervention is to assess the patient’s safety and engage in safety planning. If the patient agrees to this next step, you may wish to provide a warm handoff to a trained social worker, nurse, or psychologist in the clinic who can spend more time covering this information with the patient. Some key components of a safety assessment include determining whether the violence or threat of violence is ongoing and identifying who lives in the home (eg, the partner, children, and any pets). You and the patient can also discuss red flags that would indicate elevated risk. You should discuss red flags that are unique to the patient’s relationship as well as common factors that have been found to heighten risk for IPV (eg, partner engaging in heavy alcohol use).¹

With the patient’s permission, collaboratively construct a safety plan that details how the patient can stay safe on a daily basis and how to safely leave should a dangerous situation arise (TABLE 2^9,24). The interactive safety planning tool available on the National Domestic Violence Hotline’s website can be a valuable resource (www.thehotline.org/plan-for-safety/).²⁴ Finally, if a patient is experiencing mental health concerns associated with IPV (eg, PTSD, depression, substance misuse, suicidal ideation), consider a referral to a domestic violence counseling center or mental health provider.

Move at the patient’s pace. Even if patients are willing to disclose IPV, they will differ in their readiness to discuss psychoeducation, safety planning, and referrals. Similarly, even if a patient is experiencing severe violence, they may not be ready to leave the relationship. Thus, it’s important to ask the patient for permission before initiating each successive step of the follow-up intervention. You and the patient may wish to schedule additional appointments to discuss this information at a pace the patient finds appropriate.

You may need to spend some time helping the patient recognize the severity of their situation and to feel empowered to take action. In addition, offer information and resources to all patients, even those who do not disclose IPV. Some patients may want to receive this information even if they do not feel comfortable sharing their experiences during the appointment.²⁰ You can also inform patients that they are welcome to bring up issues related to IPV at any future appointments in order to leave the door open to future disclosures.

THE CASE

The physician determined that Ms. T had been experiencing physical and psychological IPV in her current relationship. After responding empathically and obtaining the patient’s consent, the physician provided a warm handoff to the psychologist in the clinic. With Ms. T’s permission, the psychologist provided psychoeducation about IPV, and they discussed Ms. T’s current situation and risk level. They determined that Ms. T was at risk for subsequent episodes of IPV and they collaborated on a safety plan, making sure to discuss contact information for local and national crisis resources.

Continue to: Ms. T saved the phone number...

Ms. T saved the phone number for her local domestic violence shelter in her phone under a false name in case her husband looked through her phone. She said she planned to work on several safety plan items when her husband was away from the house and it was safe to do so. For example, she planned to identify additional ways to exit the house in an emergency and she was going to put together a bag with a change of clothes and some money and drop it off at a trusted friend’s house.

Ms. T and the psychologist agreed to follow up with an office visit in 1 week to discuss any additional safety concerns and to determine whether Ms. T could benefit from a referral to domestic violence counseling services or mental health treatment. The psychologist provided a summary of the topics she and Ms. T had discussed to the physician. The physician scheduled a follow-up appointment with Ms. T in 3 weeks to assess her current safety, troubleshoot any difficulties in implementing her safety plan, and offer additional resources, as needed.

CORRESPONDENCE
Andrea Massa, PhD, 125 Doughty Street, Suite 300, Charleston, SC 29403; [email protected]

THE CASE

Louise T* is a 42-year-old woman who presented to her family medicine office for a routine annual visit. During the exam, her physician noticed bruises on Ms. T’s arms and back. Upon further inquiry, Ms. T reported that she and her husband had argued the night before the appointment. With some hesitancy, she went on to say that this was not the first time this had happened. She said that she and her husband had been arguing frequently for several years and that 6 months earlier, when he lost his job, he began hitting and pushing her.

● How would you proceed with this patient?

*The patient’s name has been changed to protect her identity.

Intimate partner violence (IPV) includes physical, sexual, or psychological aggression or stalking perpetrated by a current or former relationship partner.¹ IPV affects more than 12 million men and women living in the United States each year.² According to a national survey of IPV, approximately one-third (35.6%) of women and one-quarter (28.5%) of men living in the United States experience rape, physical violence, or stalking by an intimate partner during their lifetime.² Lifetime exposure to psychological IPV is even more prevalent, affecting nearly half of women and men (48.4% and 48.8%, respectively).²

Lifetime prevalence of any form of IPV is higher among women who identify as bisexual (59.8%) and lesbian (46.3%) compared with those who identify as heterosexual (37.2%); rates are comparable among men who identify as heterosexual (31.9%), bisexual (35.3%), and gay (35.1%).³ Preliminary data suggest that IPV may have increased in frequency and severity during the COVID-19 pandemic, particularly in the context of mandated shelter-in-place and stay-at-home orders.^4-6

IPV is associated with numerous negative health consequences. They include fear and concern for safety, mental health disorders such as posttraumatic stress disorder (PTSD), and physical health problems including physical injury, chronic pain, sleep disturbance, and frequent headaches.² IPV is also associated with a greater number of missed days from school and work and increased utilization of legal, health care, and housing services.^2,7 The overall annual cost of IPV against women is estimated at $5.8 billion, with health care costs accounting for approximately $4.1 billion.⁷ Family physicians can play an important role in curbing the devastating effects of IPV by screening patients and providing resources when needed.

Facilitate disclosure using screening tools and protocol

In Ms. T’s case, evidence of violence was clearly visible. However, not all instances of IPV leave physical marks. The US Preventive Services Task Force (USPSTF) recommends that all women of childbearing age be screened for IPV, whether or not they exhibit signs of violence.⁸ While the USPSTF has only published recommendations regarding screening women for IPV, there has been a recent push to screen all patients given that men also experience high rates of IPV.⁹

It’s helpful to ask questions such as: “Do arguments [with your partner] ever result in hitting, kicking, or pushing?” and “How often does your partner scream or curse at you?”

Utilize a brief screening tool. Directly ask patients about IPV; this can help reduce stigma, facilitate disclosure, and initiate the process of connecting patients to potentially lifesaving resources. The USPSTF lists several brief screening measures that can be used in primary care settings to assess exposure to IPV (TABLE 1^8,10-17). The brevity of these screening tools makes them well suited for busy physicians; cutoff scores facilitate the rapid identification of positive screens. While the USPSTF has not made specific recommendations regarding a screening interval, many studies examining the utility of these measures have reported on annual screenings.⁸ While there is limited evidence that brief screening alone leads to reductions in IPV,⁸ discussing IPV in a supportive and empathic manner and connecting patients to resources, such as supportive counseling, does have an important benefit: It can reduce symptoms of depression.¹⁸

Continue to: Screen patients in private; this protocol can help

Screen patients in private; this protocol can help. Given the sensitive nature of IPV and the potential danger some patients may be facing, it is important to screen patients in a safe and supportive environment.^19,20 Screening should be conducted by the primary care clinician, ideally when a trusting relationship already has been formed. Screen patients only when they are alone in a private room; avoid screening in public spaces such as clinic waiting rooms or in the vicinity of the patient’s partner or children older than age 2 years.^19,20

To provide all patients with an opportunity for private and safe IPV screening, clinics are encouraged to develop a clinic-wide policy whereby patients are routinely escorted to the exam room alone for the first portion of their visit, after which any accompanying individuals may be invited to join.²¹ Clinic staff can inform patients and accompanying individuals of this policy when they first arrive. Once in the exam room, and before the screening process begins, clearly state reporting requirements to ensure that patients can make an informed decision about whether to disclose IPV.¹⁹

Set a receptive tone. The manner in which clinicians discuss IPV with their patients is just as important as the setting. Demonstrating sensitivity and genuine concern for the patient’s safety and well-being may increase the patient’s comfort level throughout the screening process and may facilitate disclosures of IPV.^19,22 When screening patients for IPV, sit face to face rather than standing over them, maintain warm and open body language, and speak in a soft tone of voice.²²

Patients may feel more comfortable if you ask screening questions in a straightforward, nonjudgmental manner, as this helps to normalize the screening experience. We also recommend using behaviorally specific language (eg, “Do arguments [with your partner] ever result in hitting, kicking, or pushing?”¹⁶ or “How often does your partner scream or curse at you?”),¹³ as some patients who have experienced IPV will not label their experiences as “abuse” or “violence.” Not every patient who experiences IPV will be ready to disclose these events; however, maintaining a positive and supportive relationship during routine IPV screening and throughout the remainder of the medical visit may help facilitate future disclosures if, and when, a patient is ready to seek support.¹⁹

CRITICAL INTERVENTION ELEMENTS: EMPATHY AND SAFETY

A physician’s response to an IPV disclosure can have a lasting impact on the patient. We encourage family physicians to respond to IPV disclosures with empathy. Maintain eye contact and warm body language, validate the patient’s experiences (“I am sorry this happened to you,” “that must have been terrifying”), tell the patient that the violence was not their fault, and thank the patient for disclosing.²³

Continue to: Assess patient safety

Assess patient safety. Another critical component of intervention is to assess the patient’s safety and engage in safety planning. If the patient agrees to this next step, you may wish to provide a warm handoff to a trained social worker, nurse, or psychologist in the clinic who can spend more time covering this information with the patient. Some key components of a safety assessment include determining whether the violence or threat of violence is ongoing and identifying who lives in the home (eg, the partner, children, and any pets). You and the patient can also discuss red flags that would indicate elevated risk. You should discuss red flags that are unique to the patient’s relationship as well as common factors that have been found to heighten risk for IPV (eg, partner engaging in heavy alcohol use).¹

With the patient’s permission, collaboratively construct a safety plan that details how the patient can stay safe on a daily basis and how to safely leave should a dangerous situation arise (TABLE 2^9,24). The interactive safety planning tool available on the National Domestic Violence Hotline’s website can be a valuable resource (www.thehotline.org/plan-for-safety/).²⁴ Finally, if a patient is experiencing mental health concerns associated with IPV (eg, PTSD, depression, substance misuse, suicidal ideation), consider a referral to a domestic violence counseling center or mental health provider.

