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Federal Health Care Data Trends 2022
Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations.
In this issue:
- Vaccinations
- Mental Health and Related Disorders
- LGBTQ+ Veterans
- Military Sexual Trauma
- Sleep Disorders
- Respiratory Illnesses
- HIV Care in the VA
- Rheumatologic Diseases
- The Cancer-Obesity Connection
- Skin Health for Active-Duty Personnel
- Contraception
- Chronic Kidney Disease
- Cardiovascular Diseases
- Neurologic Disorders
- Hearing, Vision, and Balance
Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue:
Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN
Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations.
In this issue:
- Vaccinations
- Mental Health and Related Disorders
- LGBTQ+ Veterans
- Military Sexual Trauma
- Sleep Disorders
- Respiratory Illnesses
- HIV Care in the VA
- Rheumatologic Diseases
- The Cancer-Obesity Connection
- Skin Health for Active-Duty Personnel
- Contraception
- Chronic Kidney Disease
- Cardiovascular Diseases
- Neurologic Disorders
- Hearing, Vision, and Balance
Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue:
Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN
Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations.
In this issue:
- Vaccinations
- Mental Health and Related Disorders
- LGBTQ+ Veterans
- Military Sexual Trauma
- Sleep Disorders
- Respiratory Illnesses
- HIV Care in the VA
- Rheumatologic Diseases
- The Cancer-Obesity Connection
- Skin Health for Active-Duty Personnel
- Contraception
- Chronic Kidney Disease
- Cardiovascular Diseases
- Neurologic Disorders
- Hearing, Vision, and Balance
Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue:
Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN
‘Shocking’ and persistent gap in treatment for opioid addiction
The vast majority of Americans with opioid use disorder (OUD) do not receive potentially lifesaving medications.
Drugs such as methadone, buprenorphine, and extended-release naltrexone have been shown to reduce opioid overdoses by more than 50%. Yet a new analysis shows that only about 1 in 10 people living with OUD receive these medications.
“Even though it’s not especially surprising, it’s still disturbing and shocking in a way that we have just made such little progress on this huge issue,” study investigator Noa Krawczyk, PhD, with the Center for Opioid Epidemiology and Policy, department of population health, NYU Langone, told this news organization.
The study was published online in the International Journal of Drug Policy.
Increased urgency
Despite efforts to increase capacity for OUD treatment in the United States, how receipt of treatment compares to need for treatment remains unclear.
Dr. Krawczyk and colleagues examined the gap between new estimates of OUD prevalence and treatment at the national and state levels from 2010 through 2019.
“,” the investigators write.
Adjusted estimates suggest that past-year OUD affected roughly 7.63 million individuals in the United States (2,773 per 100,000), yet only about 1.02 million received medication (365 per 100,000), they note.
Overall, there was a 106% increase in receipt of medications for OUD across the United States from 2010 to 2019 and a 5% increase from 2018 to 2019.
Yet, as of 2019, 87% of people with OUD were not receiving medication.
“While the number of people getting treatment doubled over the last decade, it’s nowhere near the amount of people who are still struggling with an opioid use disorder, and the urgency of the problem has become much worse because of the worsening fentanyl crisis and the lethality of the drug supply,” said Dr. Krawczyk.
The study also showed wide variation in past-year OUD prevalence and treatment across the United States.
Past-year OUD rates were highest in Washington, D.C., and lowest in Minnesota. Receipt of treatment was lowest in South Dakota and highest in Vermont.
However, in all 50 states and Washington, D.C., past-year OUD prevalence was greater than rates of medication use. As of 2019, the largest treatment gaps were in Iowa, North Dakota, and Washington, D.C. The smallest treatment gaps were in Connecticut, Maryland, and Rhode Island.
Long road ahead
“Even in states with the smallest treatment gaps, at least 50% of people who could benefit from medications for opioid use disorder are still not receiving them,” senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the department of population health at NYU Langone Health, said in a statement.
“We have a long way to go in reducing stigma surrounding treatment and in devising the types of policies and programs we need to ensure these medications reach the people who need them the most,” Dr. Cerdá added.
Access to OUD treatment is an ongoing problem in the United States.
“A lot of areas don’t have specialty treatment programs that provide methadone, or they might not have addiction-trained providers who are willing to prescribe buprenorphine or have a waiver to prescribe buprenorphine, so a lot places are really struggling with where people can get treatment,” said Dr. Krawczyk.
Recent data show that 46% of counties lack an OUD medication provider, and 32% have no specialty programs to treat substance use disorders.
Dr. Krawczyk and colleagues note that COVID-19–related policy changes and recently proposed legislation to allow more flexible and convenient access to OUD treatment may be a first step toward expanding access to this lifesaving treatment.
But improving initial access to medication for OUD is “only the first step – our research and health systems have a long way to go in addressing the needs of people with OUD to support retention in treatment and services to effectively reduce overdose and improve long-term health and well-being,” the researchers write.
The study was supported by the NYU Center for Epidemiology and Policy. Dr. Krawczyk has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The vast majority of Americans with opioid use disorder (OUD) do not receive potentially lifesaving medications.
Drugs such as methadone, buprenorphine, and extended-release naltrexone have been shown to reduce opioid overdoses by more than 50%. Yet a new analysis shows that only about 1 in 10 people living with OUD receive these medications.
“Even though it’s not especially surprising, it’s still disturbing and shocking in a way that we have just made such little progress on this huge issue,” study investigator Noa Krawczyk, PhD, with the Center for Opioid Epidemiology and Policy, department of population health, NYU Langone, told this news organization.
The study was published online in the International Journal of Drug Policy.
Increased urgency
Despite efforts to increase capacity for OUD treatment in the United States, how receipt of treatment compares to need for treatment remains unclear.
Dr. Krawczyk and colleagues examined the gap between new estimates of OUD prevalence and treatment at the national and state levels from 2010 through 2019.
“,” the investigators write.
Adjusted estimates suggest that past-year OUD affected roughly 7.63 million individuals in the United States (2,773 per 100,000), yet only about 1.02 million received medication (365 per 100,000), they note.
Overall, there was a 106% increase in receipt of medications for OUD across the United States from 2010 to 2019 and a 5% increase from 2018 to 2019.
Yet, as of 2019, 87% of people with OUD were not receiving medication.
“While the number of people getting treatment doubled over the last decade, it’s nowhere near the amount of people who are still struggling with an opioid use disorder, and the urgency of the problem has become much worse because of the worsening fentanyl crisis and the lethality of the drug supply,” said Dr. Krawczyk.
The study also showed wide variation in past-year OUD prevalence and treatment across the United States.
Past-year OUD rates were highest in Washington, D.C., and lowest in Minnesota. Receipt of treatment was lowest in South Dakota and highest in Vermont.
However, in all 50 states and Washington, D.C., past-year OUD prevalence was greater than rates of medication use. As of 2019, the largest treatment gaps were in Iowa, North Dakota, and Washington, D.C. The smallest treatment gaps were in Connecticut, Maryland, and Rhode Island.
Long road ahead
“Even in states with the smallest treatment gaps, at least 50% of people who could benefit from medications for opioid use disorder are still not receiving them,” senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the department of population health at NYU Langone Health, said in a statement.
“We have a long way to go in reducing stigma surrounding treatment and in devising the types of policies and programs we need to ensure these medications reach the people who need them the most,” Dr. Cerdá added.
Access to OUD treatment is an ongoing problem in the United States.
“A lot of areas don’t have specialty treatment programs that provide methadone, or they might not have addiction-trained providers who are willing to prescribe buprenorphine or have a waiver to prescribe buprenorphine, so a lot places are really struggling with where people can get treatment,” said Dr. Krawczyk.
Recent data show that 46% of counties lack an OUD medication provider, and 32% have no specialty programs to treat substance use disorders.
Dr. Krawczyk and colleagues note that COVID-19–related policy changes and recently proposed legislation to allow more flexible and convenient access to OUD treatment may be a first step toward expanding access to this lifesaving treatment.
But improving initial access to medication for OUD is “only the first step – our research and health systems have a long way to go in addressing the needs of people with OUD to support retention in treatment and services to effectively reduce overdose and improve long-term health and well-being,” the researchers write.
The study was supported by the NYU Center for Epidemiology and Policy. Dr. Krawczyk has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The vast majority of Americans with opioid use disorder (OUD) do not receive potentially lifesaving medications.
Drugs such as methadone, buprenorphine, and extended-release naltrexone have been shown to reduce opioid overdoses by more than 50%. Yet a new analysis shows that only about 1 in 10 people living with OUD receive these medications.
“Even though it’s not especially surprising, it’s still disturbing and shocking in a way that we have just made such little progress on this huge issue,” study investigator Noa Krawczyk, PhD, with the Center for Opioid Epidemiology and Policy, department of population health, NYU Langone, told this news organization.
The study was published online in the International Journal of Drug Policy.
Increased urgency
Despite efforts to increase capacity for OUD treatment in the United States, how receipt of treatment compares to need for treatment remains unclear.
Dr. Krawczyk and colleagues examined the gap between new estimates of OUD prevalence and treatment at the national and state levels from 2010 through 2019.
“,” the investigators write.
Adjusted estimates suggest that past-year OUD affected roughly 7.63 million individuals in the United States (2,773 per 100,000), yet only about 1.02 million received medication (365 per 100,000), they note.
Overall, there was a 106% increase in receipt of medications for OUD across the United States from 2010 to 2019 and a 5% increase from 2018 to 2019.
Yet, as of 2019, 87% of people with OUD were not receiving medication.
“While the number of people getting treatment doubled over the last decade, it’s nowhere near the amount of people who are still struggling with an opioid use disorder, and the urgency of the problem has become much worse because of the worsening fentanyl crisis and the lethality of the drug supply,” said Dr. Krawczyk.
The study also showed wide variation in past-year OUD prevalence and treatment across the United States.
Past-year OUD rates were highest in Washington, D.C., and lowest in Minnesota. Receipt of treatment was lowest in South Dakota and highest in Vermont.
However, in all 50 states and Washington, D.C., past-year OUD prevalence was greater than rates of medication use. As of 2019, the largest treatment gaps were in Iowa, North Dakota, and Washington, D.C. The smallest treatment gaps were in Connecticut, Maryland, and Rhode Island.
Long road ahead
“Even in states with the smallest treatment gaps, at least 50% of people who could benefit from medications for opioid use disorder are still not receiving them,” senior author Magdalena Cerdá, DrPH, director of the Center for Opioid Epidemiology and Policy in the department of population health at NYU Langone Health, said in a statement.
“We have a long way to go in reducing stigma surrounding treatment and in devising the types of policies and programs we need to ensure these medications reach the people who need them the most,” Dr. Cerdá added.
Access to OUD treatment is an ongoing problem in the United States.
“A lot of areas don’t have specialty treatment programs that provide methadone, or they might not have addiction-trained providers who are willing to prescribe buprenorphine or have a waiver to prescribe buprenorphine, so a lot places are really struggling with where people can get treatment,” said Dr. Krawczyk.
Recent data show that 46% of counties lack an OUD medication provider, and 32% have no specialty programs to treat substance use disorders.
Dr. Krawczyk and colleagues note that COVID-19–related policy changes and recently proposed legislation to allow more flexible and convenient access to OUD treatment may be a first step toward expanding access to this lifesaving treatment.
But improving initial access to medication for OUD is “only the first step – our research and health systems have a long way to go in addressing the needs of people with OUD to support retention in treatment and services to effectively reduce overdose and improve long-term health and well-being,” the researchers write.
