Mental Health

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Providing peer or community health workers to help psychiatric patients complete psychiatric advance directives (PAD) – which govern care in advance of a mental health crisis – is associated with a significant reduction in compulsory hospital admissions, new research shows.

Results of a randomized trial showed the peer worker PAD group had a 42% reduction in compulsory admission over the following 12 months. This study group also had lower symptom scores, greater rates of recovery, and increased empowerment, compared with patients assigned to usual care.

In addition to proving that PADs are effective in reducing compulsory admission, the results show that facilitation by peer workers is relevant, study investigator Aurélie Tinland, MD, PhD, Faculté de Médecine Timone, Aix-Marseille University, Marseille, France, told delegates attending the virtual European Psychiatric Association (EPA) 2022 Congress. The study was simultaneously published online in JAMA Psychiatry.

However, Dr. Tinland noted that more research that includes “harder to reach” populations is needed. In addition, greater use of PADs is also key to reducing compulsory admissions.
 

‘Most coercive’ country

The researchers note that respect for patient autonomy is a strong pillar of health care, such that “involuntary treatment should be unusual.” However, they point out that “compulsory psychiatric admissions are far too common in countries of all income levels.”

In France, said Dr. Tinland, 24% of psychiatric hospitalizations are compulsory. The country is ranked the sixth “most coercive” country in the world, and there are concerns about human rights in French psychiatric facilities.

She added that advance care statements are the most efficient tool for reducing coercion, with one study suggesting they could cut rates by 25%, compared with usual care.

However, she noted there is an “asymmetry” between medical professionals and patients and a risk of “undue influence” when clinicians facilitate the completion of care statements.

To examine the impact on clinical outcomes of peer-worker facilitated PADs, the researchers studied adults with a diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who were admitted to a psychiatric hospital within the previous 12 months. Peer workers are individuals who have lived experience with mental illness and help inform and guide current patients about care options in the event of a mental health crisis.

Study participants were randomly assigned 1:1 to an intervention group or a usual care control group. The intervention group received a PAD document and were assigned a peer worker while the usual care group received comprehensive information about the PAD concept at study entry and were free to complete it, but they were not connected with a peer worker.

The PAD document included information about future treatment and support preferences, early signs of relapse, and coping strategies. Participants could meet the peer worker in a place of their choice and be supported in drafting the document and in sharing it with health care professionals.

In all, 394 individuals completed the study. The majority (61%) of participants were male and 66% had completed post-secondary education. Schizophrenia was diagnosed in 45%, bipolar I disorder in 36%, and schizoaffective disorder in 19%.

Participants in the intervention group were significantly younger than those in the control group, with a mean of 37.4 years versus 41 years (P = .003) and were less likely to have one or more somatic comorbidities, at 61.2% versus 69.2%.

A PAD was completed by 54.6% of individuals in the intervention group versus 7.1% of controls (P < .001). The PAD was written with peer worker support by 41.3% of those in the intervention and by 2% of controls. Of those who completed a PAD, 75.7% met care facilitators, and 27.1% used it during a crisis over the following 12 months.

Results showed that the rate of compulsory admissions was significantly lower in the peer worker PAD group, at 27% versus 39.9% in control participants, at an odds ratio of 0.58 (P = .007).

Participants in the intervention group had lower symptoms on the modified Colorado Symptom Score than usual care patients with an effect size of -0.20 (P = .03) and higher scores on the Empowerment Scale (effect size 0.30, P = .003).

Scores on the Recovery Assessment Scale were also significantly higher in the peer worker PAD group versus controls with an effect size of 0.44 (P < .001). There were no significant differences, however, in overall admission rates, the quality of the therapeutic alliance, or quality of life.
 

Putting patients in the driver’s seat

Commenting on the findings, Robert Dabney Jr., MA, MDiv, peer apprentice program manager at the Depression and Bipolar Support Alliance, Chicago, said the study “tells us there are many benefits to completing a psychiatric advance directive, but perhaps the most powerful one is putting the person receiving mental health care in the driver’s seat of their own recovery.”

However, he noted that “many people living with mental health conditions don’t know the option exists to decide on their treatment plan in advance of a crisis.”

“This is where peer support specialists can come in. Having a peer who has been through similar experiences and can guide you through the process is as comforting as it is empowering. I have witnessed and experienced firsthand the power of peer support,” he said.

“It’s my personal hope and the goal of the Depression and Bipolar Support Alliance to empower more people to either become peer support specialists or seek out peer support services, because we know it improves and even saves lives,” Mr. Dabney added.

Virginia A. Brown, PhD, department of psychiatry & behavioral sciences, University of Texas at Austin Dell Medical School, noted there are huge differences between the health care systems in France and the United States.

She explained that two of the greatest barriers to PADs in the United States is that until 2016, filling one out was not billable and that “practitioners don’t know anything about advanced care plans.”

Dr. Brown said her own work shows that individuals who support patients during a crisis believe it would be “really helpful if we had some kind of document that we could share with the health care system that says: ‘Hey, look, I’m the designated person to speak for this patient, they’ve identified me through a document.’ So, people were actually describing a need for this document but didn’t know that it existed.”

Another problem is that in the United States, hospitals operate in a “closed system” and cannot talk to an unrelated hospital or to the police department “to get information to those first responders during an emergency about who to talk to about their wishes and preferences.”

“There are a lot of hurdles that we’ve got to get over to make a more robust system that protects the autonomy of people who live with serious mental illness,” Dr. Brown said, as “losing capacity during a crisis is time-limited, and it requires us to respond to it as a medical emergency.”