Move at the patient’s pace. Even if patients are willing to disclose IPV, they will differ in their readiness to discuss psychoeducation, safety planning, and referrals. Similarly, even if a patient is experiencing severe violence, they may not be ready to leave the relationship. Thus, it’s important to ask the patient for permission before initiating each successive step of the follow-up intervention. You and the patient may wish to schedule additional appointments to discuss this information at a pace the patient finds appropriate.

You may need to spend some time helping the patient recognize the severity of their situation and to feel empowered to take action. In addition, offer information and resources to all patients, even those who do not disclose IPV. Some patients may want to receive this information even if they do not feel comfortable sharing their experiences during the appointment.²⁰ You can also inform patients that they are welcome to bring up issues related to IPV at any future appointments in order to leave the door open to future disclosures.

THE CASE

The physician determined that Ms. T had been experiencing physical and psychological IPV in her current relationship. After responding empathically and obtaining the patient’s consent, the physician provided a warm handoff to the psychologist in the clinic. With Ms. T’s permission, the psychologist provided psychoeducation about IPV, and they discussed Ms. T’s current situation and risk level. They determined that Ms. T was at risk for subsequent episodes of IPV and they collaborated on a safety plan, making sure to discuss contact information for local and national crisis resources.

Continue to: Ms. T saved the phone number...

Ms. T saved the phone number for her local domestic violence shelter in her phone under a false name in case her husband looked through her phone. She said she planned to work on several safety plan items when her husband was away from the house and it was safe to do so. For example, she planned to identify additional ways to exit the house in an emergency and she was going to put together a bag with a change of clothes and some money and drop it off at a trusted friend’s house.

Ms. T and the psychologist agreed to follow up with an office visit in 1 week to discuss any additional safety concerns and to determine whether Ms. T could benefit from a referral to domestic violence counseling services or mental health treatment. The psychologist provided a summary of the topics she and Ms. T had discussed to the physician. The physician scheduled a follow-up appointment with Ms. T in 3 weeks to assess her current safety, troubleshoot any difficulties in implementing her safety plan, and offer additional resources, as needed.

CORRESPONDENCE
Andrea Massa, PhD, 125 Doughty Street, Suite 300, Charleston, SC 29403; [email protected]

Psychedelics can produce positive changes in attitudes about death and dying – and may be a way to help ease anxiety and depression toward the end of life, new research suggests.

In a retrospective study of more than 3,000 participants, near-death experiences occurring naturally or via a psychedelic drug had a “remarkably” similar effect on attitudes about death and dying, with most participants reporting less fear and anxiety around death.

“Individuals with existential anxiety and depression at end of life account for substantial suffering and significantly increased health care expenses from desperate and often futile seeking of intensive and expensive medical treatments,” co-investigator Roland Griffiths, PhD, Center for Psychedelics and Consciousness Research at Johns Hopkins Medicine, Baltimore, told this news organization.

Direct comparisons

Both psychedelic drug experiences and near-death experiences can alter perspectives on death and dying, but there have been few direct comparisons of these phenomena, the investigators note.

In the current study, they directly compared psychedelic-occasioned and nondrug experiences, which altered individuals’ beliefs about death.

The researchers surveyed 3,192 mostly White adults from the United States, including 933 who had a natural, nondrug near-death experience and 2,259 who had psychedelic near-death experiences induced with lysergic acid diethylamide, psilocybin, ayahuasca, or N,N-dimethyltryptamine.

The psychedelic group had more men than women and tended to be younger at the time of the experience than was the nondrug group.

Nearly 90% of individuals in both groups said that they were less afraid of death than they were before their experiences.

About half of both groups said they’d encountered something they might call “God” during the experience.

Three-quarters of the psychedelic group and 85% of the nondrug group rated their experiences as among the top five most personally meaningful and spiritually significant events of their life.

Individuals in both groups also reported moderate- to strong-lasting positive changes in personal well-being and life purpose and meaning after their experiences. 

However, there were some differences between the groups.
 

More research needed

Compared with the psychedelic group, the nondrug group was more likely to report being unconscious, clinically dead, or that their life was in imminent danger.

The nonpsychedelic group was also more likely to report that their experience was very brief, lasting 5 minutes or less.

Both the psychedelic and nondrug participants showed robust increases on standardized measures of mystical and near-death experiences, but these measures were significantly greater in the psychedelic group.

The survey findings are in line with several recent clinical trials showing that a single treatment with the psychedelic psilocybin produced sustained decreases in anxiety and depression among patients with a life-threatening cancer diagnosis.

This includes a 2016 study by Dr. Griffiths and colleagues, which included 51 patients with late-stage cancer. As reported at the time, results showed a single, high dose of psilocybin had rapid, clinically significant, and lasting effects on mood and anxiety.

Limitations of the current survey cited by the researchers include the use of retrospective self-report to describe changes in death attitudes and the subjective features of the experiences. Also, respondents were a self-selected study population that may not be representative of all psychedelic or near-death experiences.

In addition, the study did not attempt to document worldview and other belief changes, such as increased belief in afterlife, that might help explain why death attitudes changed.

Looking ahead, the researchers note that future studies are needed to better understand the potential clinical use of psychedelics in ameliorating suffering related to fear of death.

Support through the Johns Hopkins Center for Psychedelic and Consciousness Research was provided by Tim Ferriss, Matt Mullenweg, Blake Mycoskie, Craig Nerenberg, and the Steven and Alexandra Cohen Foundation. Funding was also provided by the Y.C. Ho/Helen and Michael Chiang Foundation. The investigators have reported no relevant financial relationships.

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

Psychedelics can produce positive changes in attitudes about death and dying – and may be a way to help ease anxiety and depression toward the end of life, new research suggests.

In a retrospective study of more than 3,000 participants, near-death experiences occurring naturally or via a psychedelic drug had a “remarkably” similar effect on attitudes about death and dying, with most participants reporting less fear and anxiety around death.

“Individuals with existential anxiety and depression at end of life account for substantial suffering and significantly increased health care expenses from desperate and often futile seeking of intensive and expensive medical treatments,” co-investigator Roland Griffiths, PhD, Center for Psychedelics and Consciousness Research at Johns Hopkins Medicine, Baltimore, told this news organization.

Direct comparisons

Both psychedelic drug experiences and near-death experiences can alter perspectives on death and dying, but there have been few direct comparisons of these phenomena, the investigators note.

In the current study, they directly compared psychedelic-occasioned and nondrug experiences, which altered individuals’ beliefs about death.

The researchers surveyed 3,192 mostly White adults from the United States, including 933 who had a natural, nondrug near-death experience and 2,259 who had psychedelic near-death experiences induced with lysergic acid diethylamide, psilocybin, ayahuasca, or N,N-dimethyltryptamine.

The psychedelic group had more men than women and tended to be younger at the time of the experience than was the nondrug group.

Nearly 90% of individuals in both groups said that they were less afraid of death than they were before their experiences.

About half of both groups said they’d encountered something they might call “God” during the experience.

Three-quarters of the psychedelic group and 85% of the nondrug group rated their experiences as among the top five most personally meaningful and spiritually significant events of their life.

Individuals in both groups also reported moderate- to strong-lasting positive changes in personal well-being and life purpose and meaning after their experiences. 

However, there were some differences between the groups.
 

More research needed

Compared with the psychedelic group, the nondrug group was more likely to report being unconscious, clinically dead, or that their life was in imminent danger.

The nonpsychedelic group was also more likely to report that their experience was very brief, lasting 5 minutes or less.

Both the psychedelic and nondrug participants showed robust increases on standardized measures of mystical and near-death experiences, but these measures were significantly greater in the psychedelic group.

The survey findings are in line with several recent clinical trials showing that a single treatment with the psychedelic psilocybin produced sustained decreases in anxiety and depression among patients with a life-threatening cancer diagnosis.

This includes a 2016 study by Dr. Griffiths and colleagues, which included 51 patients with late-stage cancer. As reported at the time, results showed a single, high dose of psilocybin had rapid, clinically significant, and lasting effects on mood and anxiety.

Limitations of the current survey cited by the researchers include the use of retrospective self-report to describe changes in death attitudes and the subjective features of the experiences. Also, respondents were a self-selected study population that may not be representative of all psychedelic or near-death experiences.

In addition, the study did not attempt to document worldview and other belief changes, such as increased belief in afterlife, that might help explain why death attitudes changed.

Looking ahead, the researchers note that future studies are needed to better understand the potential clinical use of psychedelics in ameliorating suffering related to fear of death.

Support through the Johns Hopkins Center for Psychedelic and Consciousness Research was provided by Tim Ferriss, Matt Mullenweg, Blake Mycoskie, Craig Nerenberg, and the Steven and Alexandra Cohen Foundation. Funding was also provided by the Y.C. Ho/Helen and Michael Chiang Foundation. The investigators have reported no relevant financial relationships.