The study was supported by the NYU Center for Epidemiology and Policy. Dr. Krawczyk has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE INTERNATIONAL JOURNAL OF DRUG POLICY
Positive phase 3 results for novel schizophrenia drug
The investigational agent xanomeline-trospium (KarXT, Karuna Therapeutics), which combines a muscarinic receptor agonist with an anticholinergic agent, helps improve psychosis symptoms and is not associated with weight gain or sedation in adults with schizophrenia, new research shows.
Top-line results from the phase 3 EMERGENT-2 trial showed a significantly greater reduction from baseline on Positive and Negative Syndrome Scale (PANSS) total scores for those receiving the active drug than for those receiving placebo, meeting its primary endpoint.
and potentially usher in the first new class of medicine for these patients in more than 50 years,” Steve Paul, MD, chief executive officer, president, and chairman of Karuna Therapeutics, said in a press release.
Primary outcome met
About 20%-33% of patients with schizophrenia do not respond to conventional treatments, the company noted. Many have poor functional status and quality of life despite lifelong treatment with current antipsychotic agents.
Unlike current therapies, KarXT doesn’t rely on the dopaminergic or serotonergic pathways. It comprises the muscarinic agonist xanomeline and the muscarinic antagonist trospium and is designed to preferentially stimulate muscarinic receptors in the central nervous system.
Results from a phase 2 trial of almost 200 patients with schizophrenia were published last year in the New England Journal of Medicine. The findings showed that those who received xanomeline-trospium had a significantly greater reduction in psychosis symptoms than those who received placebo.
In the current phase 3 EMERGENT-2 trial, investigators included 252 adults aged 18-65 years who were diagnosed with schizophrenia and were experiencing symptoms of psychosis. Patients were randomly assigned to receive either a flexible dose of xanomeline-trospium or placebo twice daily.
The primary endpoint was change from baseline in the PANSS total score at week 5. Results showed a statistically significant and clinically meaningful 9.6-point reduction in the PANSS total score in participants taking the active drug, compared with those taking placebo (–21.2 vs. –11.6, respectively; P < .0001; Cohen’s d effect size, 0.61).
In addition, there was an early and sustained significant reduction of schizophrenia symptoms, as assessed by the PANSS total score, starting at week 2. This reduction was maintained through all trial timepoints.
Safety profile
The novel drug also met key secondary endpoints. In the active treatment group, there was a significant reduction on the PANSS subscales in both positive symptoms of schizophrenia, such as hallucinations or delusions, and negative symptoms, such as difficulty enjoying life or withdrawal from others.
Overall, the agent was generally well tolerated. The treatment-emergent adverse events (TEAEs) rate for xanomeline-trospium and placebo was 75% versus 58%, respectively.
The most common TEAEs for the active treatment were all mild-to-moderate in severity and included constipation, dyspepsia, nausea, vomiting, headache, increases in blood pressure, dizziness, gastroesophageal reflux disease, abdominal discomfort, and diarrhea.
As in prior trials, an increase in heart rate was also associated with the active treatment and decreased in magnitude by the end of the current study.
Discontinuation rates related to TEAEs were similar between xanomeline-trospium (7%) and placebo (6%), as were rates of serious TEAEs (2% in each group) – which included suicidal ideation, worsening of schizophrenia symptoms, and appendicitis.
Notably, the drug was not associated with common problematic adverse events of current therapies, such as weight gain, sedation, and movement disorders.
Karuna plans to submit a New Drug Application with the U.S. Food and Drug Administration for KarXT in mid-2023. In addition to schizophrenia, the drug is in development for the treatment of other psychiatric and neurological conditions, including Alzheimer’s disease.
A version of this article first appeared on Medscape.com.
The investigational agent xanomeline-trospium (KarXT, Karuna Therapeutics), which combines a muscarinic receptor agonist with an anticholinergic agent, helps improve psychosis symptoms and is not associated with weight gain or sedation in adults with schizophrenia, new research shows.
Top-line results from the phase 3 EMERGENT-2 trial showed a significantly greater reduction from baseline on Positive and Negative Syndrome Scale (PANSS) total scores for those receiving the active drug than for those receiving placebo, meeting its primary endpoint.
and potentially usher in the first new class of medicine for these patients in more than 50 years,” Steve Paul, MD, chief executive officer, president, and chairman of Karuna Therapeutics, said in a press release.
Primary outcome met
About 20%-33% of patients with schizophrenia do not respond to conventional treatments, the company noted. Many have poor functional status and quality of life despite lifelong treatment with current antipsychotic agents.
Unlike current therapies, KarXT doesn’t rely on the dopaminergic or serotonergic pathways. It comprises the muscarinic agonist xanomeline and the muscarinic antagonist trospium and is designed to preferentially stimulate muscarinic receptors in the central nervous system.
Results from a phase 2 trial of almost 200 patients with schizophrenia were published last year in the New England Journal of Medicine. The findings showed that those who received xanomeline-trospium had a significantly greater reduction in psychosis symptoms than those who received placebo.
In the current phase 3 EMERGENT-2 trial, investigators included 252 adults aged 18-65 years who were diagnosed with schizophrenia and were experiencing symptoms of psychosis. Patients were randomly assigned to receive either a flexible dose of xanomeline-trospium or placebo twice daily.
The primary endpoint was change from baseline in the PANSS total score at week 5. Results showed a statistically significant and clinically meaningful 9.6-point reduction in the PANSS total score in participants taking the active drug, compared with those taking placebo (–21.2 vs. –11.6, respectively; P < .0001; Cohen’s d effect size, 0.61).
In addition, there was an early and sustained significant reduction of schizophrenia symptoms, as assessed by the PANSS total score, starting at week 2. This reduction was maintained through all trial timepoints.
Safety profile
The novel drug also met key secondary endpoints. In the active treatment group, there was a significant reduction on the PANSS subscales in both positive symptoms of schizophrenia, such as hallucinations or delusions, and negative symptoms, such as difficulty enjoying life or withdrawal from others.
Overall, the agent was generally well tolerated. The treatment-emergent adverse events (TEAEs) rate for xanomeline-trospium and placebo was 75% versus 58%, respectively.
The most common TEAEs for the active treatment were all mild-to-moderate in severity and included constipation, dyspepsia, nausea, vomiting, headache, increases in blood pressure, dizziness, gastroesophageal reflux disease, abdominal discomfort, and diarrhea.
As in prior trials, an increase in heart rate was also associated with the active treatment and decreased in magnitude by the end of the current study.
Discontinuation rates related to TEAEs were similar between xanomeline-trospium (7%) and placebo (6%), as were rates of serious TEAEs (2% in each group) – which included suicidal ideation, worsening of schizophrenia symptoms, and appendicitis.
Notably, the drug was not associated with common problematic adverse events of current therapies, such as weight gain, sedation, and movement disorders.
Karuna plans to submit a New Drug Application with the U.S. Food and Drug Administration for KarXT in mid-2023. In addition to schizophrenia, the drug is in development for the treatment of other psychiatric and neurological conditions, including Alzheimer’s disease.
A version of this article first appeared on Medscape.com.
The investigational agent xanomeline-trospium (KarXT, Karuna Therapeutics), which combines a muscarinic receptor agonist with an anticholinergic agent, helps improve psychosis symptoms and is not associated with weight gain or sedation in adults with schizophrenia, new research shows.
Top-line results from the phase 3 EMERGENT-2 trial showed a significantly greater reduction from baseline on Positive and Negative Syndrome Scale (PANSS) total scores for those receiving the active drug than for those receiving placebo, meeting its primary endpoint.
and potentially usher in the first new class of medicine for these patients in more than 50 years,” Steve Paul, MD, chief executive officer, president, and chairman of Karuna Therapeutics, said in a press release.
Primary outcome met
About 20%-33% of patients with schizophrenia do not respond to conventional treatments, the company noted. Many have poor functional status and quality of life despite lifelong treatment with current antipsychotic agents.
Unlike current therapies, KarXT doesn’t rely on the dopaminergic or serotonergic pathways. It comprises the muscarinic agonist xanomeline and the muscarinic antagonist trospium and is designed to preferentially stimulate muscarinic receptors in the central nervous system.
Results from a phase 2 trial of almost 200 patients with schizophrenia were published last year in the New England Journal of Medicine. The findings showed that those who received xanomeline-trospium had a significantly greater reduction in psychosis symptoms than those who received placebo.
In the current phase 3 EMERGENT-2 trial, investigators included 252 adults aged 18-65 years who were diagnosed with schizophrenia and were experiencing symptoms of psychosis. Patients were randomly assigned to receive either a flexible dose of xanomeline-trospium or placebo twice daily.
The primary endpoint was change from baseline in the PANSS total score at week 5. Results showed a statistically significant and clinically meaningful 9.6-point reduction in the PANSS total score in participants taking the active drug, compared with those taking placebo (–21.2 vs. –11.6, respectively; P < .0001; Cohen’s d effect size, 0.61).
In addition, there was an early and sustained significant reduction of schizophrenia symptoms, as assessed by the PANSS total score, starting at week 2. This reduction was maintained through all trial timepoints.
Safety profile
The novel drug also met key secondary endpoints. In the active treatment group, there was a significant reduction on the PANSS subscales in both positive symptoms of schizophrenia, such as hallucinations or delusions, and negative symptoms, such as difficulty enjoying life or withdrawal from others.
Overall, the agent was generally well tolerated. The treatment-emergent adverse events (TEAEs) rate for xanomeline-trospium and placebo was 75% versus 58%, respectively.
The most common TEAEs for the active treatment were all mild-to-moderate in severity and included constipation, dyspepsia, nausea, vomiting, headache, increases in blood pressure, dizziness, gastroesophageal reflux disease, abdominal discomfort, and diarrhea.
As in prior trials, an increase in heart rate was also associated with the active treatment and decreased in magnitude by the end of the current study.
Discontinuation rates related to TEAEs were similar between xanomeline-trospium (7%) and placebo (6%), as were rates of serious TEAEs (2% in each group) – which included suicidal ideation, worsening of schizophrenia symptoms, and appendicitis.
Notably, the drug was not associated with common problematic adverse events of current therapies, such as weight gain, sedation, and movement disorders.
Karuna plans to submit a New Drug Application with the U.S. Food and Drug Administration for KarXT in mid-2023. In addition to schizophrenia, the drug is in development for the treatment of other psychiatric and neurological conditions, including Alzheimer’s disease.
A version of this article first appeared on Medscape.com.
A ‘promising target’ to improve outcomes in late-life depression
A new study sheds light on the neurologic underpinnings of late-life depression (LLD) with apathy and its frequently poor response to treatment.
Investigators headed by Faith Gunning, PhD, of the Institute of Geriatric Psychiatry, Weill Cornell Medicine, New York, analyzed baseline and posttreatment brain MRIs and functional MRIs (fMRIs) of older adults with depression who participated in a 12-week open-label nonrandomized clinical trial of escitalopram. Participants had undergone clinical and cognitive assessments.
Disturbances were found in resting state functional connectivity (rsFC) between the salience network (SN) and other large-scale networks that support goal-directed behavior, especially in patients with depression who also had features of apathy.
“This study suggests that, among older adults with depression, distinct network abnormalities may be associated with apathy and poor response to first-line pharmacotherapy and may serve as promising targets for novel interventions,” the investigators write.
The study was published online in JAMA Network Open.
A leading cause of disability
LLD is a “leading cause of disability and medical morbidity in older adulthood,” with one-third to one-half of patients with LLD also suffering from apathy, the authors write.