The study was supported by an institutional grant from the French 2017 National Program of Health Services Research. The Clinical Research Direction of Assistance Publique Hôpitaux de Marseille sponsored the trial. Dr. Tinland declares grants from the French Ministry of Health Directorate General of Health Care Services during the conduct of the study.

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

Providing peer or community health workers to help psychiatric patients complete psychiatric advance directives (PAD) – which govern care in advance of a mental health crisis – is associated with a significant reduction in compulsory hospital admissions, new research shows.

Results of a randomized trial showed the peer worker PAD group had a 42% reduction in compulsory admission over the following 12 months. This study group also had lower symptom scores, greater rates of recovery, and increased empowerment, compared with patients assigned to usual care.

In addition to proving that PADs are effective in reducing compulsory admission, the results show that facilitation by peer workers is relevant, study investigator Aurélie Tinland, MD, PhD, Faculté de Médecine Timone, Aix-Marseille University, Marseille, France, told delegates attending the virtual European Psychiatric Association (EPA) 2022 Congress. The study was simultaneously published online in JAMA Psychiatry.

However, Dr. Tinland noted that more research that includes “harder to reach” populations is needed. In addition, greater use of PADs is also key to reducing compulsory admissions.
 

‘Most coercive’ country

The researchers note that respect for patient autonomy is a strong pillar of health care, such that “involuntary treatment should be unusual.” However, they point out that “compulsory psychiatric admissions are far too common in countries of all income levels.”

In France, said Dr. Tinland, 24% of psychiatric hospitalizations are compulsory. The country is ranked the sixth “most coercive” country in the world, and there are concerns about human rights in French psychiatric facilities.

She added that advance care statements are the most efficient tool for reducing coercion, with one study suggesting they could cut rates by 25%, compared with usual care.

However, she noted there is an “asymmetry” between medical professionals and patients and a risk of “undue influence” when clinicians facilitate the completion of care statements.

To examine the impact on clinical outcomes of peer-worker facilitated PADs, the researchers studied adults with a diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who were admitted to a psychiatric hospital within the previous 12 months. Peer workers are individuals who have lived experience with mental illness and help inform and guide current patients about care options in the event of a mental health crisis.

Study participants were randomly assigned 1:1 to an intervention group or a usual care control group. The intervention group received a PAD document and were assigned a peer worker while the usual care group received comprehensive information about the PAD concept at study entry and were free to complete it, but they were not connected with a peer worker.

The PAD document included information about future treatment and support preferences, early signs of relapse, and coping strategies. Participants could meet the peer worker in a place of their choice and be supported in drafting the document and in sharing it with health care professionals.

In all, 394 individuals completed the study. The majority (61%) of participants were male and 66% had completed post-secondary education. Schizophrenia was diagnosed in 45%, bipolar I disorder in 36%, and schizoaffective disorder in 19%.

Participants in the intervention group were significantly younger than those in the control group, with a mean of 37.4 years versus 41 years (P = .003) and were less likely to have one or more somatic comorbidities, at 61.2% versus 69.2%.

A PAD was completed by 54.6% of individuals in the intervention group versus 7.1% of controls (P < .001). The PAD was written with peer worker support by 41.3% of those in the intervention and by 2% of controls. Of those who completed a PAD, 75.7% met care facilitators, and 27.1% used it during a crisis over the following 12 months.

Results showed that the rate of compulsory admissions was significantly lower in the peer worker PAD group, at 27% versus 39.9% in control participants, at an odds ratio of 0.58 (P = .007).

Participants in the intervention group had lower symptoms on the modified Colorado Symptom Score than usual care patients with an effect size of -0.20 (P = .03) and higher scores on the Empowerment Scale (effect size 0.30, P = .003).

Scores on the Recovery Assessment Scale were also significantly higher in the peer worker PAD group versus controls with an effect size of 0.44 (P < .001). There were no significant differences, however, in overall admission rates, the quality of the therapeutic alliance, or quality of life.
 

Putting patients in the driver’s seat

Commenting on the findings, Robert Dabney Jr., MA, MDiv, peer apprentice program manager at the Depression and Bipolar Support Alliance, Chicago, said the study “tells us there are many benefits to completing a psychiatric advance directive, but perhaps the most powerful one is putting the person receiving mental health care in the driver’s seat of their own recovery.”

However, he noted that “many people living with mental health conditions don’t know the option exists to decide on their treatment plan in advance of a crisis.”

“This is where peer support specialists can come in. Having a peer who has been through similar experiences and can guide you through the process is as comforting as it is empowering. I have witnessed and experienced firsthand the power of peer support,” he said.

“It’s my personal hope and the goal of the Depression and Bipolar Support Alliance to empower more people to either become peer support specialists or seek out peer support services, because we know it improves and even saves lives,” Mr. Dabney added.

Virginia A. Brown, PhD, department of psychiatry & behavioral sciences, University of Texas at Austin Dell Medical School, noted there are huge differences between the health care systems in France and the United States.

She explained that two of the greatest barriers to PADs in the United States is that until 2016, filling one out was not billable and that “practitioners don’t know anything about advanced care plans.”

Dr. Brown said her own work shows that individuals who support patients during a crisis believe it would be “really helpful if we had some kind of document that we could share with the health care system that says: ‘Hey, look, I’m the designated person to speak for this patient, they’ve identified me through a document.’ So, people were actually describing a need for this document but didn’t know that it existed.”

Another problem is that in the United States, hospitals operate in a “closed system” and cannot talk to an unrelated hospital or to the police department “to get information to those first responders during an emergency about who to talk to about their wishes and preferences.”

“There are a lot of hurdles that we’ve got to get over to make a more robust system that protects the autonomy of people who live with serious mental illness,” Dr. Brown said, as “losing capacity during a crisis is time-limited, and it requires us to respond to it as a medical emergency.”