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

Psychedelics can produce positive changes in attitudes about death and dying – and may be a way to help ease anxiety and depression toward the end of life, new research suggests.

In a retrospective study of more than 3,000 participants, near-death experiences occurring naturally or via a psychedelic drug had a “remarkably” similar effect on attitudes about death and dying, with most participants reporting less fear and anxiety around death.

“Individuals with existential anxiety and depression at end of life account for substantial suffering and significantly increased health care expenses from desperate and often futile seeking of intensive and expensive medical treatments,” co-investigator Roland Griffiths, PhD, Center for Psychedelics and Consciousness Research at Johns Hopkins Medicine, Baltimore, told this news organization.

Direct comparisons

Both psychedelic drug experiences and near-death experiences can alter perspectives on death and dying, but there have been few direct comparisons of these phenomena, the investigators note.

In the current study, they directly compared psychedelic-occasioned and nondrug experiences, which altered individuals’ beliefs about death.

The researchers surveyed 3,192 mostly White adults from the United States, including 933 who had a natural, nondrug near-death experience and 2,259 who had psychedelic near-death experiences induced with lysergic acid diethylamide, psilocybin, ayahuasca, or N,N-dimethyltryptamine.

The psychedelic group had more men than women and tended to be younger at the time of the experience than was the nondrug group.

Nearly 90% of individuals in both groups said that they were less afraid of death than they were before their experiences.

About half of both groups said they’d encountered something they might call “God” during the experience.

Three-quarters of the psychedelic group and 85% of the nondrug group rated their experiences as among the top five most personally meaningful and spiritually significant events of their life.

Individuals in both groups also reported moderate- to strong-lasting positive changes in personal well-being and life purpose and meaning after their experiences. 

However, there were some differences between the groups.
 

More research needed

Compared with the psychedelic group, the nondrug group was more likely to report being unconscious, clinically dead, or that their life was in imminent danger.

The nonpsychedelic group was also more likely to report that their experience was very brief, lasting 5 minutes or less.

Both the psychedelic and nondrug participants showed robust increases on standardized measures of mystical and near-death experiences, but these measures were significantly greater in the psychedelic group.

The survey findings are in line with several recent clinical trials showing that a single treatment with the psychedelic psilocybin produced sustained decreases in anxiety and depression among patients with a life-threatening cancer diagnosis.

This includes a 2016 study by Dr. Griffiths and colleagues, which included 51 patients with late-stage cancer. As reported at the time, results showed a single, high dose of psilocybin had rapid, clinically significant, and lasting effects on mood and anxiety.

Limitations of the current survey cited by the researchers include the use of retrospective self-report to describe changes in death attitudes and the subjective features of the experiences. Also, respondents were a self-selected study population that may not be representative of all psychedelic or near-death experiences.

In addition, the study did not attempt to document worldview and other belief changes, such as increased belief in afterlife, that might help explain why death attitudes changed.

Looking ahead, the researchers note that future studies are needed to better understand the potential clinical use of psychedelics in ameliorating suffering related to fear of death.

Support through the Johns Hopkins Center for Psychedelic and Consciousness Research was provided by Tim Ferriss, Matt Mullenweg, Blake Mycoskie, Craig Nerenberg, and the Steven and Alexandra Cohen Foundation. Funding was also provided by the Y.C. Ho/Helen and Michael Chiang Foundation. The investigators have reported no relevant financial relationships.

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

Experiencing psychological distress prior to becoming infected with SARS-CoV-2 is tied to an increased risk for post-COVID conditions often called “long COVID,” new research suggests.

In an analysis of almost 55,000 adult participants in three ongoing studies, having depression, anxiety, worry, perceived stress, or loneliness early in the pandemic, before SARS-CoV-2 infection, was associated with a 50% increased risk for developing long COVID. These types of psychological distress were also associated with a 15% to 51% greater risk for impairment in daily life among individuals with long COVID.

Psychological distress was even more strongly associated with developing long COVID than were physical health risk factors, and the increased risk was not explained by health behaviors such as smoking or physical comorbidities, researchers note.

“Our findings suggest the need to consider psychological health in addition to physical health as risk factors of long COVID-19,” lead author Siwen Wang, MD, postdoctoral fellow, department of nutrition, Harvard T. H. Chan School of Public Health, Boston, said in an interview.

“We need to increase public awareness of the importance of mental health and focus on getting mental health care for people who need it, increasing the supply of mental health clinicians and improving access to care,” she said.

The findings were published online in JAMA Psychiatry.
 

‘Poorly understood’

Postacute sequelae of SARS-CoV-2 (“long COVID”), which are “signs and symptoms consistent with COVID-19 that extend beyond 4 weeks from onset of infection” constitute “an emerging health issue,” the investigators write.

Dr. Wang noted that it has been estimated that 8-23 million Americans have developed long COVID. However, “despite the high prevalence and daily life impairment associated with long COVID, it is still poorly understood, and few risk factors have been established,” she said.

Although psychological distress may be implicated in long COVID, only three previous studies investigated psychological factors as potential contributors, the researchers note. Also, no study has investigated the potential role of other common manifestations of distress that have increased during the pandemic, such as loneliness and perceived stress, they add.

To investigate these issues, the researchers turned to three large ongoing longitudinal studies: the Nurses’ Health Study II (NSHII), the Nurses’ Health study 3 (NHS3), and the Growing Up Today Study (GUTS).

They analyzed data on 54,960 total participants (96.6% women; mean age, 57.5 years). Of the full group, 38% were active health care workers.

Participants completed an online COVID-19 questionnaire from April 2020 to Sept. 1, 2020 (baseline), and monthly surveys thereafter. Beginning in August 2020, surveys were administered quarterly. The end of follow-up was in November 2021.

The COVID questionnaires included questions about positive SARS-CoV-2 test results, COVID symptoms and hospitalization since March 1, 2020, and the presence of long-term COVID symptoms, such as fatigue, respiratory problems, persistent cough, muscle/joint/chest pain, smell/taste problems, confusion/disorientation/brain fog, depression/anxiety/changes in mood, headache, and memory problems.

Participants who reported these post-COVID conditions were asked about the frequency of symptoms and the degree of impairment in daily life.
 

Inflammation, immune dysregulation implicated?

The Patient Health Questionnaire–4 (PHQ-4) was used to assess for anxiety and depressive symptoms in the past 2 weeks. It consists of a two-item depression measure (PHQ-2) and a two-item Generalized Anxiety Disorder Scale (GAD-2).

Non–health care providers completed two additional assessments of psychological distress: the four-item Perceived Stress Scale and the three-item UCLA Loneliness Scale.

The researchers included demographic factors, weight, smoking status, marital status, and medical conditions, including diabetes, hypertension, hypercholesterolemia, asthma, and cancer, and socioeconomic factors as covariates.

For each participant, the investigators calculated the number of types of distress experienced at a high level, including probable depression, probable anxiety, worry about COVID-19, being in the top quartile of perceived stress, and loneliness.

During the 19 months of follow-up (1-47 weeks after baseline), 6% of respondents reported a positive result on a SARS-CoV-2 antibody, antigen, or polymerase chain reaction test.

Of these, 43.9% reported long-COVID conditions, with most reporting that symptoms lasted 2 months or longer; 55.8% reported at least occasional daily life impairment.

The most common post-COVID conditions were fatigue (reported by 56%), loss of smell or taste problems (44.6%), shortness of breath (25.5%), confusion/disorientation/ brain fog (24.5%), and memory issues (21.8%).

Among patients who had been infected, there was a considerably higher rate of preinfection psychological distress after adjusting for sociodemographic factors, health behaviors, and comorbidities. Each type of distress was associated with post-COVID conditions.

In addition, participants who had experienced at least two types of distress prior to infection were at nearly 50% increased risk for post–COVID conditions (risk ratio, 1.49; 95% confidence interval, 1.23-1.80).

Among those with post-COVID conditions, all types of distress were associated with increased risk for daily life impairment (RR range, 1.15-1.51).

Senior author Andrea Roberts, PhD, senior research scientist at the Harvard T. H. Chan School of Public Health, Boston, noted that the investigators did not examine biological mechanisms potentially underlying the association they found.

However, “based on prior research, it may be that inflammation and immune dysregulation related to psychological distress play a role in the association of distress with long COVID, but we can’t be sure,” Dr. Roberts said.
 

Contributes to the field

Commenting for this article, Yapeng Su, PhD, a postdoctoral researcher at the Fred Hutchinson Cancer Research Center in Seattle, called the study “great work contributing to the long-COVID research field and revealing important connections” with psychological stress prior to infection.

Dr. Su, who was not involved with the study, was previously at the Institute for Systems Biology, also in Seattle, and has written about long COVID.

He noted that the “biological mechanism of such intriguing linkage is definitely the important next step, which will likely require deep phenotyping of biological specimens from these patients longitudinally.”

Dr. Wang pointed to past research suggesting that some patients with mental illness “sometimes develop autoantibodies that have also been associated with increased risk of long COVID.” In addition, depression “affects the brain in ways that may explain certain cognitive symptoms in long COVID,” she added.

More studies are now needed to understand how psychological distress increases the risk for long COVID, said Dr. Wang.

The research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, the Dean’s Fund for Scientific Advancement Acceleration Award from the Harvard T. H. Chan School of Public Health, the Massachusetts Consortium on Pathogen Readiness Evergrande COVID-19 Response Fund Award, and the Veterans Affairs Health Services Research and Development Service funds. Dr. Wang and Dr. Roberts have reported no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Su reports no relevant financial relationships.