Older adults with depression and comorbid apathy have poorer outcomes, including lower remission rates and poorer response to first-line antidepressants, compared with those with LLD but who do not have apathy.
Despite the high prevalence of apathy in people with depression, “little is known about its optimal treatment and, more broadly, about the brain-based mechanisms of apathy,” the authors note.
An “emerging hypothesis” points to the role of a compromised SN and its large-scale connections between apathy and poor treatment response in LLD.
The SN (which includes the insula and the dorsal anterior cingulate cortex) “attributes motivational value to a stimulus” and “dynamically coordinates the activity of other large-scale networks, including the executive control network and default mode network (DMN).”
Preliminary studies of apathy in patients with depression report reduced volume in structures of the SN and suggest disruption in functional connectivity among the SN, DMN, and the executive control network; but the mechanisms linking apathy to poor antidepressant response in LLD “are not well understood.”
“Connectometry” is a “novel approach to diffusion MRI analysis that quantifies the local connectome of white matter pathways.” It has been used along with resting-state imagery, but it had not been used in studying apathy.
The researchers investigated the functional connectivity of the SN, hypothesizing that alterations in connectivity among key nodes of the SN and other core circuits that modulate goal-directed behavior (DMN and the executive control network) were implicated in individuals with depression and apathy.
They applied connectometry to “identify pathway-level disruptions in structural connectivity,” hypothesizing that compromise of frontoparietal and frontolimbic pathways would be associated with apathy in patients with LLD.
They also wanted to know whether apathy-related network abnormalities were associated with antidepressant response after 12 weeks of pharmacotherapy with the selective serotonin reuptake inhibitor escitalopram.
Emerging model
The study included 40 older adults (65% women; mean [SD] age, 70.0 [6.6] years) with DSM-IV–diagnosis major depressive disorder (without psychotic features) who were from a single-group, open-label escitalopram treatment trial.
The Hamilton-Depression (HAM-D) scale was used to assess depression, while the Apathy Evaluation Scale was used to assess apathy. On the Apathy Evaluation Scale, a score of greater than 40.5 represents “clinically significant apathy.” Participants completed these tests at baseline and after 12 weeks of escitalopram treatment.
They also completed a battery of neuropsychological tests to assess cognition and underwent MRI imaging. fMRI was used to map group differences in rsFC of the SN, and diffusion connectometry was used to “evaluate pathway-level disruptions in structural connectivity.”
Of the participants, 20 had clinically significant apathy. There were no differences in age, sex, educational level, or the severity of depression at baseline between those who did and those who did not have apathy.
Compared with participants with depression but not apathy, those with depression and comorbid apathy had lower rsFC of salience network seeds (specifically, the dorsolateral prefrontal cortex [DLPFC], premotor cortex, midcingulate cortex, and paracentral lobule).
They also had greater rsFC in the lateral temporal cortex and temporal pole (z > 2.7; Bonferroni-corrected threshold of P < .0125).
Additionally, participants with apathy had lower structural connectivity in the splenium, cingulum, and fronto-occipital fasciculus, compared with those without apathy (t > 2.5; false discovery rate–corrected P = .02).
Of the 27 participants who completed escitalopram treatment; 16 (59%) achieved remission (defined as an HAM-D score <10). Participants with apathy had poorer response to escitalopram treatment.
Lower insula-DLPFC/midcingulate cortex rsFC was associated with less improvement in depressive symptoms (HAM-D percentage change, beta [df] = .588 [26]; P = .001) as well as a greater likelihood that the participant would not achieve remission after treatment (odds ratio, 1.041; 95% confidence interval, 1.003-1.081; P = .04).
In regression models, lower insula-DLPFC/midcingulate cortex rsFC was found to be a mediator of the association between baseline apathy and persistence of depression.
The SN findings were also relevant to cognition. Lower dorsal anterior cingulate-DLPFC/paracentral rsFC was found to be associated with residual cognitive difficulties on measures of attention and executive function (beta [df] = .445 [26] and beta [df] = .384 [26], respectively; for each, P = .04).
“These findings support an emerging model of apathy, which proposes that apathy may arise from dysfunctional interactions among core networks (that is, SN, DMN, and executive control) that support motivated behavior,” the investigators write.
“This may cause a failure of network integration, leading to difficulties with salience processing, action planning, and behavioral initiation that manifests clinically as apathy,” they conclude.
One limitation they note was the lack of longitudinal follow-up after acute treatment and a “relatively limited neuropsychological battery.” Therefore, they could not “establish the persistence of treatment differences nor the specificity of cognitive associations.”
The investigators add that “novel interventions that modulate interactions among affected circuits may help to improve clinical outcomes in this distinct subgroup of older adults with depression, for whom few effective treatments exist.”
Commenting on the study, Helen Lavretsy, MD, professor of psychiatry in residence and director of the Late-Life Mood, Stress, and Wellness Research Program and the Integrative Psychiatry Clinic, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, said, the findings “can be used in future studies targeting apathy and the underlying neural mechanisms of brain connectivity.” Dr. Lavretsy was not involved with the study.
The study was supported by grants from the National Institute of Mental Health. Dr. Gunning reported receiving grants from the National Institute of Mental Health during the conduct of the study and grants from Akili Interactive. The other authors’ disclosures are listed on the original article. Dr. Lavretsky reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A new study sheds light on the neurologic underpinnings of late-life depression (LLD) with apathy and its frequently poor response to treatment.
Investigators headed by Faith Gunning, PhD, of the Institute of Geriatric Psychiatry, Weill Cornell Medicine, New York, analyzed baseline and posttreatment brain MRIs and functional MRIs (fMRIs) of older adults with depression who participated in a 12-week open-label nonrandomized clinical trial of escitalopram. Participants had undergone clinical and cognitive assessments.
Disturbances were found in resting state functional connectivity (rsFC) between the salience network (SN) and other large-scale networks that support goal-directed behavior, especially in patients with depression who also had features of apathy.
“This study suggests that, among older adults with depression, distinct network abnormalities may be associated with apathy and poor response to first-line pharmacotherapy and may serve as promising targets for novel interventions,” the investigators write.
The study was published online in JAMA Network Open.
A leading cause of disability
LLD is a “leading cause of disability and medical morbidity in older adulthood,” with one-third to one-half of patients with LLD also suffering from apathy, the authors write.
Older adults with depression and comorbid apathy have poorer outcomes, including lower remission rates and poorer response to first-line antidepressants, compared with those with LLD but who do not have apathy.
Despite the high prevalence of apathy in people with depression, “little is known about its optimal treatment and, more broadly, about the brain-based mechanisms of apathy,” the authors note.
An “emerging hypothesis” points to the role of a compromised SN and its large-scale connections between apathy and poor treatment response in LLD.
The SN (which includes the insula and the dorsal anterior cingulate cortex) “attributes motivational value to a stimulus” and “dynamically coordinates the activity of other large-scale networks, including the executive control network and default mode network (DMN).”
Preliminary studies of apathy in patients with depression report reduced volume in structures of the SN and suggest disruption in functional connectivity among the SN, DMN, and the executive control network; but the mechanisms linking apathy to poor antidepressant response in LLD “are not well understood.”
“Connectometry” is a “novel approach to diffusion MRI analysis that quantifies the local connectome of white matter pathways.” It has been used along with resting-state imagery, but it had not been used in studying apathy.
The researchers investigated the functional connectivity of the SN, hypothesizing that alterations in connectivity among key nodes of the SN and other core circuits that modulate goal-directed behavior (DMN and the executive control network) were implicated in individuals with depression and apathy.
They applied connectometry to “identify pathway-level disruptions in structural connectivity,” hypothesizing that compromise of frontoparietal and frontolimbic pathways would be associated with apathy in patients with LLD.
They also wanted to know whether apathy-related network abnormalities were associated with antidepressant response after 12 weeks of pharmacotherapy with the selective serotonin reuptake inhibitor escitalopram.
Emerging model
The study included 40 older adults (65% women; mean [SD] age, 70.0 [6.6] years) with DSM-IV–diagnosis major depressive disorder (without psychotic features) who were from a single-group, open-label escitalopram treatment trial.
The Hamilton-Depression (HAM-D) scale was used to assess depression, while the Apathy Evaluation Scale was used to assess apathy. On the Apathy Evaluation Scale, a score of greater than 40.5 represents “clinically significant apathy.” Participants completed these tests at baseline and after 12 weeks of escitalopram treatment.
They also completed a battery of neuropsychological tests to assess cognition and underwent MRI imaging. fMRI was used to map group differences in rsFC of the SN, and diffusion connectometry was used to “evaluate pathway-level disruptions in structural connectivity.”
Of the participants, 20 had clinically significant apathy. There were no differences in age, sex, educational level, or the severity of depression at baseline between those who did and those who did not have apathy.
Compared with participants with depression but not apathy, those with depression and comorbid apathy had lower rsFC of salience network seeds (specifically, the dorsolateral prefrontal cortex [DLPFC], premotor cortex, midcingulate cortex, and paracentral lobule).
They also had greater rsFC in the lateral temporal cortex and temporal pole (z > 2.7; Bonferroni-corrected threshold of P < .0125).
Additionally, participants with apathy had lower structural connectivity in the splenium, cingulum, and fronto-occipital fasciculus, compared with those without apathy (t > 2.5; false discovery rate–corrected P = .02).
Of the 27 participants who completed escitalopram treatment; 16 (59%) achieved remission (defined as an HAM-D score <10). Participants with apathy had poorer response to escitalopram treatment.
Lower insula-DLPFC/midcingulate cortex rsFC was associated with less improvement in depressive symptoms (HAM-D percentage change, beta [df] = .588 [26]; P = .001) as well as a greater likelihood that the participant would not achieve remission after treatment (odds ratio, 1.041; 95% confidence interval, 1.003-1.081; P = .04).
In regression models, lower insula-DLPFC/midcingulate cortex rsFC was found to be a mediator of the association between baseline apathy and persistence of depression.
The SN findings were also relevant to cognition. Lower dorsal anterior cingulate-DLPFC/paracentral rsFC was found to be associated with residual cognitive difficulties on measures of attention and executive function (beta [df] = .445 [26] and beta [df] = .384 [26], respectively; for each, P = .04).
“These findings support an emerging model of apathy, which proposes that apathy may arise from dysfunctional interactions among core networks (that is, SN, DMN, and executive control) that support motivated behavior,” the investigators write.
“This may cause a failure of network integration, leading to difficulties with salience processing, action planning, and behavioral initiation that manifests clinically as apathy,” they conclude.
One limitation they note was the lack of longitudinal follow-up after acute treatment and a “relatively limited neuropsychological battery.” Therefore, they could not “establish the persistence of treatment differences nor the specificity of cognitive associations.”
The investigators add that “novel interventions that modulate interactions among affected circuits may help to improve clinical outcomes in this distinct subgroup of older adults with depression, for whom few effective treatments exist.”
Commenting on the study, Helen Lavretsy, MD, professor of psychiatry in residence and director of the Late-Life Mood, Stress, and Wellness Research Program and the Integrative Psychiatry Clinic, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, said, the findings “can be used in future studies targeting apathy and the underlying neural mechanisms of brain connectivity.” Dr. Lavretsy was not involved with the study.
The study was supported by grants from the National Institute of Mental Health. Dr. Gunning reported receiving grants from the National Institute of Mental Health during the conduct of the study and grants from Akili Interactive. The other authors’ disclosures are listed on the original article. Dr. Lavretsky reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A new study sheds light on the neurologic underpinnings of late-life depression (LLD) with apathy and its frequently poor response to treatment.