The study was supported by an institutional grant from the French 2017 National Program of Health Services Research. The Clinical Research Direction of Assistance Publique Hôpitaux de Marseille sponsored the trial. Dr. Tinland declares grants from the French Ministry of Health Directorate General of Health Care Services during the conduct of the study.

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

Providing peer or community health workers to help psychiatric patients complete psychiatric advance directives (PAD) – which govern care in advance of a mental health crisis – is associated with a significant reduction in compulsory hospital admissions, new research shows.

Results of a randomized trial showed the peer worker PAD group had a 42% reduction in compulsory admission over the following 12 months. This study group also had lower symptom scores, greater rates of recovery, and increased empowerment, compared with patients assigned to usual care.

In addition to proving that PADs are effective in reducing compulsory admission, the results show that facilitation by peer workers is relevant, study investigator Aurélie Tinland, MD, PhD, Faculté de Médecine Timone, Aix-Marseille University, Marseille, France, told delegates attending the virtual European Psychiatric Association (EPA) 2022 Congress. The study was simultaneously published online in JAMA Psychiatry.

However, Dr. Tinland noted that more research that includes “harder to reach” populations is needed. In addition, greater use of PADs is also key to reducing compulsory admissions.
 

‘Most coercive’ country

The researchers note that respect for patient autonomy is a strong pillar of health care, such that “involuntary treatment should be unusual.” However, they point out that “compulsory psychiatric admissions are far too common in countries of all income levels.”

In France, said Dr. Tinland, 24% of psychiatric hospitalizations are compulsory. The country is ranked the sixth “most coercive” country in the world, and there are concerns about human rights in French psychiatric facilities.

She added that advance care statements are the most efficient tool for reducing coercion, with one study suggesting they could cut rates by 25%, compared with usual care.

However, she noted there is an “asymmetry” between medical professionals and patients and a risk of “undue influence” when clinicians facilitate the completion of care statements.

To examine the impact on clinical outcomes of peer-worker facilitated PADs, the researchers studied adults with a diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who were admitted to a psychiatric hospital within the previous 12 months. Peer workers are individuals who have lived experience with mental illness and help inform and guide current patients about care options in the event of a mental health crisis.

Study participants were randomly assigned 1:1 to an intervention group or a usual care control group. The intervention group received a PAD document and were assigned a peer worker while the usual care group received comprehensive information about the PAD concept at study entry and were free to complete it, but they were not connected with a peer worker.

The PAD document included information about future treatment and support preferences, early signs of relapse, and coping strategies. Participants could meet the peer worker in a place of their choice and be supported in drafting the document and in sharing it with health care professionals.

In all, 394 individuals completed the study. The majority (61%) of participants were male and 66% had completed post-secondary education. Schizophrenia was diagnosed in 45%, bipolar I disorder in 36%, and schizoaffective disorder in 19%.

Participants in the intervention group were significantly younger than those in the control group, with a mean of 37.4 years versus 41 years (P = .003) and were less likely to have one or more somatic comorbidities, at 61.2% versus 69.2%.

A PAD was completed by 54.6% of individuals in the intervention group versus 7.1% of controls (P < .001). The PAD was written with peer worker support by 41.3% of those in the intervention and by 2% of controls. Of those who completed a PAD, 75.7% met care facilitators, and 27.1% used it during a crisis over the following 12 months.

Results showed that the rate of compulsory admissions was significantly lower in the peer worker PAD group, at 27% versus 39.9% in control participants, at an odds ratio of 0.58 (P = .007).

Participants in the intervention group had lower symptoms on the modified Colorado Symptom Score than usual care patients with an effect size of -0.20 (P = .03) and higher scores on the Empowerment Scale (effect size 0.30, P = .003).

Scores on the Recovery Assessment Scale were also significantly higher in the peer worker PAD group versus controls with an effect size of 0.44 (P < .001). There were no significant differences, however, in overall admission rates, the quality of the therapeutic alliance, or quality of life.
 

Putting patients in the driver’s seat

Commenting on the findings, Robert Dabney Jr., MA, MDiv, peer apprentice program manager at the Depression and Bipolar Support Alliance, Chicago, said the study “tells us there are many benefits to completing a psychiatric advance directive, but perhaps the most powerful one is putting the person receiving mental health care in the driver’s seat of their own recovery.”

However, he noted that “many people living with mental health conditions don’t know the option exists to decide on their treatment plan in advance of a crisis.”

“This is where peer support specialists can come in. Having a peer who has been through similar experiences and can guide you through the process is as comforting as it is empowering. I have witnessed and experienced firsthand the power of peer support,” he said.

“It’s my personal hope and the goal of the Depression and Bipolar Support Alliance to empower more people to either become peer support specialists or seek out peer support services, because we know it improves and even saves lives,” Mr. Dabney added.

Virginia A. Brown, PhD, department of psychiatry & behavioral sciences, University of Texas at Austin Dell Medical School, noted there are huge differences between the health care systems in France and the United States.

She explained that two of the greatest barriers to PADs in the United States is that until 2016, filling one out was not billable and that “practitioners don’t know anything about advanced care plans.”

Dr. Brown said her own work shows that individuals who support patients during a crisis believe it would be “really helpful if we had some kind of document that we could share with the health care system that says: ‘Hey, look, I’m the designated person to speak for this patient, they’ve identified me through a document.’ So, people were actually describing a need for this document but didn’t know that it existed.”

Another problem is that in the United States, hospitals operate in a “closed system” and cannot talk to an unrelated hospital or to the police department “to get information to those first responders during an emergency about who to talk to about their wishes and preferences.”