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

Experiencing psychological distress prior to becoming infected with SARS-CoV-2 is tied to an increased risk for post-COVID conditions often called “long COVID,” new research suggests.

In an analysis of almost 55,000 adult participants in three ongoing studies, having depression, anxiety, worry, perceived stress, or loneliness early in the pandemic, before SARS-CoV-2 infection, was associated with a 50% increased risk for developing long COVID. These types of psychological distress were also associated with a 15% to 51% greater risk for impairment in daily life among individuals with long COVID.

Psychological distress was even more strongly associated with developing long COVID than were physical health risk factors, and the increased risk was not explained by health behaviors such as smoking or physical comorbidities, researchers note.

“Our findings suggest the need to consider psychological health in addition to physical health as risk factors of long COVID-19,” lead author Siwen Wang, MD, postdoctoral fellow, department of nutrition, Harvard T. H. Chan School of Public Health, Boston, said in an interview.

“We need to increase public awareness of the importance of mental health and focus on getting mental health care for people who need it, increasing the supply of mental health clinicians and improving access to care,” she said.

The findings were published online in JAMA Psychiatry.
 

‘Poorly understood’

Postacute sequelae of SARS-CoV-2 (“long COVID”), which are “signs and symptoms consistent with COVID-19 that extend beyond 4 weeks from onset of infection” constitute “an emerging health issue,” the investigators write.

Dr. Wang noted that it has been estimated that 8-23 million Americans have developed long COVID. However, “despite the high prevalence and daily life impairment associated with long COVID, it is still poorly understood, and few risk factors have been established,” she said.

Although psychological distress may be implicated in long COVID, only three previous studies investigated psychological factors as potential contributors, the researchers note. Also, no study has investigated the potential role of other common manifestations of distress that have increased during the pandemic, such as loneliness and perceived stress, they add.

To investigate these issues, the researchers turned to three large ongoing longitudinal studies: the Nurses’ Health Study II (NSHII), the Nurses’ Health study 3 (NHS3), and the Growing Up Today Study (GUTS).

They analyzed data on 54,960 total participants (96.6% women; mean age, 57.5 years). Of the full group, 38% were active health care workers.

Participants completed an online COVID-19 questionnaire from April 2020 to Sept. 1, 2020 (baseline), and monthly surveys thereafter. Beginning in August 2020, surveys were administered quarterly. The end of follow-up was in November 2021.

The COVID questionnaires included questions about positive SARS-CoV-2 test results, COVID symptoms and hospitalization since March 1, 2020, and the presence of long-term COVID symptoms, such as fatigue, respiratory problems, persistent cough, muscle/joint/chest pain, smell/taste problems, confusion/disorientation/brain fog, depression/anxiety/changes in mood, headache, and memory problems.

Participants who reported these post-COVID conditions were asked about the frequency of symptoms and the degree of impairment in daily life.
 

Inflammation, immune dysregulation implicated?

The Patient Health Questionnaire–4 (PHQ-4) was used to assess for anxiety and depressive symptoms in the past 2 weeks. It consists of a two-item depression measure (PHQ-2) and a two-item Generalized Anxiety Disorder Scale (GAD-2).

Non–health care providers completed two additional assessments of psychological distress: the four-item Perceived Stress Scale and the three-item UCLA Loneliness Scale.

The researchers included demographic factors, weight, smoking status, marital status, and medical conditions, including diabetes, hypertension, hypercholesterolemia, asthma, and cancer, and socioeconomic factors as covariates.

For each participant, the investigators calculated the number of types of distress experienced at a high level, including probable depression, probable anxiety, worry about COVID-19, being in the top quartile of perceived stress, and loneliness.

During the 19 months of follow-up (1-47 weeks after baseline), 6% of respondents reported a positive result on a SARS-CoV-2 antibody, antigen, or polymerase chain reaction test.

Of these, 43.9% reported long-COVID conditions, with most reporting that symptoms lasted 2 months or longer; 55.8% reported at least occasional daily life impairment.

The most common post-COVID conditions were fatigue (reported by 56%), loss of smell or taste problems (44.6%), shortness of breath (25.5%), confusion/disorientation/ brain fog (24.5%), and memory issues (21.8%).

Among patients who had been infected, there was a considerably higher rate of preinfection psychological distress after adjusting for sociodemographic factors, health behaviors, and comorbidities. Each type of distress was associated with post-COVID conditions.

In addition, participants who had experienced at least two types of distress prior to infection were at nearly 50% increased risk for post–COVID conditions (risk ratio, 1.49; 95% confidence interval, 1.23-1.80).

Among those with post-COVID conditions, all types of distress were associated with increased risk for daily life impairment (RR range, 1.15-1.51).

Senior author Andrea Roberts, PhD, senior research scientist at the Harvard T. H. Chan School of Public Health, Boston, noted that the investigators did not examine biological mechanisms potentially underlying the association they found.

However, “based on prior research, it may be that inflammation and immune dysregulation related to psychological distress play a role in the association of distress with long COVID, but we can’t be sure,” Dr. Roberts said.
 

Contributes to the field

Commenting for this article, Yapeng Su, PhD, a postdoctoral researcher at the Fred Hutchinson Cancer Research Center in Seattle, called the study “great work contributing to the long-COVID research field and revealing important connections” with psychological stress prior to infection.

Dr. Su, who was not involved with the study, was previously at the Institute for Systems Biology, also in Seattle, and has written about long COVID.

He noted that the “biological mechanism of such intriguing linkage is definitely the important next step, which will likely require deep phenotyping of biological specimens from these patients longitudinally.”

Dr. Wang pointed to past research suggesting that some patients with mental illness “sometimes develop autoantibodies that have also been associated with increased risk of long COVID.” In addition, depression “affects the brain in ways that may explain certain cognitive symptoms in long COVID,” she added.

More studies are now needed to understand how psychological distress increases the risk for long COVID, said Dr. Wang.

The research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, the Dean’s Fund for Scientific Advancement Acceleration Award from the Harvard T. H. Chan School of Public Health, the Massachusetts Consortium on Pathogen Readiness Evergrande COVID-19 Response Fund Award, and the Veterans Affairs Health Services Research and Development Service funds. Dr. Wang and Dr. Roberts have reported no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Su reports no relevant financial relationships.

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

Experiencing psychological distress prior to becoming infected with SARS-CoV-2 is tied to an increased risk for post-COVID conditions often called “long COVID,” new research suggests.

In an analysis of almost 55,000 adult participants in three ongoing studies, having depression, anxiety, worry, perceived stress, or loneliness early in the pandemic, before SARS-CoV-2 infection, was associated with a 50% increased risk for developing long COVID. These types of psychological distress were also associated with a 15% to 51% greater risk for impairment in daily life among individuals with long COVID.

Psychological distress was even more strongly associated with developing long COVID than were physical health risk factors, and the increased risk was not explained by health behaviors such as smoking or physical comorbidities, researchers note.

“Our findings suggest the need to consider psychological health in addition to physical health as risk factors of long COVID-19,” lead author Siwen Wang, MD, postdoctoral fellow, department of nutrition, Harvard T. H. Chan School of Public Health, Boston, said in an interview.

“We need to increase public awareness of the importance of mental health and focus on getting mental health care for people who need it, increasing the supply of mental health clinicians and improving access to care,” she said.

The findings were published online in JAMA Psychiatry.
 

‘Poorly understood’

Postacute sequelae of SARS-CoV-2 (“long COVID”), which are “signs and symptoms consistent with COVID-19 that extend beyond 4 weeks from onset of infection” constitute “an emerging health issue,” the investigators write.

Dr. Wang noted that it has been estimated that 8-23 million Americans have developed long COVID. However, “despite the high prevalence and daily life impairment associated with long COVID, it is still poorly understood, and few risk factors have been established,” she said.

Although psychological distress may be implicated in long COVID, only three previous studies investigated psychological factors as potential contributors, the researchers note. Also, no study has investigated the potential role of other common manifestations of distress that have increased during the pandemic, such as loneliness and perceived stress, they add.

To investigate these issues, the researchers turned to three large ongoing longitudinal studies: the Nurses’ Health Study II (NSHII), the Nurses’ Health study 3 (NHS3), and the Growing Up Today Study (GUTS).

They analyzed data on 54,960 total participants (96.6% women; mean age, 57.5 years). Of the full group, 38% were active health care workers.

Participants completed an online COVID-19 questionnaire from April 2020 to Sept. 1, 2020 (baseline), and monthly surveys thereafter. Beginning in August 2020, surveys were administered quarterly. The end of follow-up was in November 2021.

The COVID questionnaires included questions about positive SARS-CoV-2 test results, COVID symptoms and hospitalization since March 1, 2020, and the presence of long-term COVID symptoms, such as fatigue, respiratory problems, persistent cough, muscle/joint/chest pain, smell/taste problems, confusion/disorientation/brain fog, depression/anxiety/changes in mood, headache, and memory problems.

Participants who reported these post-COVID conditions were asked about the frequency of symptoms and the degree of impairment in daily life.
 

Inflammation, immune dysregulation implicated?

The Patient Health Questionnaire–4 (PHQ-4) was used to assess for anxiety and depressive symptoms in the past 2 weeks. It consists of a two-item depression measure (PHQ-2) and a two-item Generalized Anxiety Disorder Scale (GAD-2).