Investigators headed by Faith Gunning, PhD, of the Institute of Geriatric Psychiatry, Weill Cornell Medicine, New York, analyzed baseline and posttreatment brain MRIs and functional MRIs (fMRIs) of older adults with depression who participated in a 12-week open-label nonrandomized clinical trial of escitalopram. Participants had undergone clinical and cognitive assessments.
Disturbances were found in resting state functional connectivity (rsFC) between the salience network (SN) and other large-scale networks that support goal-directed behavior, especially in patients with depression who also had features of apathy.
“This study suggests that, among older adults with depression, distinct network abnormalities may be associated with apathy and poor response to first-line pharmacotherapy and may serve as promising targets for novel interventions,” the investigators write.
The study was published online in JAMA Network Open.
A leading cause of disability
LLD is a “leading cause of disability and medical morbidity in older adulthood,” with one-third to one-half of patients with LLD also suffering from apathy, the authors write.
Older adults with depression and comorbid apathy have poorer outcomes, including lower remission rates and poorer response to first-line antidepressants, compared with those with LLD but who do not have apathy.
Despite the high prevalence of apathy in people with depression, “little is known about its optimal treatment and, more broadly, about the brain-based mechanisms of apathy,” the authors note.
An “emerging hypothesis” points to the role of a compromised SN and its large-scale connections between apathy and poor treatment response in LLD.
The SN (which includes the insula and the dorsal anterior cingulate cortex) “attributes motivational value to a stimulus” and “dynamically coordinates the activity of other large-scale networks, including the executive control network and default mode network (DMN).”
Preliminary studies of apathy in patients with depression report reduced volume in structures of the SN and suggest disruption in functional connectivity among the SN, DMN, and the executive control network; but the mechanisms linking apathy to poor antidepressant response in LLD “are not well understood.”
“Connectometry” is a “novel approach to diffusion MRI analysis that quantifies the local connectome of white matter pathways.” It has been used along with resting-state imagery, but it had not been used in studying apathy.
The researchers investigated the functional connectivity of the SN, hypothesizing that alterations in connectivity among key nodes of the SN and other core circuits that modulate goal-directed behavior (DMN and the executive control network) were implicated in individuals with depression and apathy.
They applied connectometry to “identify pathway-level disruptions in structural connectivity,” hypothesizing that compromise of frontoparietal and frontolimbic pathways would be associated with apathy in patients with LLD.
They also wanted to know whether apathy-related network abnormalities were associated with antidepressant response after 12 weeks of pharmacotherapy with the selective serotonin reuptake inhibitor escitalopram.
Emerging model
The study included 40 older adults (65% women; mean [SD] age, 70.0 [6.6] years) with DSM-IV–diagnosis major depressive disorder (without psychotic features) who were from a single-group, open-label escitalopram treatment trial.
The Hamilton-Depression (HAM-D) scale was used to assess depression, while the Apathy Evaluation Scale was used to assess apathy. On the Apathy Evaluation Scale, a score of greater than 40.5 represents “clinically significant apathy.” Participants completed these tests at baseline and after 12 weeks of escitalopram treatment.
They also completed a battery of neuropsychological tests to assess cognition and underwent MRI imaging. fMRI was used to map group differences in rsFC of the SN, and diffusion connectometry was used to “evaluate pathway-level disruptions in structural connectivity.”
Of the participants, 20 had clinically significant apathy. There were no differences in age, sex, educational level, or the severity of depression at baseline between those who did and those who did not have apathy.
Compared with participants with depression but not apathy, those with depression and comorbid apathy had lower rsFC of salience network seeds (specifically, the dorsolateral prefrontal cortex [DLPFC], premotor cortex, midcingulate cortex, and paracentral lobule).
They also had greater rsFC in the lateral temporal cortex and temporal pole (z > 2.7; Bonferroni-corrected threshold of P < .0125).
Additionally, participants with apathy had lower structural connectivity in the splenium, cingulum, and fronto-occipital fasciculus, compared with those without apathy (t > 2.5; false discovery rate–corrected P = .02).
Of the 27 participants who completed escitalopram treatment; 16 (59%) achieved remission (defined as an HAM-D score <10). Participants with apathy had poorer response to escitalopram treatment.
Lower insula-DLPFC/midcingulate cortex rsFC was associated with less improvement in depressive symptoms (HAM-D percentage change, beta [df] = .588 [26]; P = .001) as well as a greater likelihood that the participant would not achieve remission after treatment (odds ratio, 1.041; 95% confidence interval, 1.003-1.081; P = .04).
In regression models, lower insula-DLPFC/midcingulate cortex rsFC was found to be a mediator of the association between baseline apathy and persistence of depression.
The SN findings were also relevant to cognition. Lower dorsal anterior cingulate-DLPFC/paracentral rsFC was found to be associated with residual cognitive difficulties on measures of attention and executive function (beta [df] = .445 [26] and beta [df] = .384 [26], respectively; for each, P = .04).
“These findings support an emerging model of apathy, which proposes that apathy may arise from dysfunctional interactions among core networks (that is, SN, DMN, and executive control) that support motivated behavior,” the investigators write.
“This may cause a failure of network integration, leading to difficulties with salience processing, action planning, and behavioral initiation that manifests clinically as apathy,” they conclude.
One limitation they note was the lack of longitudinal follow-up after acute treatment and a “relatively limited neuropsychological battery.” Therefore, they could not “establish the persistence of treatment differences nor the specificity of cognitive associations.”
The investigators add that “novel interventions that modulate interactions among affected circuits may help to improve clinical outcomes in this distinct subgroup of older adults with depression, for whom few effective treatments exist.”
Commenting on the study, Helen Lavretsy, MD, professor of psychiatry in residence and director of the Late-Life Mood, Stress, and Wellness Research Program and the Integrative Psychiatry Clinic, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, said, the findings “can be used in future studies targeting apathy and the underlying neural mechanisms of brain connectivity.” Dr. Lavretsy was not involved with the study.
The study was supported by grants from the National Institute of Mental Health. Dr. Gunning reported receiving grants from the National Institute of Mental Health during the conduct of the study and grants from Akili Interactive. The other authors’ disclosures are listed on the original article. Dr. Lavretsky reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
McLean Hospital No. 1 for psychiatric care
McLean Hospital claimed the top spot this year from Johns Hopkins Hospital, Baltimore, which held the top spot in last year’s psychiatry ranking and now holds the No. 2 spot for psychiatry care.
Massachusetts General Hospital in Boston is ranked No. 3, and NewYork–Presbyterian Hospital – Columbia and Cornell in New York City is ranked No. 4 for psychiatry care this year, with no change from last year.
This year, UCSF Health–UCSF Medical Center, San Francisco, grabbed the No. 5 spot on the list of best psychiatry hospitals, beating out Resnick Neuropsychiatric Hospital at UCLA, Los Angeles, which held the No. 5 spot last year. Resnick is now No. 6 on the list.
Rounding out the top 10 psychiatry hospitals (in order) are Mayo Clinic, Rochester, Minn.; Yale–New Haven Hospital, New Haven, Conn.; Sheppard Pratt Hospital, Baltimore; and Menninger Clinic, Houston, and NYU Langone Hospitals, New York (tied for number 10).
“For patients considering their options for where to get care, the Best Hospitals rankings are designed to help them and their medical professionals identify hospitals that excel in the kind of care they may need,” Ben Harder, chief of health analysis and managing editor at U.S. News & World Report, said in a news release.
Mayo Clinic tops overall
In the overall 2022-2023 rankings and ratings, U.S. News & World Report compared more than 4,500 hospitals across 15 specialties and 20 procedures and conditions.
As reported by this news organization, in the overall rankings of best hospitals, the Mayo Clinic claimed the top spot on the honor roll for the seventh consecutive year, followed by Cedars-Sinai Medical Center at No. 2, and NYU Langone Hospitals at No. 3.
Cleveland Clinic in Ohio holds the No. 4 spot in the overall rankings, and Johns Hopkins Hospital in Baltimore, and UCLA Medical Center in Los Angeles are tied for fifth place.
This year marks the 33rd edition of the magazine’s best hospitals rankings or hospitals overall and by key specialties.
According to a news release from U.S. News & World Report, the Best Hospitals rankings consider a variety of data provided by the Centers for Medicare & Medicaid Services, American Hospital Association, professional organizations, and medical specialists.
The full report for best hospitals, best specialty hospitals and methodology is available online.
A version of this article first appeared on Medscape.com.
McLean Hospital claimed the top spot this year from Johns Hopkins Hospital, Baltimore, which held the top spot in last year’s psychiatry ranking and now holds the No. 2 spot for psychiatry care.
Massachusetts General Hospital in Boston is ranked No. 3, and NewYork–Presbyterian Hospital – Columbia and Cornell in New York City is ranked No. 4 for psychiatry care this year, with no change from last year.
This year, UCSF Health–UCSF Medical Center, San Francisco, grabbed the No. 5 spot on the list of best psychiatry hospitals, beating out Resnick Neuropsychiatric Hospital at UCLA, Los Angeles, which held the No. 5 spot last year. Resnick is now No. 6 on the list.
Rounding out the top 10 psychiatry hospitals (in order) are Mayo Clinic, Rochester, Minn.; Yale–New Haven Hospital, New Haven, Conn.; Sheppard Pratt Hospital, Baltimore; and Menninger Clinic, Houston, and NYU Langone Hospitals, New York (tied for number 10).
“For patients considering their options for where to get care, the Best Hospitals rankings are designed to help them and their medical professionals identify hospitals that excel in the kind of care they may need,” Ben Harder, chief of health analysis and managing editor at U.S. News & World Report, said in a news release.
Mayo Clinic tops overall
In the overall 2022-2023 rankings and ratings, U.S. News & World Report compared more than 4,500 hospitals across 15 specialties and 20 procedures and conditions.
As reported by this news organization, in the overall rankings of best hospitals, the Mayo Clinic claimed the top spot on the honor roll for the seventh consecutive year, followed by Cedars-Sinai Medical Center at No. 2, and NYU Langone Hospitals at No. 3.
Cleveland Clinic in Ohio holds the No. 4 spot in the overall rankings, and Johns Hopkins Hospital in Baltimore, and UCLA Medical Center in Los Angeles are tied for fifth place.
This year marks the 33rd edition of the magazine’s best hospitals rankings or hospitals overall and by key specialties.
According to a news release from U.S. News & World Report, the Best Hospitals rankings consider a variety of data provided by the Centers for Medicare & Medicaid Services, American Hospital Association, professional organizations, and medical specialists.
The full report for best hospitals, best specialty hospitals and methodology is available online.
A version of this article first appeared on Medscape.com.
McLean Hospital claimed the top spot this year from Johns Hopkins Hospital, Baltimore, which held the top spot in last year’s psychiatry ranking and now holds the No. 2 spot for psychiatry care.
Massachusetts General Hospital in Boston is ranked No. 3, and NewYork–Presbyterian Hospital – Columbia and Cornell in New York City is ranked No. 4 for psychiatry care this year, with no change from last year.
This year, UCSF Health–UCSF Medical Center, San Francisco, grabbed the No. 5 spot on the list of best psychiatry hospitals, beating out Resnick Neuropsychiatric Hospital at UCLA, Los Angeles, which held the No. 5 spot last year. Resnick is now No. 6 on the list.