“There are a lot of hurdles that we’ve got to get over to make a more robust system that protects the autonomy of people who live with serious mental illness,” Dr. Brown said, as “losing capacity during a crisis is time-limited, and it requires us to respond to it as a medical emergency.”

The study was supported by an institutional grant from the French 2017 National Program of Health Services Research. The Clinical Research Direction of Assistance Publique Hôpitaux de Marseille sponsored the trial. Dr. Tinland declares grants from the French Ministry of Health Directorate General of Health Care Services during the conduct of the study.

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

A U.S. Food and Drug Administration advisory panel has rejected the atypical antipsychotic pimavanserin (Nuplazid, Acadia Pharmaceuticals) for the treatment of Alzheimer’s disease psychosis (ADP).

In a 9-3 vote, the Psychopharmacologic Drugs Advisory Committee (PDAC) found that the drug’s manufacturer failed to offer convincing evidence of its efficacy in patients with ADP.

The June 17 rejection was the second rejection in as many years for a new indication for pimavanserin, which was approved in 2016 for Parkinson’s disease psychosis (PDP).

In April 2021, the FDA denied Acadia’s supplemental new drug application to expand the drug’s indication to include the treatment of all dementia-related psychosis, regardless of the underlying cause of dementia, citing issues with two studies the company presented as evidence of efficacy.

Waldemarus/iStock/Getty Images Plus

Lack of efficacy

Pimavanserin is a selective serotonin inverse agonist and antagonist preferentially targeting 5-HT2A receptors, which are thought to play an important role in psychosis, schizophrenia, depression, and other neuropsychiatric disorders.

When it rejected Acadia’s original, broader application for pimavanserin for all dementia-related psychosis, the FDA found that the HARMONY phase 3 trial, previously covered by this news organization, was underpowered to assess efficacy in specific dementia patient subgroups and lacked statistical significance of efficacy in patients with AD. In addition, it noted that overall findings appeared to be driven by results in patients with Parkinson’s disease dementia, a condition already covered by the approved indication.

The FDA found that the second study, referred to in the June 17 hearing as Study 019, which was also previously reported by this news organization, was not “an adequate and well-controlled study.”

Specifically, the agency raised concerns about “protocol deviations,” such as the inclusion of patients who lacked clear documentation that psychotic symptoms developed after an AD diagnosis had been established and patients who received exclusionary medications at the time of randomization.

Discussions between Acadia and the FDA continued over the past year, with the company submitting new analyses and responses. An FDA briefing document published in advance of the committee meeting seemed to suggest the agency was satisfied with Acadia’s response.
 

Lack of diversity

The advisory committee disagreed, pointing to the same concerns raised last year. Members raised concerns about patient diversity in the HARMONY trial, which included an almost entirely White and mostly male study population.

In addition, although the findings at 26 weeks did demonstrate a marked improvement in psychosis symptoms overall, committee members noted that, again, those findings were largely driven by efficacy in patients with Parkinson’s disease dementia, for which the drug is already approved.

When discussing the phase 2 Study 019, the committee noted that while the study met the primary outcome of improvement in psychosis at 6 weeks, those positive responses were not found at any other timepoint in the 12-week study.  

“While it might have had a positive numerical effect in the study, the evidence is really not there to support it,” Dr. Follmann said.

Dr. Follmann and other committee members called for additional trials that focus on patients with Alzheimer’s disease, have a longer follow-up, and include more gender and racial diversity in the study population. They also called for more information about any off-label use of pimavanserin for ADP since it was approved for PDP in 2016.
 

An unmet need

Most individuals who testified during the public comment period pleaded with the committee to vote in favor of the new indication, sharing stories of family members and patients with ADP.

“I have been caring for and studying patients with Alzheimer’s disease and other dementias for more than 30 years, and I can tell you very simply that if left untreated, psychosis has significant and sometimes devastating consequences for our patients,” said Pierre Tariot, MD, director of the Banner Alzheimer’s Institute and a research professor of psychiatry at the University of Arizona College of Medicine, Tucson, and an investigator on the HARMONY trial.

Those on the committee who voted against the application were quick to agree that lack of an approved treatment for ADP presents a hardship.

“I’m a neurologist who has cared for patients for more than 20 years,” said Madhav R. Thambisetty, MD, PhD, senior investigator for the National Institute on Aging and an adjunct professor of neurology at Johns Hopkins University School of Medicine, Baltimore. “I recognize the unmet need in the field, I just think that the unmet need should not be a justification to cut corners.”

The committee did not focus on drug safety or unmet need in its deliberations, although information on both were presented during the meeting.

Commenting on his “no” vote, PDAC member Walter S. Dunn, MD, PhD, assistant clinical professor of psychiatry at the University of California, Los Angeles, and director of Interventional Psychiatry Service at West Los Angeles Veterans Affairs Medical Center, said he hopes that the FDA will consider those issues more broadly as they complete their review.

“The questions before the committee have been narrow and precise, so I trust the agency will take a broader approach in their final decision about approval,” Dr. Dunn said.

Commenting on the decision, Howard Fillit, MD, cofounder and chief science officer, Alzheimer’s Drug Discovery Foundation, called the news disappointing, “but while the unmet need for a treatment for ADP is clear, it is vital that approved treatments meet stringent safety and efficacy criteria so we can offer patients medications with clear benefits.”

The FDA will make its final decision by August 4.

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

A U.S. Food and Drug Administration advisory panel has rejected the atypical antipsychotic pimavanserin (Nuplazid, Acadia Pharmaceuticals) for the treatment of Alzheimer’s disease psychosis (ADP).