Non–health care providers completed two additional assessments of psychological distress: the four-item Perceived Stress Scale and the three-item UCLA Loneliness Scale.

The researchers included demographic factors, weight, smoking status, marital status, and medical conditions, including diabetes, hypertension, hypercholesterolemia, asthma, and cancer, and socioeconomic factors as covariates.

For each participant, the investigators calculated the number of types of distress experienced at a high level, including probable depression, probable anxiety, worry about COVID-19, being in the top quartile of perceived stress, and loneliness.

During the 19 months of follow-up (1-47 weeks after baseline), 6% of respondents reported a positive result on a SARS-CoV-2 antibody, antigen, or polymerase chain reaction test.

Of these, 43.9% reported long-COVID conditions, with most reporting that symptoms lasted 2 months or longer; 55.8% reported at least occasional daily life impairment.

The most common post-COVID conditions were fatigue (reported by 56%), loss of smell or taste problems (44.6%), shortness of breath (25.5%), confusion/disorientation/ brain fog (24.5%), and memory issues (21.8%).

Among patients who had been infected, there was a considerably higher rate of preinfection psychological distress after adjusting for sociodemographic factors, health behaviors, and comorbidities. Each type of distress was associated with post-COVID conditions.

In addition, participants who had experienced at least two types of distress prior to infection were at nearly 50% increased risk for post–COVID conditions (risk ratio, 1.49; 95% confidence interval, 1.23-1.80).

Among those with post-COVID conditions, all types of distress were associated with increased risk for daily life impairment (RR range, 1.15-1.51).

Senior author Andrea Roberts, PhD, senior research scientist at the Harvard T. H. Chan School of Public Health, Boston, noted that the investigators did not examine biological mechanisms potentially underlying the association they found.

However, “based on prior research, it may be that inflammation and immune dysregulation related to psychological distress play a role in the association of distress with long COVID, but we can’t be sure,” Dr. Roberts said.
 

Contributes to the field

Commenting for this article, Yapeng Su, PhD, a postdoctoral researcher at the Fred Hutchinson Cancer Research Center in Seattle, called the study “great work contributing to the long-COVID research field and revealing important connections” with psychological stress prior to infection.

Dr. Su, who was not involved with the study, was previously at the Institute for Systems Biology, also in Seattle, and has written about long COVID.

He noted that the “biological mechanism of such intriguing linkage is definitely the important next step, which will likely require deep phenotyping of biological specimens from these patients longitudinally.”

Dr. Wang pointed to past research suggesting that some patients with mental illness “sometimes develop autoantibodies that have also been associated with increased risk of long COVID.” In addition, depression “affects the brain in ways that may explain certain cognitive symptoms in long COVID,” she added.

More studies are now needed to understand how psychological distress increases the risk for long COVID, said Dr. Wang.

The research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health, the Dean’s Fund for Scientific Advancement Acceleration Award from the Harvard T. H. Chan School of Public Health, the Massachusetts Consortium on Pathogen Readiness Evergrande COVID-19 Response Fund Award, and the Veterans Affairs Health Services Research and Development Service funds. Dr. Wang and Dr. Roberts have reported no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Su reports no relevant financial relationships.

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

People with serious mental illness (SMI) are at substantial risk for premature mortality, dying on average 10 to 20 years earlier than others.¹ The reasons for this disparity are complex; however, the high prevalence of chronic disease and physical comorbidities in the SMI population have been identified as prominent factors.² Engagement and reengagement in care, including primary care for medical comorbidities, can mitigate these mortality risks.^2-4 Among veterans with SMI lost to follow-up care for more than 12 months, those not successfully reengaged in care were more likely to die compared with those reengaged in care.^2,3

Given this evidence, health care systems, including the US Department of Veterans Affairs (VA), have looked to better engage these patients in care. These efforts have included mental health population health management, colocation of mental health with primary care, designation of primary care teams specializing in SMI, and integration of mental health and primary care services for patients experiencing homelessness.^5-8

As part of a national approach to encourage locally driven quality improvement (QI), the VA compiles performance metrics for each facility, across a gamut of care settings, conditions, and veteran populations.⁹ Quarterly facility report cards, with longitudinal data and cross-facility comparisons, enable facilities to identify targets for QI and track improvement progress. One metric reports on the proportion of enrolled veterans with SMI who have primary care engagement, defined as having an assigned primary care practitioner (PCP) and a primary care visit in the prior 12 months.

In support of a QI initiative at the VA Greater Los Angeles Healthcare System (VAGLAHS), we sought to describe promising practices being utilized by VA facilities with higher levels of primary care engagement among their veterans with SMI populations.

Methods

We conducted semistructured telephone interviews with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All project components were conducted by an interdisciplinary team, which included a medical anthropologist (JM), a mental health physician (PR), an internal medicine physician (KC), and other health services researchers (JB, AG). Because the primary objective of the project was QI, this project was designated as nonresearch by the VAGLAHS Institutional Review Board.

The VA Facility Complexity Model classifies facilities into 5 tiers: 1a (most complex), 1b, 1c, 2, and 3 (least complex), based on patient care volume, patient risk, complexity of clinical programs, and size of research and teaching programs. We sampled informants at VA facilities with complexity ratings of 1a or 1b with better than median scores for primary care engagement of veterans with SMI based on report cards from January 2019 to March 2019. To increase the likelihood of identifying lessons that can generalize to the VAGLAHS with its large population of veterans experiencing homelessness, we selected facilities serving populations consisting of more than 1000 veterans experiencing homelessness.

At each selected facility, we first aimed to interview mental health leaders responsible for quality measurement and improvement identified from a national VA database. We then used snowball sampling to identify other informants at these VA facilities who were knowledgeable about relevant processes. Potential interviewees were contacted via email.

Interviews

The interview guide was developed by the interdisciplinary team and based on published literature about strategies for engaging patients with SMI in care. Interview guide questions focused on local practice arrangements, panel management, population health practices, and quality measurement and improvement efforts for engaging veterans with SMI in primary care (Appendix). Interviews were conducted by telephone, from May 2019 through July 2019, by experienced qualitative interviewers (JM, JB). Interviewees were assured confidentiality of their responses.

Interview audio recordings were used to generate detailed notes (AG). Structured summaries were prepared from these notes, using a template based on the interview guide. We organized these summaries into matrices for analysis, grouping summarized points by interview domains to facilitate comparison across interviews.^10-11 Our team reviewed and discussed the matrices, and iteratively identified and defined themes to identify the common engagement approaches and the nature of the connections between mental health and primary care. To ensure rigor, findings were checked by the senior qualitative lead (JM).

Results

The median SMI engagement score—defined as the proportion of veterans with SMI who have had a primary care visit in the prior 12 months and who have an assigned PCP—was 75.6% across 1a and 1b VA facilities. We identified 16 VA facilities that had a median or higher score and more than 1000 enrolled veterans experiencing homelessness. From these16 facilities, we emailed 31 potential interviewees, 14 of whom were identified from a VA database and 17 referred by other interviewees. In total, we interviewed 18 key informants across 11 (69%) facilities, including chiefs of psychology and mental health services, PCPs with mental health expertise, QI specialists, a psychosocial rehabilitation leader, and a local recovery coordinator, who helps veterans with SMI access recovery-oriented services. Characteristics of the facilities and interviewees are shown in Table 1. Interviews lasted a mean 35 (range, 26-50) minutes.

Engagement Approaches

The strategies used to engage veterans with SMI were heterogenous, with no single strategy common across all facilities. However, we identified 2 categories of engagement approaches: targeted outreach and routine practices.

Targeted outreach strategies included deliberate, systematic approaches to reach veterans with SMI outside of regularly scheduled visits. These strategies were designed to be proactive, often prioritizing veterans at risk of disengaging from care. Designated VA care team members identified and reached out to veterans well before 12 months had passed since their prior visit (the VA definition of disengagement from care); visits included any care at VA, including, but not exclusively, primary care. Table 2 describes the key components of targeted outreach strategies: (1) identifying veterans’ last visit; (2) prioritizing which veterans to outreach to; and (3) assigning responsibility and reaching out. A key defining feature of targeted outreach is that veterans were identified and prioritized for outreach independent from any visits with mental health or other VA services.

At some facilities, mental health support staff were able to directly schedule primary care appointments, which was identified as an important enabling factor in promoting mental health patient engagement in primary care. Some interviewees seemed to take for granted the idea that mental health practitioners would help engage patients in primary care—suggesting that these practices had perhaps become a cultural norm within their facility. However, some interviewees identified clear strategies for making these practices a consistent part of care—for example, by designing a protocol for initial mental health assessments to include a routine check for primary care engagement.

Mental Health/Primary Care Connections

Interviewees characterized the nature of the connections between mental health and primary care at their facilities. Nearly all interviewees described that their medical centers had extensive ties, formal and informal, between mental health and primary care.

Formal ties may include the reverse integration care model, in which primary care services are embedded in mental health settings. Interviewees at sites with programs based on this model noted that these programs enabled warm hand-offs from mental health to primary care and suggested that it can foster integration between primary care and mental health care for patients with SMI. However, the size, scope, and structure of these programs varied, sometimes serving a small proportion of a facility’s population of SMI patients. Other examples of formal ties included written agreements, establishing frequent, regular meetings between mental health and primary care leadership and front-line staff, and giving mental health clerks the ability to directly schedule primary care appointments.