Rounding out the top 10 psychiatry hospitals (in order) are Mayo Clinic, Rochester, Minn.; Yale–New Haven Hospital, New Haven, Conn.; Sheppard Pratt Hospital, Baltimore; and Menninger Clinic, Houston, and NYU Langone Hospitals, New York (tied for number 10).
“For patients considering their options for where to get care, the Best Hospitals rankings are designed to help them and their medical professionals identify hospitals that excel in the kind of care they may need,” Ben Harder, chief of health analysis and managing editor at U.S. News & World Report, said in a news release.
Mayo Clinic tops overall
In the overall 2022-2023 rankings and ratings, U.S. News & World Report compared more than 4,500 hospitals across 15 specialties and 20 procedures and conditions.
As reported by this news organization, in the overall rankings of best hospitals, the Mayo Clinic claimed the top spot on the honor roll for the seventh consecutive year, followed by Cedars-Sinai Medical Center at No. 2, and NYU Langone Hospitals at No. 3.
Cleveland Clinic in Ohio holds the No. 4 spot in the overall rankings, and Johns Hopkins Hospital in Baltimore, and UCLA Medical Center in Los Angeles are tied for fifth place.
This year marks the 33rd edition of the magazine’s best hospitals rankings or hospitals overall and by key specialties.
According to a news release from U.S. News & World Report, the Best Hospitals rankings consider a variety of data provided by the Centers for Medicare & Medicaid Services, American Hospital Association, professional organizations, and medical specialists.
The full report for best hospitals, best specialty hospitals and methodology is available online.
A version of this article first appeared on Medscape.com.
‘Go Ask Alice’: A fake view of teen mental health
If you grew up in the 1970s and 1980s, chances are high you’re familiar with “Go Ask Alice.”
What was then said to be the real diary of a 15-year-old promising teen turned drug addict was released in 1971 as a cautionary tale and has since sold over 5 million copies. The diary was harrowing against the backdrop of the war on drugs and soon became both acclaimed and banned from classrooms across the country.
Schools citied “inappropriate” language that “borders on pornography” as grounds to prohibit teenagers from reading Alice’s story. But as much as the book’s vivid writing offended readers, it drew millions in with its profanity and graphic descriptions of sex, drugs, and mental health struggles.
At the time, The New York Times reviewed the book as “a strong, painfully honest, nakedly candid and true story ... a document of horrifying reality,” but the popular diary was later found to be a ploy – a fake story written by a 54-year-old Mormon youth counselor named Beatrice Sparks.
Now, Ms. Sparks, who died in 2012, has been further exposed in radio personality Rick Emerson’s new book, “Unmask Alice: LSD, Satanic Panic, and the Imposter Behind the World’s Most Notorious Diaries.” Mr. Emerson published the exposé in July, years after he had the idea to investigate Ms. Sparks’s work in 2015. The book details Ms. Sparks’s background, her journey in creating Alice, and her quest to be recognized for the teen diary she had published as “Anonymous.”
“After 30 years of trying, Beatrice Sparks had changed the world. And nobody knew it,” Mr. Emerson told the New York Post.In his work, Mr. Emerson also dives into the profound impact of the diary at a time when not as much research existed on teen mental health.
When the teenager whose diary inspired Ms. Sparks’s writing “died in March 1971, the very first true study of adolescent psychology had just barely come out,” Mr. Emerson said to Rolling Stone. “Mental health, especially for young people, was still very much on training wheels.”
According to Mr. Emerson, a lack of insight into mental health issues allowed Ms. Sparks’s description to go relatively unchallenged and for the book’s influence to spread despite its misinformation.
“It’s indisputable that large sections of ‘Go Ask Alice’ are just embellished and/or false,” he told the Post.
Then versus now
This landscape is in stark contrast to today, where thousands of studies on the topic have been done, compared with the mere dozens in the 1970s.
Anxiety and depression in minors have increased over time, a trend worsened by the COVID-19 pandemic, according to the CDC. Studies have shown that reported drug use in teens has decreased over time, proving significant during the pandemic, according to the National Institutes of Health.
While Alice from “Go Ask Alice” has not existed in either, comparing the two periods can offer insight into teen struggles in the 1970s versus today and sheds light on how literature – fiction or even faked nonfiction – can transform a nation.
A version of this article first appeared on WebMD.com.
If you grew up in the 1970s and 1980s, chances are high you’re familiar with “Go Ask Alice.”
What was then said to be the real diary of a 15-year-old promising teen turned drug addict was released in 1971 as a cautionary tale and has since sold over 5 million copies. The diary was harrowing against the backdrop of the war on drugs and soon became both acclaimed and banned from classrooms across the country.
Schools citied “inappropriate” language that “borders on pornography” as grounds to prohibit teenagers from reading Alice’s story. But as much as the book’s vivid writing offended readers, it drew millions in with its profanity and graphic descriptions of sex, drugs, and mental health struggles.
At the time, The New York Times reviewed the book as “a strong, painfully honest, nakedly candid and true story ... a document of horrifying reality,” but the popular diary was later found to be a ploy – a fake story written by a 54-year-old Mormon youth counselor named Beatrice Sparks.
Now, Ms. Sparks, who died in 2012, has been further exposed in radio personality Rick Emerson’s new book, “Unmask Alice: LSD, Satanic Panic, and the Imposter Behind the World’s Most Notorious Diaries.” Mr. Emerson published the exposé in July, years after he had the idea to investigate Ms. Sparks’s work in 2015. The book details Ms. Sparks’s background, her journey in creating Alice, and her quest to be recognized for the teen diary she had published as “Anonymous.”
“After 30 years of trying, Beatrice Sparks had changed the world. And nobody knew it,” Mr. Emerson told the New York Post.In his work, Mr. Emerson also dives into the profound impact of the diary at a time when not as much research existed on teen mental health.
When the teenager whose diary inspired Ms. Sparks’s writing “died in March 1971, the very first true study of adolescent psychology had just barely come out,” Mr. Emerson said to Rolling Stone. “Mental health, especially for young people, was still very much on training wheels.”
According to Mr. Emerson, a lack of insight into mental health issues allowed Ms. Sparks’s description to go relatively unchallenged and for the book’s influence to spread despite its misinformation.
“It’s indisputable that large sections of ‘Go Ask Alice’ are just embellished and/or false,” he told the Post.
Then versus now
This landscape is in stark contrast to today, where thousands of studies on the topic have been done, compared with the mere dozens in the 1970s.
Anxiety and depression in minors have increased over time, a trend worsened by the COVID-19 pandemic, according to the CDC. Studies have shown that reported drug use in teens has decreased over time, proving significant during the pandemic, according to the National Institutes of Health.
While Alice from “Go Ask Alice” has not existed in either, comparing the two periods can offer insight into teen struggles in the 1970s versus today and sheds light on how literature – fiction or even faked nonfiction – can transform a nation.
A version of this article first appeared on WebMD.com.
If you grew up in the 1970s and 1980s, chances are high you’re familiar with “Go Ask Alice.”
What was then said to be the real diary of a 15-year-old promising teen turned drug addict was released in 1971 as a cautionary tale and has since sold over 5 million copies. The diary was harrowing against the backdrop of the war on drugs and soon became both acclaimed and banned from classrooms across the country.
Schools citied “inappropriate” language that “borders on pornography” as grounds to prohibit teenagers from reading Alice’s story. But as much as the book’s vivid writing offended readers, it drew millions in with its profanity and graphic descriptions of sex, drugs, and mental health struggles.
At the time, The New York Times reviewed the book as “a strong, painfully honest, nakedly candid and true story ... a document of horrifying reality,” but the popular diary was later found to be a ploy – a fake story written by a 54-year-old Mormon youth counselor named Beatrice Sparks.
Now, Ms. Sparks, who died in 2012, has been further exposed in radio personality Rick Emerson’s new book, “Unmask Alice: LSD, Satanic Panic, and the Imposter Behind the World’s Most Notorious Diaries.” Mr. Emerson published the exposé in July, years after he had the idea to investigate Ms. Sparks’s work in 2015. The book details Ms. Sparks’s background, her journey in creating Alice, and her quest to be recognized for the teen diary she had published as “Anonymous.”
“After 30 years of trying, Beatrice Sparks had changed the world. And nobody knew it,” Mr. Emerson told the New York Post.In his work, Mr. Emerson also dives into the profound impact of the diary at a time when not as much research existed on teen mental health.
When the teenager whose diary inspired Ms. Sparks’s writing “died in March 1971, the very first true study of adolescent psychology had just barely come out,” Mr. Emerson said to Rolling Stone. “Mental health, especially for young people, was still very much on training wheels.”
According to Mr. Emerson, a lack of insight into mental health issues allowed Ms. Sparks’s description to go relatively unchallenged and for the book’s influence to spread despite its misinformation.
“It’s indisputable that large sections of ‘Go Ask Alice’ are just embellished and/or false,” he told the Post.
Then versus now
This landscape is in stark contrast to today, where thousands of studies on the topic have been done, compared with the mere dozens in the 1970s.
Anxiety and depression in minors have increased over time, a trend worsened by the COVID-19 pandemic, according to the CDC. Studies have shown that reported drug use in teens has decreased over time, proving significant during the pandemic, according to the National Institutes of Health.
While Alice from “Go Ask Alice” has not existed in either, comparing the two periods can offer insight into teen struggles in the 1970s versus today and sheds light on how literature – fiction or even faked nonfiction – can transform a nation.
A version of this article first appeared on WebMD.com.
Burnout and stress of today: How do we cope?
Interestingly, the group that seems to be least impacted by this was health care administrators (with 12% of them planning on leaving their jobs).
I couldn’t stop thinking about these percentages.
I am reminded every day of the commitment and excellence of my colleagues in the health care field, and I do not want to lose them. I am hoping the following information and my thoughts on this topic will be helpful for those thinking about leaving health care.
Surgeon general’s burnout report
The surgeon general recently released a report on addressing health care worker burnout.2 It includes several very interesting and appropriate observations. I will summarize the most important ones here:
1. Our health depends on the well-being of our health workforce.
2. Direct harm to health care workers can lead to anxiety, depression, insomnia, and interpersonal and relationship struggles.
3. Health care workers experience exhaustion from providing overwhelming care and empathy.
4. Health care workers spend less time with patients and too much time with EHRs.
5. There are health workforce shortages.
The report is comprehensive, and everything in it is correct. The real issue is how does it go from being a report to true actionable items that we as health care professionals benefit from? I think in regards to exhaustion from overwhelming care responsibilities, and empathy fatigue, we need better boundaries.
Those who go into medicine, and especially those who go into primary care, always put the patients’ needs first. When operating in a broken system, it stays broken when individuals cover for the deficiencies in the system. Adding four extra patients every day because there is no one to refer them to with availability is injurious to the health care provider, and those providers who accept these additional patients will eventually be part of the 23% who want to leave their jobs. It feels awful to say no, but until the system stops accommodating there will not be substantial change.
The empathy drain
One of the unreported stresses of open access for patients through EHR communications is the empathy drain on physicians. When I see a patient in clinic with chronic symptoms or issues, I spend important time making sure we have a plan and an agreed upon time frame.
With the EHR, patients frequently send multiple messages for the same symptoms between visits. It is okay to redirect the patient and share that these issues will be discussed at length at appointments. My reasoning on this is that I think it is better for me to better care for myself and stay as the doctor for my patients, than always say yes to limitless needs and soon be looking for the off ramp.
The following statistic in the surgeon general’s report really hit home. For every hour of direct patient care, physicians currently spend 2 hours on the EHR system. Most practices allow 10%-20% of time for catch up, where with statistics like this it should be 50%. This concept is fully lost on administrators, or ignored.