In a 9-3 vote, the Psychopharmacologic Drugs Advisory Committee (PDAC) found that the drug’s manufacturer failed to offer convincing evidence of its efficacy in patients with ADP.

The June 17 rejection was the second rejection in as many years for a new indication for pimavanserin, which was approved in 2016 for Parkinson’s disease psychosis (PDP).

In April 2021, the FDA denied Acadia’s supplemental new drug application to expand the drug’s indication to include the treatment of all dementia-related psychosis, regardless of the underlying cause of dementia, citing issues with two studies the company presented as evidence of efficacy.

Waldemarus/iStock/Getty Images Plus

Lack of efficacy

Pimavanserin is a selective serotonin inverse agonist and antagonist preferentially targeting 5-HT2A receptors, which are thought to play an important role in psychosis, schizophrenia, depression, and other neuropsychiatric disorders.

When it rejected Acadia’s original, broader application for pimavanserin for all dementia-related psychosis, the FDA found that the HARMONY phase 3 trial, previously covered by this news organization, was underpowered to assess efficacy in specific dementia patient subgroups and lacked statistical significance of efficacy in patients with AD. In addition, it noted that overall findings appeared to be driven by results in patients with Parkinson’s disease dementia, a condition already covered by the approved indication.

The FDA found that the second study, referred to in the June 17 hearing as Study 019, which was also previously reported by this news organization, was not “an adequate and well-controlled study.”

Specifically, the agency raised concerns about “protocol deviations,” such as the inclusion of patients who lacked clear documentation that psychotic symptoms developed after an AD diagnosis had been established and patients who received exclusionary medications at the time of randomization.

Discussions between Acadia and the FDA continued over the past year, with the company submitting new analyses and responses. An FDA briefing document published in advance of the committee meeting seemed to suggest the agency was satisfied with Acadia’s response.
 

Lack of diversity

The advisory committee disagreed, pointing to the same concerns raised last year. Members raised concerns about patient diversity in the HARMONY trial, which included an almost entirely White and mostly male study population.

In addition, although the findings at 26 weeks did demonstrate a marked improvement in psychosis symptoms overall, committee members noted that, again, those findings were largely driven by efficacy in patients with Parkinson’s disease dementia, for which the drug is already approved.

When discussing the phase 2 Study 019, the committee noted that while the study met the primary outcome of improvement in psychosis at 6 weeks, those positive responses were not found at any other timepoint in the 12-week study.  

“While it might have had a positive numerical effect in the study, the evidence is really not there to support it,” Dr. Follmann said.

Dr. Follmann and other committee members called for additional trials that focus on patients with Alzheimer’s disease, have a longer follow-up, and include more gender and racial diversity in the study population. They also called for more information about any off-label use of pimavanserin for ADP since it was approved for PDP in 2016.
 

An unmet need

Most individuals who testified during the public comment period pleaded with the committee to vote in favor of the new indication, sharing stories of family members and patients with ADP.

“I have been caring for and studying patients with Alzheimer’s disease and other dementias for more than 30 years, and I can tell you very simply that if left untreated, psychosis has significant and sometimes devastating consequences for our patients,” said Pierre Tariot, MD, director of the Banner Alzheimer’s Institute and a research professor of psychiatry at the University of Arizona College of Medicine, Tucson, and an investigator on the HARMONY trial.

Those on the committee who voted against the application were quick to agree that lack of an approved treatment for ADP presents a hardship.

“I’m a neurologist who has cared for patients for more than 20 years,” said Madhav R. Thambisetty, MD, PhD, senior investigator for the National Institute on Aging and an adjunct professor of neurology at Johns Hopkins University School of Medicine, Baltimore. “I recognize the unmet need in the field, I just think that the unmet need should not be a justification to cut corners.”

The committee did not focus on drug safety or unmet need in its deliberations, although information on both were presented during the meeting.

Commenting on his “no” vote, PDAC member Walter S. Dunn, MD, PhD, assistant clinical professor of psychiatry at the University of California, Los Angeles, and director of Interventional Psychiatry Service at West Los Angeles Veterans Affairs Medical Center, said he hopes that the FDA will consider those issues more broadly as they complete their review.

“The questions before the committee have been narrow and precise, so I trust the agency will take a broader approach in their final decision about approval,” Dr. Dunn said.

Commenting on the decision, Howard Fillit, MD, cofounder and chief science officer, Alzheimer’s Drug Discovery Foundation, called the news disappointing, “but while the unmet need for a treatment for ADP is clear, it is vital that approved treatments meet stringent safety and efficacy criteria so we can offer patients medications with clear benefits.”

The FDA will make its final decision by August 4.

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

A U.S. Food and Drug Administration advisory panel has rejected the atypical antipsychotic pimavanserin (Nuplazid, Acadia Pharmaceuticals) for the treatment of Alzheimer’s disease psychosis (ADP).

In a 9-3 vote, the Psychopharmacologic Drugs Advisory Committee (PDAC) found that the drug’s manufacturer failed to offer convincing evidence of its efficacy in patients with ADP.

The June 17 rejection was the second rejection in as many years for a new indication for pimavanserin, which was approved in 2016 for Parkinson’s disease psychosis (PDP).

In April 2021, the FDA denied Acadia’s supplemental new drug application to expand the drug’s indication to include the treatment of all dementia-related psychosis, regardless of the underlying cause of dementia, citing issues with two studies the company presented as evidence of efficacy.

Waldemarus/iStock/Getty Images Plus

Lack of efficacy

Pimavanserin is a selective serotonin inverse agonist and antagonist preferentially targeting 5-HT2A receptors, which are thought to play an important role in psychosis, schizophrenia, depression, and other neuropsychiatric disorders.