Discussion

VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. In both approaches, intentional organizational structural and process decisions, as well as formal and informal ties between mental health and primary care, established and supported them. In addition, organizational cultural factors were especially relevant to routine practice strategies.

To enable targeted outreach, a bevy of organizational resources, both local and national were required. Large accountable care organizations and integrated delivery systems, like the VA, are often better able to create dashboards and other informational resources for population health management compared with smaller, less integrated health care systems. Though these resources are difficult to create in fragmented systems, comparable tools have been explored by multiple state health departments.¹² Our findings suggest that these data tools, though resource intensive to develop, may enable facilities to be more methodical and reliable in conducting outreach to vulnerable patients.

In contrast to targeted outreach, routine practices depend less on population health management resources and more on cultural norms. Such norms are notoriously difficult to change, but intentional structural decisions like embedding primary care engagement in mental health protocols may signal that primary care engagement is an important and legitimate consideration for mental health care.¹³

We identified extensive and heterogenous connections between mental health and primary care in our sample of VA facilities with high engagement of patients with SMI in primary care. A growing body of literature on relational coordination studies the factors that contribute to organizational siloing and mechanisms for breaking down those silos so work can be coordinated across boundaries (eg, the organizational boundary between mental health and primary care).¹⁴ Coordinating care across these boundaries, through good relational coordination practices has been shown to improve outcomes in health care and other sectors. Notably, VA facilities in our sample had several of the defining characteristics of good relational coordination: relationships between mental health and primary care that include shared goals, shared knowledge, and mutual respect, all reinforced by frequent communication structured around problem solving.¹⁵ The relational coordination literature also offers a way to identify evidence-based interventions for facilitating relational coordination in places where it is lacking, for example, with information systems, boundary-spanning individuals, facility design, and formal conflict resolution.¹⁵ Future work might explore how relational coordination can be further used to optimize mental health and primary care connections to keep veterans with SMI engaged in care.

Our approach of interviewing informants in higher-performing facilities draws heavily on the idea of positive deviance, which holds that information on what works in health care is available from organizations that already are demonstrating “consistently exceptional performance.”¹⁶ This approach works best when high performance and organizational characteristics are observable for a large number of facilities, and when high-performing facilities are willing to share their strategies. These features allow investigators to identify promising practices and hypotheses that can then be empirically tested and compared. Such testing, including assessing for unintended consequences, is needed for the approaches we identified. Research is also needed to assess for factors that would promote the implementation of effective strategies.

Limitations

As a QI project seeking to identify promising practices, our interviews were limited to 18 key informants across 11 VA facilities with high engagement of care among veterans with SMI. No inferences can be made that these practices are directly related to this high level of engagement, nor the differential impact of different practices. Future work is needed to assess for these relationships. We also did not interview veterans to understand their perspectives on these strategies, which is an additional important topic for future work. In addition, these interviews were performed before the start of the COVID-19 pandemic. Further work is needed to understand how these strategies may have been modified in response to changes in practice. The shift to care from in-person to virtual services may have impacted both clinical interactions with veterans, as well as between clinicians.

Conclusions

Interviews with key informants demonstrate that while engaging and retaining veterans with SMI in primary care is vital, it also requires intentional and potentially resource-intensive practices, including targeted outreach and routine engagement strategies embedded into mental health visits. These promising practices can provide valuable insights for both VA and community health care systems providing care to patients with SMI.

Acknowledgments

We thank Gracielle J. Tan, MD for administrative assistance in preparing this manuscript.

People with serious mental illness (SMI) are at substantial risk for premature mortality, dying on average 10 to 20 years earlier than others.¹ The reasons for this disparity are complex; however, the high prevalence of chronic disease and physical comorbidities in the SMI population have been identified as prominent factors.² Engagement and reengagement in care, including primary care for medical comorbidities, can mitigate these mortality risks.^2-4 Among veterans with SMI lost to follow-up care for more than 12 months, those not successfully reengaged in care were more likely to die compared with those reengaged in care.^2,3

Given this evidence, health care systems, including the US Department of Veterans Affairs (VA), have looked to better engage these patients in care. These efforts have included mental health population health management, colocation of mental health with primary care, designation of primary care teams specializing in SMI, and integration of mental health and primary care services for patients experiencing homelessness.^5-8

As part of a national approach to encourage locally driven quality improvement (QI), the VA compiles performance metrics for each facility, across a gamut of care settings, conditions, and veteran populations.⁹ Quarterly facility report cards, with longitudinal data and cross-facility comparisons, enable facilities to identify targets for QI and track improvement progress. One metric reports on the proportion of enrolled veterans with SMI who have primary care engagement, defined as having an assigned primary care practitioner (PCP) and a primary care visit in the prior 12 months.

In support of a QI initiative at the VA Greater Los Angeles Healthcare System (VAGLAHS), we sought to describe promising practices being utilized by VA facilities with higher levels of primary care engagement among their veterans with SMI populations.

Methods

We conducted semistructured telephone interviews with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All project components were conducted by an interdisciplinary team, which included a medical anthropologist (JM), a mental health physician (PR), an internal medicine physician (KC), and other health services researchers (JB, AG). Because the primary objective of the project was QI, this project was designated as nonresearch by the VAGLAHS Institutional Review Board.

The VA Facility Complexity Model classifies facilities into 5 tiers: 1a (most complex), 1b, 1c, 2, and 3 (least complex), based on patient care volume, patient risk, complexity of clinical programs, and size of research and teaching programs. We sampled informants at VA facilities with complexity ratings of 1a or 1b with better than median scores for primary care engagement of veterans with SMI based on report cards from January 2019 to March 2019. To increase the likelihood of identifying lessons that can generalize to the VAGLAHS with its large population of veterans experiencing homelessness, we selected facilities serving populations consisting of more than 1000 veterans experiencing homelessness.

At each selected facility, we first aimed to interview mental health leaders responsible for quality measurement and improvement identified from a national VA database. We then used snowball sampling to identify other informants at these VA facilities who were knowledgeable about relevant processes. Potential interviewees were contacted via email.

Interviews

The interview guide was developed by the interdisciplinary team and based on published literature about strategies for engaging patients with SMI in care. Interview guide questions focused on local practice arrangements, panel management, population health practices, and quality measurement and improvement efforts for engaging veterans with SMI in primary care (Appendix). Interviews were conducted by telephone, from May 2019 through July 2019, by experienced qualitative interviewers (JM, JB). Interviewees were assured confidentiality of their responses.

Interview audio recordings were used to generate detailed notes (AG). Structured summaries were prepared from these notes, using a template based on the interview guide. We organized these summaries into matrices for analysis, grouping summarized points by interview domains to facilitate comparison across interviews.^10-11 Our team reviewed and discussed the matrices, and iteratively identified and defined themes to identify the common engagement approaches and the nature of the connections between mental health and primary care. To ensure rigor, findings were checked by the senior qualitative lead (JM).

Results

The median SMI engagement score—defined as the proportion of veterans with SMI who have had a primary care visit in the prior 12 months and who have an assigned PCP—was 75.6% across 1a and 1b VA facilities. We identified 16 VA facilities that had a median or higher score and more than 1000 enrolled veterans experiencing homelessness. From these16 facilities, we emailed 31 potential interviewees, 14 of whom were identified from a VA database and 17 referred by other interviewees. In total, we interviewed 18 key informants across 11 (69%) facilities, including chiefs of psychology and mental health services, PCPs with mental health expertise, QI specialists, a psychosocial rehabilitation leader, and a local recovery coordinator, who helps veterans with SMI access recovery-oriented services. Characteristics of the facilities and interviewees are shown in Table 1. Interviews lasted a mean 35 (range, 26-50) minutes.

Engagement Approaches

The strategies used to engage veterans with SMI were heterogenous, with no single strategy common across all facilities. However, we identified 2 categories of engagement approaches: targeted outreach and routine practices.

Targeted outreach strategies included deliberate, systematic approaches to reach veterans with SMI outside of regularly scheduled visits. These strategies were designed to be proactive, often prioritizing veterans at risk of disengaging from care. Designated VA care team members identified and reached out to veterans well before 12 months had passed since their prior visit (the VA definition of disengagement from care); visits included any care at VA, including, but not exclusively, primary care. Table 2 describes the key components of targeted outreach strategies: (1) identifying veterans’ last visit; (2) prioritizing which veterans to outreach to; and (3) assigning responsibility and reaching out. A key defining feature of targeted outreach is that veterans were identified and prioritized for outreach independent from any visits with mental health or other VA services.

At some facilities, mental health support staff were able to directly schedule primary care appointments, which was identified as an important enabling factor in promoting mental health patient engagement in primary care. Some interviewees seemed to take for granted the idea that mental health practitioners would help engage patients in primary care—suggesting that these practices had perhaps become a cultural norm within their facility. However, some interviewees identified clear strategies for making these practices a consistent part of care—for example, by designing a protocol for initial mental health assessments to include a routine check for primary care engagement.

Mental Health/Primary Care Connections

Interviewees characterized the nature of the connections between mental health and primary care at their facilities. Nearly all interviewees described that their medical centers had extensive ties, formal and informal, between mental health and primary care.

Formal ties may include the reverse integration care model, in which primary care services are embedded in mental health settings. Interviewees at sites with programs based on this model noted that these programs enabled warm hand-offs from mental health to primary care and suggested that it can foster integration between primary care and mental health care for patients with SMI. However, the size, scope, and structure of these programs varied, sometimes serving a small proportion of a facility’s population of SMI patients. Other examples of formal ties included written agreements, establishing frequent, regular meetings between mental health and primary care leadership and front-line staff, and giving mental health clerks the ability to directly schedule primary care appointments.