It is only when we refuse to continue to accept and follow a broken system that it will change. A minority of internal medicine and family doctors (4.5% in 2018) practice in direct primary care models, where these issues are addressed. Unfortunately, this model as it is currently available is not an option for lower income patients.
A major theme in the surgeon general’s report was that administrative burdens need to be reduced by 75% by 2025. When I look at the report, I see the suggestions, I just don’t see how it will be achieved. Despite almost all clinics moving to the EHR, paperwork in the form of faxes and forms has increased.
A sweeping reform would be needed to eliminate daily faxes from PT offices, visiting nurse services, prior authorization, patients reminders from insurance companies, and disability forms from patients. I am glad that there is acknowledgment of the problem, but this change will take more than 3 years.
Takeaways
So what do we do?
Be good to yourself, and your colleagues. The pandemic has isolated us, which accelerates burnout.
Reach out to people you care about.
We are all feeling this. Set boundaries that allow you to care for yourself, and accept that you are doing your best, even if you can’t meet the needs of all your patients all the time.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Sinsky CA et al. Covid-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes. 2021 Dec;5(6):1165-73.
2. Addressing health worker burnout. The U.S. Surgeon General’s advisory on building a thriving health workforce.
Interestingly, the group that seems to be least impacted by this was health care administrators (with 12% of them planning on leaving their jobs).
I couldn’t stop thinking about these percentages.
I am reminded every day of the commitment and excellence of my colleagues in the health care field, and I do not want to lose them. I am hoping the following information and my thoughts on this topic will be helpful for those thinking about leaving health care.
Surgeon general’s burnout report
The surgeon general recently released a report on addressing health care worker burnout.2 It includes several very interesting and appropriate observations. I will summarize the most important ones here:
1. Our health depends on the well-being of our health workforce.
2. Direct harm to health care workers can lead to anxiety, depression, insomnia, and interpersonal and relationship struggles.
3. Health care workers experience exhaustion from providing overwhelming care and empathy.
4. Health care workers spend less time with patients and too much time with EHRs.
5. There are health workforce shortages.
The report is comprehensive, and everything in it is correct. The real issue is how does it go from being a report to true actionable items that we as health care professionals benefit from? I think in regards to exhaustion from overwhelming care responsibilities, and empathy fatigue, we need better boundaries.
Those who go into medicine, and especially those who go into primary care, always put the patients’ needs first. When operating in a broken system, it stays broken when individuals cover for the deficiencies in the system. Adding four extra patients every day because there is no one to refer them to with availability is injurious to the health care provider, and those providers who accept these additional patients will eventually be part of the 23% who want to leave their jobs. It feels awful to say no, but until the system stops accommodating there will not be substantial change.
The empathy drain
One of the unreported stresses of open access for patients through EHR communications is the empathy drain on physicians. When I see a patient in clinic with chronic symptoms or issues, I spend important time making sure we have a plan and an agreed upon time frame.
With the EHR, patients frequently send multiple messages for the same symptoms between visits. It is okay to redirect the patient and share that these issues will be discussed at length at appointments. My reasoning on this is that I think it is better for me to better care for myself and stay as the doctor for my patients, than always say yes to limitless needs and soon be looking for the off ramp.
The following statistic in the surgeon general’s report really hit home. For every hour of direct patient care, physicians currently spend 2 hours on the EHR system. Most practices allow 10%-20% of time for catch up, where with statistics like this it should be 50%. This concept is fully lost on administrators, or ignored.
It is only when we refuse to continue to accept and follow a broken system that it will change. A minority of internal medicine and family doctors (4.5% in 2018) practice in direct primary care models, where these issues are addressed. Unfortunately, this model as it is currently available is not an option for lower income patients.
A major theme in the surgeon general’s report was that administrative burdens need to be reduced by 75% by 2025. When I look at the report, I see the suggestions, I just don’t see how it will be achieved. Despite almost all clinics moving to the EHR, paperwork in the form of faxes and forms has increased.
A sweeping reform would be needed to eliminate daily faxes from PT offices, visiting nurse services, prior authorization, patients reminders from insurance companies, and disability forms from patients. I am glad that there is acknowledgment of the problem, but this change will take more than 3 years.
Takeaways
So what do we do?
Be good to yourself, and your colleagues. The pandemic has isolated us, which accelerates burnout.
Reach out to people you care about.
We are all feeling this. Set boundaries that allow you to care for yourself, and accept that you are doing your best, even if you can’t meet the needs of all your patients all the time.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Sinsky CA et al. Covid-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes. 2021 Dec;5(6):1165-73.
2. Addressing health worker burnout. The U.S. Surgeon General’s advisory on building a thriving health workforce.
Interestingly, the group that seems to be least impacted by this was health care administrators (with 12% of them planning on leaving their jobs).
I couldn’t stop thinking about these percentages.
I am reminded every day of the commitment and excellence of my colleagues in the health care field, and I do not want to lose them. I am hoping the following information and my thoughts on this topic will be helpful for those thinking about leaving health care.
Surgeon general’s burnout report
The surgeon general recently released a report on addressing health care worker burnout.2 It includes several very interesting and appropriate observations. I will summarize the most important ones here:
1. Our health depends on the well-being of our health workforce.
2. Direct harm to health care workers can lead to anxiety, depression, insomnia, and interpersonal and relationship struggles.
3. Health care workers experience exhaustion from providing overwhelming care and empathy.
4. Health care workers spend less time with patients and too much time with EHRs.
5. There are health workforce shortages.
The report is comprehensive, and everything in it is correct. The real issue is how does it go from being a report to true actionable items that we as health care professionals benefit from? I think in regards to exhaustion from overwhelming care responsibilities, and empathy fatigue, we need better boundaries.
Those who go into medicine, and especially those who go into primary care, always put the patients’ needs first. When operating in a broken system, it stays broken when individuals cover for the deficiencies in the system. Adding four extra patients every day because there is no one to refer them to with availability is injurious to the health care provider, and those providers who accept these additional patients will eventually be part of the 23% who want to leave their jobs. It feels awful to say no, but until the system stops accommodating there will not be substantial change.
The empathy drain
One of the unreported stresses of open access for patients through EHR communications is the empathy drain on physicians. When I see a patient in clinic with chronic symptoms or issues, I spend important time making sure we have a plan and an agreed upon time frame.
With the EHR, patients frequently send multiple messages for the same symptoms between visits. It is okay to redirect the patient and share that these issues will be discussed at length at appointments. My reasoning on this is that I think it is better for me to better care for myself and stay as the doctor for my patients, than always say yes to limitless needs and soon be looking for the off ramp.
The following statistic in the surgeon general’s report really hit home. For every hour of direct patient care, physicians currently spend 2 hours on the EHR system. Most practices allow 10%-20% of time for catch up, where with statistics like this it should be 50%. This concept is fully lost on administrators, or ignored.
It is only when we refuse to continue to accept and follow a broken system that it will change. A minority of internal medicine and family doctors (4.5% in 2018) practice in direct primary care models, where these issues are addressed. Unfortunately, this model as it is currently available is not an option for lower income patients.
A major theme in the surgeon general’s report was that administrative burdens need to be reduced by 75% by 2025. When I look at the report, I see the suggestions, I just don’t see how it will be achieved. Despite almost all clinics moving to the EHR, paperwork in the form of faxes and forms has increased.
A sweeping reform would be needed to eliminate daily faxes from PT offices, visiting nurse services, prior authorization, patients reminders from insurance companies, and disability forms from patients. I am glad that there is acknowledgment of the problem, but this change will take more than 3 years.
Takeaways
So what do we do?
Be good to yourself, and your colleagues. The pandemic has isolated us, which accelerates burnout.
Reach out to people you care about.
We are all feeling this. Set boundaries that allow you to care for yourself, and accept that you are doing your best, even if you can’t meet the needs of all your patients all the time.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].
References
1. Sinsky CA et al. Covid-related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes. 2021 Dec;5(6):1165-73.
2. Addressing health worker burnout. The U.S. Surgeon General’s advisory on building a thriving health workforce.
Mixed results for intensive home care for psychiatric crises
Intensive home treatment may offer an alternative to inpatient care for patients in acute psychiatric crisis – but the intervention is no outright substitute, new research suggests.
However, there was no difference between treatment groups in improvement in quality of life or patient satisfaction; and a reduction in symptom severity noted after 6 weeks of home treatment faded within 6 months.
“We found no differences in admission rates either, which suggests that intensive home treatment is not a substitute for inpatient care but a different treatment opportunity for psychiatric patients in crisis,” Jurgen Cornelis, MD, Arkin Institute for Mental Health, Amsterdam, and colleagues write.
The findings were published online in The Lancet Psychiatry.
Increasingly popular
“Intensive home treatment is increasingly popular as an alternative to hospitalization. It was developed to prevent or reduce levels of inpatient care and facilitate the transition between inpatient care and low-intensity outpatient care,” the investigators write.
However, there have previously been only two randomized controlled trials published that assessed this type of care, resulting in “somewhat conflicting findings,” they add.
For the current study, participants presented to psychiatric emergency wards at two medical centers in the Netherlands. They were included only if they were able to offer informed consent within 14 days.
The intensive home treatment group (n = 183) worked with a multidisciplinary team that designed a care plan tailored to their specific crisis. Treatment components included pharmacotherapy, up to three home visits each day, psychoeducation, brief supportive and cognitive behavioral therapy, social care, and support and empowerment of the patient’s informal care system.
The usual care group (n = 63) commonly received a combination of highly intensive inpatient treatment in the first phase and outpatient treatment up to two times a week in the second phase. Treatment included similar components as those in intensive home treatment.
The most common primary clinical diagnosis in both groups was mood disorder, followed by psychotic disorders, personality disorders, or anxiety disorders.
The home treatment group had a significantly higher total mean item score on the Brief Psychiatric Rating Scale (BPRS) at baseline (2.23 vs. 2.04, P = .04).
Mixed results
Results at 6 weeks showed the number of hospital days was 25.3% lower in the home treatment group, compared with those who received usual care.
That trend continued at 1 year, with the intensive home treatment group recording 36.6% fewer hospital days than the usual care group (mean, 42.5 days vs. 67 days, respectively; P = .03).
However, the number of patients who were admitted in the first 6 weeks and at 1 year stayed the same, as did the mean number of admissions per patient over 12 months.
The home treatment group reported significantly fewer symptoms on the BPRS depression and anxiety scale at 6 weeks, compared with the usual treatment group (P = .025), but that difference was not maintained after 6 months.
The number of adverse events, including suicide attempts, was similar between the groups. Three patients in the home treatment group and two in the usual care group died by suicide.
“Future research should focus on which components of intensive home treatment or hospitalization can be used when, for whom, and meet which goals, so that both hospital care and intensive home treatment can be used proportionally and efficiently for patients in psychiatric crisis,” the investigators write.
Not generalizable?
In an accompanying editorial, Claire Henderson, PhD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, noted that generalizing the study’s results to other countries could be problematic, especially to regions such as North America, which have shorter lengths of stay for psychiatric hospitalization.
“Future trials looking at intensive home treatment would be most informative if done in countries with relatively short lengths of stay, and without separate crisis services for people receiving assertive community treatment,” Dr. Henderson writes.
The study was funded by De Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken. The investigators and Dr. Henderson have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Intensive home treatment may offer an alternative to inpatient care for patients in acute psychiatric crisis – but the intervention is no outright substitute, new research suggests.