When it rejected Acadia’s original, broader application for pimavanserin for all dementia-related psychosis, the FDA found that the HARMONY phase 3 trial, previously covered by this news organization, was underpowered to assess efficacy in specific dementia patient subgroups and lacked statistical significance of efficacy in patients with AD. In addition, it noted that overall findings appeared to be driven by results in patients with Parkinson’s disease dementia, a condition already covered by the approved indication.

The FDA found that the second study, referred to in the June 17 hearing as Study 019, which was also previously reported by this news organization, was not “an adequate and well-controlled study.”

Specifically, the agency raised concerns about “protocol deviations,” such as the inclusion of patients who lacked clear documentation that psychotic symptoms developed after an AD diagnosis had been established and patients who received exclusionary medications at the time of randomization.

Discussions between Acadia and the FDA continued over the past year, with the company submitting new analyses and responses. An FDA briefing document published in advance of the committee meeting seemed to suggest the agency was satisfied with Acadia’s response.
 

Lack of diversity

The advisory committee disagreed, pointing to the same concerns raised last year. Members raised concerns about patient diversity in the HARMONY trial, which included an almost entirely White and mostly male study population.

In addition, although the findings at 26 weeks did demonstrate a marked improvement in psychosis symptoms overall, committee members noted that, again, those findings were largely driven by efficacy in patients with Parkinson’s disease dementia, for which the drug is already approved.

When discussing the phase 2 Study 019, the committee noted that while the study met the primary outcome of improvement in psychosis at 6 weeks, those positive responses were not found at any other timepoint in the 12-week study.  

“While it might have had a positive numerical effect in the study, the evidence is really not there to support it,” Dr. Follmann said.

Dr. Follmann and other committee members called for additional trials that focus on patients with Alzheimer’s disease, have a longer follow-up, and include more gender and racial diversity in the study population. They also called for more information about any off-label use of pimavanserin for ADP since it was approved for PDP in 2016.
 

An unmet need

Most individuals who testified during the public comment period pleaded with the committee to vote in favor of the new indication, sharing stories of family members and patients with ADP.

“I have been caring for and studying patients with Alzheimer’s disease and other dementias for more than 30 years, and I can tell you very simply that if left untreated, psychosis has significant and sometimes devastating consequences for our patients,” said Pierre Tariot, MD, director of the Banner Alzheimer’s Institute and a research professor of psychiatry at the University of Arizona College of Medicine, Tucson, and an investigator on the HARMONY trial.

Those on the committee who voted against the application were quick to agree that lack of an approved treatment for ADP presents a hardship.

“I’m a neurologist who has cared for patients for more than 20 years,” said Madhav R. Thambisetty, MD, PhD, senior investigator for the National Institute on Aging and an adjunct professor of neurology at Johns Hopkins University School of Medicine, Baltimore. “I recognize the unmet need in the field, I just think that the unmet need should not be a justification to cut corners.”

The committee did not focus on drug safety or unmet need in its deliberations, although information on both were presented during the meeting.

Commenting on his “no” vote, PDAC member Walter S. Dunn, MD, PhD, assistant clinical professor of psychiatry at the University of California, Los Angeles, and director of Interventional Psychiatry Service at West Los Angeles Veterans Affairs Medical Center, said he hopes that the FDA will consider those issues more broadly as they complete their review.

“The questions before the committee have been narrow and precise, so I trust the agency will take a broader approach in their final decision about approval,” Dr. Dunn said.

Commenting on the decision, Howard Fillit, MD, cofounder and chief science officer, Alzheimer’s Drug Discovery Foundation, called the news disappointing, “but while the unmet need for a treatment for ADP is clear, it is vital that approved treatments meet stringent safety and efficacy criteria so we can offer patients medications with clear benefits.”

The FDA will make its final decision by August 4.

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

During the coronavirus pandemic, several substance use behaviors decreased among youths, namely drinking, smoking, vaping, and cannabis use, according to a recent study published in the journal Current Psychiatry Reports.

That likely happened because they had to spend more time at home and less time with their friends, the study authors wrote, adding that youth substance use should be monitored in the post-pandemic years.

“One of the driving factors for youth substance use is access to substances,” Hannah Layman, one of the co-authors and a social and behavioral sciences doctoral student at West Virginia University, said in a statement.

“With stay-at-home orders, virtual schooling, and social distancing, children have been spending more time with family and are more socially isolated from peers than before,” she said. “Although social isolation from peers may have a negative impact on their mental health, it may just be one of the desirable outcomes of the pandemic when considering substance use in children.”

Ms. Layman and colleagues analyzed 49 studies that followed substance use of alcohol, cannabis, tobacco, e-cigarettes/vaping, and other drugs among children, teens, and youths under age 24. The studies spanned across several countries, including 22 in North America and 19 in Europe.

The research team found that most studies across all categories reported reductions in prevalence, except for the category of “other drugs and unspecific drugs,” which included three studies that showed an increase in use and three studies that showed a decrease in use.

Teens and preteens tend to have easier access to alcohol, tobacco, cannabis products, and vaping products and see them as less serious than “hard drugs,” the authors said.

Future research should analyze the long-term effects of the pandemic on youth substance use, the study authors wrote, paying attention to differences by gender and those who face the highest risks for substance use. Previous studies have shown an increase in substance use among youths, particularly among those in low-income neighborhoods or in difficult family circumstances.

“Substance use can affect a young person’s body in many ways, such as the development of mental health issues (depression, anxiety, conduct problems, personality disorders, and suicidal thoughts), injuries due to accidents, decreased bone mineral density, preventing proper brain growth and function, delayed puberty, liver damage, and so much more,” Ms. Layman said.