Discussion

VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. In both approaches, intentional organizational structural and process decisions, as well as formal and informal ties between mental health and primary care, established and supported them. In addition, organizational cultural factors were especially relevant to routine practice strategies.

To enable targeted outreach, a bevy of organizational resources, both local and national were required. Large accountable care organizations and integrated delivery systems, like the VA, are often better able to create dashboards and other informational resources for population health management compared with smaller, less integrated health care systems. Though these resources are difficult to create in fragmented systems, comparable tools have been explored by multiple state health departments.¹² Our findings suggest that these data tools, though resource intensive to develop, may enable facilities to be more methodical and reliable in conducting outreach to vulnerable patients.

In contrast to targeted outreach, routine practices depend less on population health management resources and more on cultural norms. Such norms are notoriously difficult to change, but intentional structural decisions like embedding primary care engagement in mental health protocols may signal that primary care engagement is an important and legitimate consideration for mental health care.¹³

We identified extensive and heterogenous connections between mental health and primary care in our sample of VA facilities with high engagement of patients with SMI in primary care. A growing body of literature on relational coordination studies the factors that contribute to organizational siloing and mechanisms for breaking down those silos so work can be coordinated across boundaries (eg, the organizational boundary between mental health and primary care).¹⁴ Coordinating care across these boundaries, through good relational coordination practices has been shown to improve outcomes in health care and other sectors. Notably, VA facilities in our sample had several of the defining characteristics of good relational coordination: relationships between mental health and primary care that include shared goals, shared knowledge, and mutual respect, all reinforced by frequent communication structured around problem solving.¹⁵ The relational coordination literature also offers a way to identify evidence-based interventions for facilitating relational coordination in places where it is lacking, for example, with information systems, boundary-spanning individuals, facility design, and formal conflict resolution.¹⁵ Future work might explore how relational coordination can be further used to optimize mental health and primary care connections to keep veterans with SMI engaged in care.

Our approach of interviewing informants in higher-performing facilities draws heavily on the idea of positive deviance, which holds that information on what works in health care is available from organizations that already are demonstrating “consistently exceptional performance.”¹⁶ This approach works best when high performance and organizational characteristics are observable for a large number of facilities, and when high-performing facilities are willing to share their strategies. These features allow investigators to identify promising practices and hypotheses that can then be empirically tested and compared. Such testing, including assessing for unintended consequences, is needed for the approaches we identified. Research is also needed to assess for factors that would promote the implementation of effective strategies.

Limitations

As a QI project seeking to identify promising practices, our interviews were limited to 18 key informants across 11 VA facilities with high engagement of care among veterans with SMI. No inferences can be made that these practices are directly related to this high level of engagement, nor the differential impact of different practices. Future work is needed to assess for these relationships. We also did not interview veterans to understand their perspectives on these strategies, which is an additional important topic for future work. In addition, these interviews were performed before the start of the COVID-19 pandemic. Further work is needed to understand how these strategies may have been modified in response to changes in practice. The shift to care from in-person to virtual services may have impacted both clinical interactions with veterans, as well as between clinicians.

Conclusions

Interviews with key informants demonstrate that while engaging and retaining veterans with SMI in primary care is vital, it also requires intentional and potentially resource-intensive practices, including targeted outreach and routine engagement strategies embedded into mental health visits. These promising practices can provide valuable insights for both VA and community health care systems providing care to patients with SMI.

Acknowledgments

We thank Gracielle J. Tan, MD for administrative assistance in preparing this manuscript.

People with serious mental illness (SMI) are at substantial risk for premature mortality, dying on average 10 to 20 years earlier than others.¹ The reasons for this disparity are complex; however, the high prevalence of chronic disease and physical comorbidities in the SMI population have been identified as prominent factors.² Engagement and reengagement in care, including primary care for medical comorbidities, can mitigate these mortality risks.^2-4 Among veterans with SMI lost to follow-up care for more than 12 months, those not successfully reengaged in care were more likely to die compared with those reengaged in care.^2,3

Given this evidence, health care systems, including the US Department of Veterans Affairs (VA), have looked to better engage these patients in care. These efforts have included mental health population health management, colocation of mental health with primary care, designation of primary care teams specializing in SMI, and integration of mental health and primary care services for patients experiencing homelessness.^5-8

As part of a national approach to encourage locally driven quality improvement (QI), the VA compiles performance metrics for each facility, across a gamut of care settings, conditions, and veteran populations.⁹ Quarterly facility report cards, with longitudinal data and cross-facility comparisons, enable facilities to identify targets for QI and track improvement progress. One metric reports on the proportion of enrolled veterans with SMI who have primary care engagement, defined as having an assigned primary care practitioner (PCP) and a primary care visit in the prior 12 months.

In support of a QI initiative at the VA Greater Los Angeles Healthcare System (VAGLAHS), we sought to describe promising practices being utilized by VA facilities with higher levels of primary care engagement among their veterans with SMI populations.

Methods

We conducted semistructured telephone interviews with a purposeful sample of key informants at VA facilities with high levels of engagement in primary care among veterans with SMI. All project components were conducted by an interdisciplinary team, which included a medical anthropologist (JM), a mental health physician (PR), an internal medicine physician (KC), and other health services researchers (JB, AG). Because the primary objective of the project was QI, this project was designated as nonresearch by the VAGLAHS Institutional Review Board.

The VA Facility Complexity Model classifies facilities into 5 tiers: 1a (most complex), 1b, 1c, 2, and 3 (least complex), based on patient care volume, patient risk, complexity of clinical programs, and size of research and teaching programs. We sampled informants at VA facilities with complexity ratings of 1a or 1b with better than median scores for primary care engagement of veterans with SMI based on report cards from January 2019 to March 2019. To increase the likelihood of identifying lessons that can generalize to the VAGLAHS with its large population of veterans experiencing homelessness, we selected facilities serving populations consisting of more than 1000 veterans experiencing homelessness.

At each selected facility, we first aimed to interview mental health leaders responsible for quality measurement and improvement identified from a national VA database. We then used snowball sampling to identify other informants at these VA facilities who were knowledgeable about relevant processes. Potential interviewees were contacted via email.

Interviews

The interview guide was developed by the interdisciplinary team and based on published literature about strategies for engaging patients with SMI in care. Interview guide questions focused on local practice arrangements, panel management, population health practices, and quality measurement and improvement efforts for engaging veterans with SMI in primary care (Appendix). Interviews were conducted by telephone, from May 2019 through July 2019, by experienced qualitative interviewers (JM, JB). Interviewees were assured confidentiality of their responses.

Interview audio recordings were used to generate detailed notes (AG). Structured summaries were prepared from these notes, using a template based on the interview guide. We organized these summaries into matrices for analysis, grouping summarized points by interview domains to facilitate comparison across interviews.^10-11 Our team reviewed and discussed the matrices, and iteratively identified and defined themes to identify the common engagement approaches and the nature of the connections between mental health and primary care. To ensure rigor, findings were checked by the senior qualitative lead (JM).

Results

The median SMI engagement score—defined as the proportion of veterans with SMI who have had a primary care visit in the prior 12 months and who have an assigned PCP—was 75.6% across 1a and 1b VA facilities. We identified 16 VA facilities that had a median or higher score and more than 1000 enrolled veterans experiencing homelessness. From these16 facilities, we emailed 31 potential interviewees, 14 of whom were identified from a VA database and 17 referred by other interviewees. In total, we interviewed 18 key informants across 11 (69%) facilities, including chiefs of psychology and mental health services, PCPs with mental health expertise, QI specialists, a psychosocial rehabilitation leader, and a local recovery coordinator, who helps veterans with SMI access recovery-oriented services. Characteristics of the facilities and interviewees are shown in Table 1. Interviews lasted a mean 35 (range, 26-50) minutes.

Engagement Approaches

The strategies used to engage veterans with SMI were heterogenous, with no single strategy common across all facilities. However, we identified 2 categories of engagement approaches: targeted outreach and routine practices.

Targeted outreach strategies included deliberate, systematic approaches to reach veterans with SMI outside of regularly scheduled visits. These strategies were designed to be proactive, often prioritizing veterans at risk of disengaging from care. Designated VA care team members identified and reached out to veterans well before 12 months had passed since their prior visit (the VA definition of disengagement from care); visits included any care at VA, including, but not exclusively, primary care. Table 2 describes the key components of targeted outreach strategies: (1) identifying veterans’ last visit; (2) prioritizing which veterans to outreach to; and (3) assigning responsibility and reaching out. A key defining feature of targeted outreach is that veterans were identified and prioritized for outreach independent from any visits with mental health or other VA services.

At some facilities, mental health support staff were able to directly schedule primary care appointments, which was identified as an important enabling factor in promoting mental health patient engagement in primary care. Some interviewees seemed to take for granted the idea that mental health practitioners would help engage patients in primary care—suggesting that these practices had perhaps become a cultural norm within their facility. However, some interviewees identified clear strategies for making these practices a consistent part of care—for example, by designing a protocol for initial mental health assessments to include a routine check for primary care engagement.

Mental Health/Primary Care Connections

Interviewees characterized the nature of the connections between mental health and primary care at their facilities. Nearly all interviewees described that their medical centers had extensive ties, formal and informal, between mental health and primary care.