However, there was no difference between treatment groups in improvement in quality of life or patient satisfaction; and a reduction in symptom severity noted after 6 weeks of home treatment faded within 6 months.
“We found no differences in admission rates either, which suggests that intensive home treatment is not a substitute for inpatient care but a different treatment opportunity for psychiatric patients in crisis,” Jurgen Cornelis, MD, Arkin Institute for Mental Health, Amsterdam, and colleagues write.
The findings were published online in The Lancet Psychiatry.
Increasingly popular
“Intensive home treatment is increasingly popular as an alternative to hospitalization. It was developed to prevent or reduce levels of inpatient care and facilitate the transition between inpatient care and low-intensity outpatient care,” the investigators write.
However, there have previously been only two randomized controlled trials published that assessed this type of care, resulting in “somewhat conflicting findings,” they add.
For the current study, participants presented to psychiatric emergency wards at two medical centers in the Netherlands. They were included only if they were able to offer informed consent within 14 days.
The intensive home treatment group (n = 183) worked with a multidisciplinary team that designed a care plan tailored to their specific crisis. Treatment components included pharmacotherapy, up to three home visits each day, psychoeducation, brief supportive and cognitive behavioral therapy, social care, and support and empowerment of the patient’s informal care system.
The usual care group (n = 63) commonly received a combination of highly intensive inpatient treatment in the first phase and outpatient treatment up to two times a week in the second phase. Treatment included similar components as those in intensive home treatment.
The most common primary clinical diagnosis in both groups was mood disorder, followed by psychotic disorders, personality disorders, or anxiety disorders.
The home treatment group had a significantly higher total mean item score on the Brief Psychiatric Rating Scale (BPRS) at baseline (2.23 vs. 2.04, P = .04).
Mixed results
Results at 6 weeks showed the number of hospital days was 25.3% lower in the home treatment group, compared with those who received usual care.
That trend continued at 1 year, with the intensive home treatment group recording 36.6% fewer hospital days than the usual care group (mean, 42.5 days vs. 67 days, respectively; P = .03).
However, the number of patients who were admitted in the first 6 weeks and at 1 year stayed the same, as did the mean number of admissions per patient over 12 months.
The home treatment group reported significantly fewer symptoms on the BPRS depression and anxiety scale at 6 weeks, compared with the usual treatment group (P = .025), but that difference was not maintained after 6 months.
The number of adverse events, including suicide attempts, was similar between the groups. Three patients in the home treatment group and two in the usual care group died by suicide.
“Future research should focus on which components of intensive home treatment or hospitalization can be used when, for whom, and meet which goals, so that both hospital care and intensive home treatment can be used proportionally and efficiently for patients in psychiatric crisis,” the investigators write.
Not generalizable?
In an accompanying editorial, Claire Henderson, PhD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, noted that generalizing the study’s results to other countries could be problematic, especially to regions such as North America, which have shorter lengths of stay for psychiatric hospitalization.
“Future trials looking at intensive home treatment would be most informative if done in countries with relatively short lengths of stay, and without separate crisis services for people receiving assertive community treatment,” Dr. Henderson writes.
The study was funded by De Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken. The investigators and Dr. Henderson have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Intensive home treatment may offer an alternative to inpatient care for patients in acute psychiatric crisis – but the intervention is no outright substitute, new research suggests.
However, there was no difference between treatment groups in improvement in quality of life or patient satisfaction; and a reduction in symptom severity noted after 6 weeks of home treatment faded within 6 months.
“We found no differences in admission rates either, which suggests that intensive home treatment is not a substitute for inpatient care but a different treatment opportunity for psychiatric patients in crisis,” Jurgen Cornelis, MD, Arkin Institute for Mental Health, Amsterdam, and colleagues write.
The findings were published online in The Lancet Psychiatry.
Increasingly popular
“Intensive home treatment is increasingly popular as an alternative to hospitalization. It was developed to prevent or reduce levels of inpatient care and facilitate the transition between inpatient care and low-intensity outpatient care,” the investigators write.
However, there have previously been only two randomized controlled trials published that assessed this type of care, resulting in “somewhat conflicting findings,” they add.
For the current study, participants presented to psychiatric emergency wards at two medical centers in the Netherlands. They were included only if they were able to offer informed consent within 14 days.
The intensive home treatment group (n = 183) worked with a multidisciplinary team that designed a care plan tailored to their specific crisis. Treatment components included pharmacotherapy, up to three home visits each day, psychoeducation, brief supportive and cognitive behavioral therapy, social care, and support and empowerment of the patient’s informal care system.
The usual care group (n = 63) commonly received a combination of highly intensive inpatient treatment in the first phase and outpatient treatment up to two times a week in the second phase. Treatment included similar components as those in intensive home treatment.
The most common primary clinical diagnosis in both groups was mood disorder, followed by psychotic disorders, personality disorders, or anxiety disorders.
The home treatment group had a significantly higher total mean item score on the Brief Psychiatric Rating Scale (BPRS) at baseline (2.23 vs. 2.04, P = .04).
Mixed results
Results at 6 weeks showed the number of hospital days was 25.3% lower in the home treatment group, compared with those who received usual care.
That trend continued at 1 year, with the intensive home treatment group recording 36.6% fewer hospital days than the usual care group (mean, 42.5 days vs. 67 days, respectively; P = .03).
However, the number of patients who were admitted in the first 6 weeks and at 1 year stayed the same, as did the mean number of admissions per patient over 12 months.
The home treatment group reported significantly fewer symptoms on the BPRS depression and anxiety scale at 6 weeks, compared with the usual treatment group (P = .025), but that difference was not maintained after 6 months.
The number of adverse events, including suicide attempts, was similar between the groups. Three patients in the home treatment group and two in the usual care group died by suicide.
“Future research should focus on which components of intensive home treatment or hospitalization can be used when, for whom, and meet which goals, so that both hospital care and intensive home treatment can be used proportionally and efficiently for patients in psychiatric crisis,” the investigators write.
Not generalizable?
In an accompanying editorial, Claire Henderson, PhD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, noted that generalizing the study’s results to other countries could be problematic, especially to regions such as North America, which have shorter lengths of stay for psychiatric hospitalization.
“Future trials looking at intensive home treatment would be most informative if done in countries with relatively short lengths of stay, and without separate crisis services for people receiving assertive community treatment,” Dr. Henderson writes.
The study was funded by De Stichting tot Steun Vereniging voor Christelijke Verzorging van Geestes-en Zenuwzieken. The investigators and Dr. Henderson have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PSYCHIATRY
University to train ‘trip facilitators’ for psychedelic therapy
The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.
Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.
“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.
Nine-month program
The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.
The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.
Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.
In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.
Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.
At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
Growing acceptance in psychiatry
Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.
“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.
He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.
“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.
Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.
In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.
Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.
Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.
She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.
A version of this article first appeared on Medscape.com.
The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.
Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.
“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.
Nine-month program
The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.
The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.
Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.
In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.
Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.
At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
Growing acceptance in psychiatry
Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.
“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.
He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.
“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.
Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.
In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.
Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.
Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.
She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.
A version of this article first appeared on Medscape.com.
The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.
Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.
“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.
Nine-month program
The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.
The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.
Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.
In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.
Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.
At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
Growing acceptance in psychiatry
Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.
“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.
He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.
“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.
Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.
In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.
Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.
Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.
She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.
A version of this article first appeared on Medscape.com.
Sexual assault flagged as a possible psychosis trigger
A new study sheds light on some of the risk factors for the development of psychosis, including the potentially causative role of sexual assault.
Investigators conducted an exposome-wide association analysis on more than 155,000 individuals. Of more than 140 correlates of psychotic experiences that they identified, they narrowed it down to 36 variables, which they further explored using Mendelian randomization analysis.
On the other hand, having experienced a physical violent crime, cannabis use, and prolonged worry after embarrassment showed a pleiotropic association and appeared to be an aftereffect of psychotic experience.
“From a public health perspective, we need more investment in comprehensive strategies to prevent traumatic experiences at the population level to decrease the burden of psychosis,” senior author Sinan Gülöksüz, MD, PhD, associate professor in the department of psychiatry and neuropsychiatry, Maastricht University Medical Center, the Netherlands, said in an interview.
“From a clinical perspective, clinicians should be aware of the harmful influence of traumatic experiences on mental health and address this through interventions such as trauma-informed care,” he said.
The study was published online in JAMA Psychiatry.
‘Disentangling’ cause and effect
“Previous research has shown associations between psychosis and a few environmental factors, such as substance use, urbanicity, pregnancy complications, and traumatic experiences, but research has so far investigated only a few specific environmental factors by singling them out in individual studies,” Dr. Gülöksüz said.
“Yet, environment is a much more complex and interactive network that includes many factors shaping our health – where we live, what we eat, our lifestyle preferences and habits such as exercise and smoking, and our social surrounding,” he continued. “Rarely has it been possible to understand whether these environmental factors have causal roles in developing psychosis.”
To investigate the question, the researchers turned to the UK Biobank, one of the largest population-based datasets in the world. The current study focused on individuals with completed data on mental questionnaires that assessed psychotic experiences (n = 155,247; mean [SD] age, 55.94 [7.74] years; 57% female).
They began by conducting an exposome-wide association study, using logistic regression analyses with psychotic experiences as the outcome and adjusting all analyses for age and sex.
“Initially, we identified many associations between environmental factors and psychotic experiences in this large cohort,” Dr. Gülöksüz reported.
In the final multivariable model, variables associated with psychotic experiences were further analyzed using “genetically informed approaches to probe potential associations.”
The researchers utilized Mendelian randomization (MR) methodology “to disentangle cause and effect in this observational study,” Dr. Gülöksüz said. “This method reduces confounding and reverse causation in observational studies by using genetic variants that have been passed on from generation to generation randomly as instruments.”
MR analysis “has allowed us to assess whether these associations reflect potentially causal influences of environmental factors on psychotic experiences,” he added.
Well-studied and unexplored risk factors
The researchers identified 162 variables associated with psychotic experiences in the discovery dataset and were able to replicate 148. When these 148 variables were subjected to multivariable analyses, 36 were found to be statistically significantly associated with psychotic experiences. Of these variables, 28 had “significant genetic overlap” with psychotic experiences.
When the researchers conducted one-sample MR analyses, they found forward associations with three variables and reverse associations with three variables.
Forward associations were found with ever having experienced sexual assault (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.14-1.52; P = 2.67), and forward associations (with pleiotropy) were found with ever having experienced a physically violent crime and risk-taking behavior (OR, 1.25, 95% CI, 1.11-1.41; P = 3.28 and OR, 1.21, 95% CI, 1.08-1.35; P = 1.34, respectively).
“The allele scores for these 3 variables explained 0.03% to 0.23% variance of the corresponding variable” and the F statistics “ranged from 21.53 to 181.84, indicating that the results did not suffer from a weak-instrument bias,” the authors reported.
The researchers calculated an instrument based on increasing psychotic experiences risk allele scores and found that these scores explained 0.14% variance of psychotic experiences (F statistic, 19.26).
Using that calculation, they found a reverse association with having experienced a physically violent crime (OR, 1.08; 95% CI, 1.04-1.13; P = 3.92 × 10-4), cannabis use (OR, 1.11; 95% CI, 1.06-1.15; P = 2.64 × 10-6), and worrying too long after embarrassment (OR, 1.06; 95% CI, 1.03-1.10; P = 3.96 × 10-4). They then validated these associations.
The presence of all five correlates was associated with tenfold increased odds of psychotic experiences (OR, 10.63; 95% CI, 8.27-13.65, P = 1.2 × 10-114).