Increased parent or caregiver supervision can help prevent substance use problems, she noted. Early intervention, open support in conversations, and ongoing education about the dangers of substance use can help as well.

“Our findings also identified the importance of improving youth mental health and the value of telemedicine to address young people’s needs during the pandemic,” she said.

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

During the coronavirus pandemic, several substance use behaviors decreased among youths, namely drinking, smoking, vaping, and cannabis use, according to a recent study published in the journal Current Psychiatry Reports.

That likely happened because they had to spend more time at home and less time with their friends, the study authors wrote, adding that youth substance use should be monitored in the post-pandemic years.

“One of the driving factors for youth substance use is access to substances,” Hannah Layman, one of the co-authors and a social and behavioral sciences doctoral student at West Virginia University, said in a statement.

“With stay-at-home orders, virtual schooling, and social distancing, children have been spending more time with family and are more socially isolated from peers than before,” she said. “Although social isolation from peers may have a negative impact on their mental health, it may just be one of the desirable outcomes of the pandemic when considering substance use in children.”

Ms. Layman and colleagues analyzed 49 studies that followed substance use of alcohol, cannabis, tobacco, e-cigarettes/vaping, and other drugs among children, teens, and youths under age 24. The studies spanned across several countries, including 22 in North America and 19 in Europe.

The research team found that most studies across all categories reported reductions in prevalence, except for the category of “other drugs and unspecific drugs,” which included three studies that showed an increase in use and three studies that showed a decrease in use.

Teens and preteens tend to have easier access to alcohol, tobacco, cannabis products, and vaping products and see them as less serious than “hard drugs,” the authors said.

Future research should analyze the long-term effects of the pandemic on youth substance use, the study authors wrote, paying attention to differences by gender and those who face the highest risks for substance use. Previous studies have shown an increase in substance use among youths, particularly among those in low-income neighborhoods or in difficult family circumstances.

“Substance use can affect a young person’s body in many ways, such as the development of mental health issues (depression, anxiety, conduct problems, personality disorders, and suicidal thoughts), injuries due to accidents, decreased bone mineral density, preventing proper brain growth and function, delayed puberty, liver damage, and so much more,” Ms. Layman said.

Increased parent or caregiver supervision can help prevent substance use problems, she noted. Early intervention, open support in conversations, and ongoing education about the dangers of substance use can help as well.

“Our findings also identified the importance of improving youth mental health and the value of telemedicine to address young people’s needs during the pandemic,” she said.

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

During the coronavirus pandemic, several substance use behaviors decreased among youths, namely drinking, smoking, vaping, and cannabis use, according to a recent study published in the journal Current Psychiatry Reports.

That likely happened because they had to spend more time at home and less time with their friends, the study authors wrote, adding that youth substance use should be monitored in the post-pandemic years.

“One of the driving factors for youth substance use is access to substances,” Hannah Layman, one of the co-authors and a social and behavioral sciences doctoral student at West Virginia University, said in a statement.

“With stay-at-home orders, virtual schooling, and social distancing, children have been spending more time with family and are more socially isolated from peers than before,” she said. “Although social isolation from peers may have a negative impact on their mental health, it may just be one of the desirable outcomes of the pandemic when considering substance use in children.”

Ms. Layman and colleagues analyzed 49 studies that followed substance use of alcohol, cannabis, tobacco, e-cigarettes/vaping, and other drugs among children, teens, and youths under age 24. The studies spanned across several countries, including 22 in North America and 19 in Europe.

The research team found that most studies across all categories reported reductions in prevalence, except for the category of “other drugs and unspecific drugs,” which included three studies that showed an increase in use and three studies that showed a decrease in use.

Teens and preteens tend to have easier access to alcohol, tobacco, cannabis products, and vaping products and see them as less serious than “hard drugs,” the authors said.

Future research should analyze the long-term effects of the pandemic on youth substance use, the study authors wrote, paying attention to differences by gender and those who face the highest risks for substance use. Previous studies have shown an increase in substance use among youths, particularly among those in low-income neighborhoods or in difficult family circumstances.

“Substance use can affect a young person’s body in many ways, such as the development of mental health issues (depression, anxiety, conduct problems, personality disorders, and suicidal thoughts), injuries due to accidents, decreased bone mineral density, preventing proper brain growth and function, delayed puberty, liver damage, and so much more,” Ms. Layman said.

Increased parent or caregiver supervision can help prevent substance use problems, she noted. Early intervention, open support in conversations, and ongoing education about the dangers of substance use can help as well.

“Our findings also identified the importance of improving youth mental health and the value of telemedicine to address young people’s needs during the pandemic,” she said.

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

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Illinois has a new law designed to boost the mental health care workforce at a time when it has been devastated by the COVID-19 pandemic, say state leaders.

Governor J.B. Pritzker (D) signed the legislation, which took effect on June 10.

The law seeks to attract psychologists, social workers, and counselors who have left the workforce within the past 5 years by temporarily ending relicensing requirements, including the need for continuing education credit completion, passing new exams, and fee payments. It also eases the process for those practicing in other states to become licensed in Illinois.

State legislators said there is currently a crushing need for mental health providers, estimating that there are only 14 behavioral health care professionals for every 10,000 Illinois residents. The preamble to the law noted that there will be 8,353 unfilled mental health care jobs in Illinois by 2026.

“We need a mental health care workforce that is robust enough to get people help when they need it – not after months on a waiting list,” Governor Pritzker said in news release. “This legislation invests in mental health infrastructure – and that infrastructure is people,” he added.
 

Grant pathway

“Being told you have to wait weeks – or months – for care is extremely discouraging,” State Senator Laura Fine (D), a lead sponsor of the legislation, noted in the release.

“We need to support people struggling with mental and behavioral health issues, as well as address difficulties our mental health providers are facing trying to see as many patients as possible,” said Senator Fine.

Marvin Lindsey, CEO of the Community Behavioral Healthcare Association, added that the law would “accelerate the process for out-of-state professionals to obtain their Illinois licensure and [increase] the pipeline and diversity of the behavioral health workforce by implementing a funding mechanism that supports new or existing licensure training of interns.”

The law sets up a grant pathway for community mental health centers, which often serve as training sites. The grants would provide funds to establish or enhance training and supervision of interns and behavioral health providers-in-training seeking to become licensed clinical social workers, licensed clinical professional counselors, or licensed marriage and family therapists.

The money for those grants still has to be appropriated.

The law will also allow patient visits at Specialized Mental Health Rehabilitation Facilities conducted by either a psychiatrist or an advanced practice registered mental health or psychiatric nurse.

Finally, it would establish tax credits for employers who hire individuals in recovery from a substance use disorder or a behavioral disorder. Beginning in January 2023, employers will be eligible for up to $2,000 in credits per employee hired.

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

Illinois has a new law designed to boost the mental health care workforce at a time when it has been devastated by the COVID-19 pandemic, say state leaders.

Governor J.B. Pritzker (D) signed the legislation, which took effect on June 10.

The law seeks to attract psychologists, social workers, and counselors who have left the workforce within the past 5 years by temporarily ending relicensing requirements, including the need for continuing education credit completion, passing new exams, and fee payments. It also eases the process for those practicing in other states to become licensed in Illinois.

State legislators said there is currently a crushing need for mental health providers, estimating that there are only 14 behavioral health care professionals for every 10,000 Illinois residents. The preamble to the law noted that there will be 8,353 unfilled mental health care jobs in Illinois by 2026.

“We need a mental health care workforce that is robust enough to get people help when they need it – not after months on a waiting list,” Governor Pritzker said in news release. “This legislation invests in mental health infrastructure – and that infrastructure is people,” he added.
 

Grant pathway

“Being told you have to wait weeks – or months – for care is extremely discouraging,” State Senator Laura Fine (D), a lead sponsor of the legislation, noted in the release.

“We need to support people struggling with mental and behavioral health issues, as well as address difficulties our mental health providers are facing trying to see as many patients as possible,” said Senator Fine.

Marvin Lindsey, CEO of the Community Behavioral Healthcare Association, added that the law would “accelerate the process for out-of-state professionals to obtain their Illinois licensure and [increase] the pipeline and diversity of the behavioral health workforce by implementing a funding mechanism that supports new or existing licensure training of interns.”

The law sets up a grant pathway for community mental health centers, which often serve as training sites. The grants would provide funds to establish or enhance training and supervision of interns and behavioral health providers-in-training seeking to become licensed clinical social workers, licensed clinical professional counselors, or licensed marriage and family therapists.

The money for those grants still has to be appropriated.

The law will also allow patient visits at Specialized Mental Health Rehabilitation Facilities conducted by either a psychiatrist or an advanced practice registered mental health or psychiatric nurse.

Finally, it would establish tax credits for employers who hire individuals in recovery from a substance use disorder or a behavioral disorder. Beginning in January 2023, employers will be eligible for up to $2,000 in credits per employee hired.

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

Illinois has a new law designed to boost the mental health care workforce at a time when it has been devastated by the COVID-19 pandemic, say state leaders.

Governor J.B. Pritzker (D) signed the legislation, which took effect on June 10.

The law seeks to attract psychologists, social workers, and counselors who have left the workforce within the past 5 years by temporarily ending relicensing requirements, including the need for continuing education credit completion, passing new exams, and fee payments. It also eases the process for those practicing in other states to become licensed in Illinois.

State legislators said there is currently a crushing need for mental health providers, estimating that there are only 14 behavioral health care professionals for every 10,000 Illinois residents. The preamble to the law noted that there will be 8,353 unfilled mental health care jobs in Illinois by 2026.

“We need a mental health care workforce that is robust enough to get people help when they need it – not after months on a waiting list,” Governor Pritzker said in news release. “This legislation invests in mental health infrastructure – and that infrastructure is people,” he added.
 

Grant pathway

“Being told you have to wait weeks – or months – for care is extremely discouraging,” State Senator Laura Fine (D), a lead sponsor of the legislation, noted in the release.

“We need to support people struggling with mental and behavioral health issues, as well as address difficulties our mental health providers are facing trying to see as many patients as possible,” said Senator Fine.

Marvin Lindsey, CEO of the Community Behavioral Healthcare Association, added that the law would “accelerate the process for out-of-state professionals to obtain their Illinois licensure and [increase] the pipeline and diversity of the behavioral health workforce by implementing a funding mechanism that supports new or existing licensure training of interns.”

The law sets up a grant pathway for community mental health centers, which often serve as training sites. The grants would provide funds to establish or enhance training and supervision of interns and behavioral health providers-in-training seeking to become licensed clinical social workers, licensed clinical professional counselors, or licensed marriage and family therapists.

The money for those grants still has to be appropriated.

The law will also allow patient visits at Specialized Mental Health Rehabilitation Facilities conducted by either a psychiatrist or an advanced practice registered mental health or psychiatric nurse.

Finally, it would establish tax credits for employers who hire individuals in recovery from a substance use disorder or a behavioral disorder. Beginning in January 2023, employers will be eligible for up to $2,000 in credits per employee hired.

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

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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