Formal ties may include the reverse integration care model, in which primary care services are embedded in mental health settings. Interviewees at sites with programs based on this model noted that these programs enabled warm hand-offs from mental health to primary care and suggested that it can foster integration between primary care and mental health care for patients with SMI. However, the size, scope, and structure of these programs varied, sometimes serving a small proportion of a facility’s population of SMI patients. Other examples of formal ties included written agreements, establishing frequent, regular meetings between mental health and primary care leadership and front-line staff, and giving mental health clerks the ability to directly schedule primary care appointments.

Discussion

VA facilities with high levels of primary care engagement among veterans with SMI used extensive engagement strategies, including a diverse array of targeted outreach and routine practices. In both approaches, intentional organizational structural and process decisions, as well as formal and informal ties between mental health and primary care, established and supported them. In addition, organizational cultural factors were especially relevant to routine practice strategies.

To enable targeted outreach, a bevy of organizational resources, both local and national were required. Large accountable care organizations and integrated delivery systems, like the VA, are often better able to create dashboards and other informational resources for population health management compared with smaller, less integrated health care systems. Though these resources are difficult to create in fragmented systems, comparable tools have been explored by multiple state health departments.¹² Our findings suggest that these data tools, though resource intensive to develop, may enable facilities to be more methodical and reliable in conducting outreach to vulnerable patients.

In contrast to targeted outreach, routine practices depend less on population health management resources and more on cultural norms. Such norms are notoriously difficult to change, but intentional structural decisions like embedding primary care engagement in mental health protocols may signal that primary care engagement is an important and legitimate consideration for mental health care.¹³

We identified extensive and heterogenous connections between mental health and primary care in our sample of VA facilities with high engagement of patients with SMI in primary care. A growing body of literature on relational coordination studies the factors that contribute to organizational siloing and mechanisms for breaking down those silos so work can be coordinated across boundaries (eg, the organizational boundary between mental health and primary care).¹⁴ Coordinating care across these boundaries, through good relational coordination practices has been shown to improve outcomes in health care and other sectors. Notably, VA facilities in our sample had several of the defining characteristics of good relational coordination: relationships between mental health and primary care that include shared goals, shared knowledge, and mutual respect, all reinforced by frequent communication structured around problem solving.¹⁵ The relational coordination literature also offers a way to identify evidence-based interventions for facilitating relational coordination in places where it is lacking, for example, with information systems, boundary-spanning individuals, facility design, and formal conflict resolution.¹⁵ Future work might explore how relational coordination can be further used to optimize mental health and primary care connections to keep veterans with SMI engaged in care.

Our approach of interviewing informants in higher-performing facilities draws heavily on the idea of positive deviance, which holds that information on what works in health care is available from organizations that already are demonstrating “consistently exceptional performance.”¹⁶ This approach works best when high performance and organizational characteristics are observable for a large number of facilities, and when high-performing facilities are willing to share their strategies. These features allow investigators to identify promising practices and hypotheses that can then be empirically tested and compared. Such testing, including assessing for unintended consequences, is needed for the approaches we identified. Research is also needed to assess for factors that would promote the implementation of effective strategies.

Limitations

As a QI project seeking to identify promising practices, our interviews were limited to 18 key informants across 11 VA facilities with high engagement of care among veterans with SMI. No inferences can be made that these practices are directly related to this high level of engagement, nor the differential impact of different practices. Future work is needed to assess for these relationships. We also did not interview veterans to understand their perspectives on these strategies, which is an additional important topic for future work. In addition, these interviews were performed before the start of the COVID-19 pandemic. Further work is needed to understand how these strategies may have been modified in response to changes in practice. The shift to care from in-person to virtual services may have impacted both clinical interactions with veterans, as well as between clinicians.

Conclusions

Interviews with key informants demonstrate that while engaging and retaining veterans with SMI in primary care is vital, it also requires intentional and potentially resource-intensive practices, including targeted outreach and routine engagement strategies embedded into mental health visits. These promising practices can provide valuable insights for both VA and community health care systems providing care to patients with SMI.

Acknowledgments

We thank Gracielle J. Tan, MD for administrative assistance in preparing this manuscript.

There’s strong evidence that training parents to guide the development of children with autism reaps consistent benefits, according to a systematic review and meta-analysis of more than 50 high-quality studies.

“Referrals for parent training should now be considered the expected standard for medical practice,” said a member of the research team, Timothy B. Smith, PhD, a professor of psychology at Brigham Young University, Provo, Utah.

Methods and results

The meta-analysis included 54 papers based on randomized clinical trials involving 2,895 children, which compared the effects of various parent interventions with professional treatment, treatment as usual, or being on a wait-list to receive an intervention.

Overall the research team reported “moderately strong” average benefits from the parent-mediated interventions (Hedges’ g, 0.553), indicating a medium effect size. Parent interventions had the greatest effect on outcomes involving positive behavior and social skills (0.603), followed by language and communication (0.545), maladaptive behavior (0.519), and life skills (0.239).

Similar benefits were observed regardless of a child’s age or sex or which parent or parents implemented an intervention. The effects also appeared to be consistent regardless of intervention characteristics, such as the number of training sessions parents received, although the researchers noted that many studies did not provide data on such details.

Paul Carbone, MD, a professor of pediatrics at the University of Utah, Salt Lake City, who was not involved in the review, said it demonstrates that such parental engagement is “vitally important” and pediatricians “should not hesitate to refer interested families.”

Overcoming limitations, future research needs

The research team attempted to overcome limitations with previous reviews by using comprehensive search terms and other methods to identify relevant studies, including some that had not been published. They included only studies that reflect common practice of training multiple parents simultaneously, they wrote.

Dr. Smith noted that long-term outcomes data and further study to compare effects on children with mild, moderate, and severe autism are needed.

Although logic would suggest greater benefits for children with severe disease, there are no data to demonstrate that, he said.

The authors of the study and Dr. Carbone reported no relevant competing interests.

There’s strong evidence that training parents to guide the development of children with autism reaps consistent benefits, according to a systematic review and meta-analysis of more than 50 high-quality studies.

“Referrals for parent training should now be considered the expected standard for medical practice,” said a member of the research team, Timothy B. Smith, PhD, a professor of psychology at Brigham Young University, Provo, Utah.

Methods and results

The meta-analysis included 54 papers based on randomized clinical trials involving 2,895 children, which compared the effects of various parent interventions with professional treatment, treatment as usual, or being on a wait-list to receive an intervention.

Overall the research team reported “moderately strong” average benefits from the parent-mediated interventions (Hedges’ g, 0.553), indicating a medium effect size. Parent interventions had the greatest effect on outcomes involving positive behavior and social skills (0.603), followed by language and communication (0.545), maladaptive behavior (0.519), and life skills (0.239).

Similar benefits were observed regardless of a child’s age or sex or which parent or parents implemented an intervention. The effects also appeared to be consistent regardless of intervention characteristics, such as the number of training sessions parents received, although the researchers noted that many studies did not provide data on such details.

Paul Carbone, MD, a professor of pediatrics at the University of Utah, Salt Lake City, who was not involved in the review, said it demonstrates that such parental engagement is “vitally important” and pediatricians “should not hesitate to refer interested families.”

Overcoming limitations, future research needs

The research team attempted to overcome limitations with previous reviews by using comprehensive search terms and other methods to identify relevant studies, including some that had not been published. They included only studies that reflect common practice of training multiple parents simultaneously, they wrote.

Dr. Smith noted that long-term outcomes data and further study to compare effects on children with mild, moderate, and severe autism are needed.

Although logic would suggest greater benefits for children with severe disease, there are no data to demonstrate that, he said.

The authors of the study and Dr. Carbone reported no relevant competing interests.

There’s strong evidence that training parents to guide the development of children with autism reaps consistent benefits, according to a systematic review and meta-analysis of more than 50 high-quality studies.

“Referrals for parent training should now be considered the expected standard for medical practice,” said a member of the research team, Timothy B. Smith, PhD, a professor of psychology at Brigham Young University, Provo, Utah.

Methods and results

The meta-analysis included 54 papers based on randomized clinical trials involving 2,895 children, which compared the effects of various parent interventions with professional treatment, treatment as usual, or being on a wait-list to receive an intervention.

Overall the research team reported “moderately strong” average benefits from the parent-mediated interventions (Hedges’ g, 0.553), indicating a medium effect size. Parent interventions had the greatest effect on outcomes involving positive behavior and social skills (0.603), followed by language and communication (0.545), maladaptive behavior (0.519), and life skills (0.239).

Similar benefits were observed regardless of a child’s age or sex or which parent or parents implemented an intervention. The effects also appeared to be consistent regardless of intervention characteristics, such as the number of training sessions parents received, although the researchers noted that many studies did not provide data on such details.

Paul Carbone, MD, a professor of pediatrics at the University of Utah, Salt Lake City, who was not involved in the review, said it demonstrates that such parental engagement is “vitally important” and pediatricians “should not hesitate to refer interested families.”

Overcoming limitations, future research needs

The research team attempted to overcome limitations with previous reviews by using comprehensive search terms and other methods to identify relevant studies, including some that had not been published. They included only studies that reflect common practice of training multiple parents simultaneously, they wrote.

Dr. Smith noted that long-term outcomes data and further study to compare effects on children with mild, moderate, and severe autism are needed.

Although logic would suggest greater benefits for children with severe disease, there are no data to demonstrate that, he said.

The authors of the study and Dr. Carbone reported no relevant competing interests.