“Associations with psychotic experiences were found with both well-studied and unexplored multiple correlated variables,” the authors stated.
Era of ‘big data’
In a comment, Chirag Patel, PhD, associate professor of biomedical informatics at Harvard Medical School, Boston, who was not involved with the study, said he thought the study was “a nice example of a data-driven and comprehensive study of the environment coupled with attempts to triangulate evidence from genetics, made possible by biobank data.
“To guide public health policies and implementation of prevention strategies for psychosis, we need more systematic analyses and triangulate evidence with genetically informed methods to identify potentially modifiable risk factors in the era of ‘big data,’ ” he said.
“For instance, traumatic experiences contribute to poor mental and physical health, including psychosis,” Dr. Gülöksüz added.
The Kootstra Talent Fellowship, the Ophelia Research Project, and the Vidi Award from the Netherlands Scientific Organization provided funding to individual investigators. Dr. Gülöksüz and coauthors declared no relevant financial conflicts. Dr. Patel served as a reviewer on the study.
A version of this article first appeared on Medscape.com.
A new study sheds light on some of the risk factors for the development of psychosis, including the potentially causative role of sexual assault.
Investigators conducted an exposome-wide association analysis on more than 155,000 individuals. Of more than 140 correlates of psychotic experiences that they identified, they narrowed it down to 36 variables, which they further explored using Mendelian randomization analysis.
On the other hand, having experienced a physical violent crime, cannabis use, and prolonged worry after embarrassment showed a pleiotropic association and appeared to be an aftereffect of psychotic experience.
“From a public health perspective, we need more investment in comprehensive strategies to prevent traumatic experiences at the population level to decrease the burden of psychosis,” senior author Sinan Gülöksüz, MD, PhD, associate professor in the department of psychiatry and neuropsychiatry, Maastricht University Medical Center, the Netherlands, said in an interview.
“From a clinical perspective, clinicians should be aware of the harmful influence of traumatic experiences on mental health and address this through interventions such as trauma-informed care,” he said.
The study was published online in JAMA Psychiatry.
‘Disentangling’ cause and effect
“Previous research has shown associations between psychosis and a few environmental factors, such as substance use, urbanicity, pregnancy complications, and traumatic experiences, but research has so far investigated only a few specific environmental factors by singling them out in individual studies,” Dr. Gülöksüz said.
“Yet, environment is a much more complex and interactive network that includes many factors shaping our health – where we live, what we eat, our lifestyle preferences and habits such as exercise and smoking, and our social surrounding,” he continued. “Rarely has it been possible to understand whether these environmental factors have causal roles in developing psychosis.”
To investigate the question, the researchers turned to the UK Biobank, one of the largest population-based datasets in the world. The current study focused on individuals with completed data on mental questionnaires that assessed psychotic experiences (n = 155,247; mean [SD] age, 55.94 [7.74] years; 57% female).
They began by conducting an exposome-wide association study, using logistic regression analyses with psychotic experiences as the outcome and adjusting all analyses for age and sex.
“Initially, we identified many associations between environmental factors and psychotic experiences in this large cohort,” Dr. Gülöksüz reported.
In the final multivariable model, variables associated with psychotic experiences were further analyzed using “genetically informed approaches to probe potential associations.”
The researchers utilized Mendelian randomization (MR) methodology “to disentangle cause and effect in this observational study,” Dr. Gülöksüz said. “This method reduces confounding and reverse causation in observational studies by using genetic variants that have been passed on from generation to generation randomly as instruments.”
MR analysis “has allowed us to assess whether these associations reflect potentially causal influences of environmental factors on psychotic experiences,” he added.
Well-studied and unexplored risk factors
The researchers identified 162 variables associated with psychotic experiences in the discovery dataset and were able to replicate 148. When these 148 variables were subjected to multivariable analyses, 36 were found to be statistically significantly associated with psychotic experiences. Of these variables, 28 had “significant genetic overlap” with psychotic experiences.
When the researchers conducted one-sample MR analyses, they found forward associations with three variables and reverse associations with three variables.
Forward associations were found with ever having experienced sexual assault (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.14-1.52; P = 2.67), and forward associations (with pleiotropy) were found with ever having experienced a physically violent crime and risk-taking behavior (OR, 1.25, 95% CI, 1.11-1.41; P = 3.28 and OR, 1.21, 95% CI, 1.08-1.35; P = 1.34, respectively).
“The allele scores for these 3 variables explained 0.03% to 0.23% variance of the corresponding variable” and the F statistics “ranged from 21.53 to 181.84, indicating that the results did not suffer from a weak-instrument bias,” the authors reported.
The researchers calculated an instrument based on increasing psychotic experiences risk allele scores and found that these scores explained 0.14% variance of psychotic experiences (F statistic, 19.26).
Using that calculation, they found a reverse association with having experienced a physically violent crime (OR, 1.08; 95% CI, 1.04-1.13; P = 3.92 × 10-4), cannabis use (OR, 1.11; 95% CI, 1.06-1.15; P = 2.64 × 10-6), and worrying too long after embarrassment (OR, 1.06; 95% CI, 1.03-1.10; P = 3.96 × 10-4). They then validated these associations.
The presence of all five correlates was associated with tenfold increased odds of psychotic experiences (OR, 10.63; 95% CI, 8.27-13.65, P = 1.2 × 10-114).
“Associations with psychotic experiences were found with both well-studied and unexplored multiple correlated variables,” the authors stated.
Era of ‘big data’
In a comment, Chirag Patel, PhD, associate professor of biomedical informatics at Harvard Medical School, Boston, who was not involved with the study, said he thought the study was “a nice example of a data-driven and comprehensive study of the environment coupled with attempts to triangulate evidence from genetics, made possible by biobank data.
“To guide public health policies and implementation of prevention strategies for psychosis, we need more systematic analyses and triangulate evidence with genetically informed methods to identify potentially modifiable risk factors in the era of ‘big data,’ ” he said.
“For instance, traumatic experiences contribute to poor mental and physical health, including psychosis,” Dr. Gülöksüz added.
The Kootstra Talent Fellowship, the Ophelia Research Project, and the Vidi Award from the Netherlands Scientific Organization provided funding to individual investigators. Dr. Gülöksüz and coauthors declared no relevant financial conflicts. Dr. Patel served as a reviewer on the study.
A version of this article first appeared on Medscape.com.
A new study sheds light on some of the risk factors for the development of psychosis, including the potentially causative role of sexual assault.
Investigators conducted an exposome-wide association analysis on more than 155,000 individuals. Of more than 140 correlates of psychotic experiences that they identified, they narrowed it down to 36 variables, which they further explored using Mendelian randomization analysis.
On the other hand, having experienced a physical violent crime, cannabis use, and prolonged worry after embarrassment showed a pleiotropic association and appeared to be an aftereffect of psychotic experience.
“From a public health perspective, we need more investment in comprehensive strategies to prevent traumatic experiences at the population level to decrease the burden of psychosis,” senior author Sinan Gülöksüz, MD, PhD, associate professor in the department of psychiatry and neuropsychiatry, Maastricht University Medical Center, the Netherlands, said in an interview.
“From a clinical perspective, clinicians should be aware of the harmful influence of traumatic experiences on mental health and address this through interventions such as trauma-informed care,” he said.
The study was published online in JAMA Psychiatry.
‘Disentangling’ cause and effect
“Previous research has shown associations between psychosis and a few environmental factors, such as substance use, urbanicity, pregnancy complications, and traumatic experiences, but research has so far investigated only a few specific environmental factors by singling them out in individual studies,” Dr. Gülöksüz said.
“Yet, environment is a much more complex and interactive network that includes many factors shaping our health – where we live, what we eat, our lifestyle preferences and habits such as exercise and smoking, and our social surrounding,” he continued. “Rarely has it been possible to understand whether these environmental factors have causal roles in developing psychosis.”
To investigate the question, the researchers turned to the UK Biobank, one of the largest population-based datasets in the world. The current study focused on individuals with completed data on mental questionnaires that assessed psychotic experiences (n = 155,247; mean [SD] age, 55.94 [7.74] years; 57% female).
They began by conducting an exposome-wide association study, using logistic regression analyses with psychotic experiences as the outcome and adjusting all analyses for age and sex.
“Initially, we identified many associations between environmental factors and psychotic experiences in this large cohort,” Dr. Gülöksüz reported.
In the final multivariable model, variables associated with psychotic experiences were further analyzed using “genetically informed approaches to probe potential associations.”
The researchers utilized Mendelian randomization (MR) methodology “to disentangle cause and effect in this observational study,” Dr. Gülöksüz said. “This method reduces confounding and reverse causation in observational studies by using genetic variants that have been passed on from generation to generation randomly as instruments.”
MR analysis “has allowed us to assess whether these associations reflect potentially causal influences of environmental factors on psychotic experiences,” he added.
Well-studied and unexplored risk factors
The researchers identified 162 variables associated with psychotic experiences in the discovery dataset and were able to replicate 148. When these 148 variables were subjected to multivariable analyses, 36 were found to be statistically significantly associated with psychotic experiences. Of these variables, 28 had “significant genetic overlap” with psychotic experiences.
When the researchers conducted one-sample MR analyses, they found forward associations with three variables and reverse associations with three variables.
Forward associations were found with ever having experienced sexual assault (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.14-1.52; P = 2.67), and forward associations (with pleiotropy) were found with ever having experienced a physically violent crime and risk-taking behavior (OR, 1.25, 95% CI, 1.11-1.41; P = 3.28 and OR, 1.21, 95% CI, 1.08-1.35; P = 1.34, respectively).
“The allele scores for these 3 variables explained 0.03% to 0.23% variance of the corresponding variable” and the F statistics “ranged from 21.53 to 181.84, indicating that the results did not suffer from a weak-instrument bias,” the authors reported.
The researchers calculated an instrument based on increasing psychotic experiences risk allele scores and found that these scores explained 0.14% variance of psychotic experiences (F statistic, 19.26).
Using that calculation, they found a reverse association with having experienced a physically violent crime (OR, 1.08; 95% CI, 1.04-1.13; P = 3.92 × 10-4), cannabis use (OR, 1.11; 95% CI, 1.06-1.15; P = 2.64 × 10-6), and worrying too long after embarrassment (OR, 1.06; 95% CI, 1.03-1.10; P = 3.96 × 10-4). They then validated these associations.
The presence of all five correlates was associated with tenfold increased odds of psychotic experiences (OR, 10.63; 95% CI, 8.27-13.65, P = 1.2 × 10-114).
“Associations with psychotic experiences were found with both well-studied and unexplored multiple correlated variables,” the authors stated.
Era of ‘big data’
In a comment, Chirag Patel, PhD, associate professor of biomedical informatics at Harvard Medical School, Boston, who was not involved with the study, said he thought the study was “a nice example of a data-driven and comprehensive study of the environment coupled with attempts to triangulate evidence from genetics, made possible by biobank data.
“To guide public health policies and implementation of prevention strategies for psychosis, we need more systematic analyses and triangulate evidence with genetically informed methods to identify potentially modifiable risk factors in the era of ‘big data,’ ” he said.
“For instance, traumatic experiences contribute to poor mental and physical health, including psychosis,” Dr. Gülöksüz added.
The Kootstra Talent Fellowship, the Ophelia Research Project, and the Vidi Award from the Netherlands Scientific Organization provided funding to individual investigators. Dr. Gülöksüz and coauthors declared no relevant financial conflicts. Dr. Patel served as a reviewer on the study.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY