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Excessive drooling is a sign of greater dysfunction in patients with Parkinson’s disease
, new research shows. “Sialorrhea is not just a cosmetic problem,” study investigator Francesca Morgante, MD, associate professor of neurology, St. George’s University, London, told this news organization.
“We need to understand the relationship between sialorrhea and these speech and swallowing disturbances and whether treatment for sialorrhea improves that,” Dr. Morgante added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Underrecognized symptom
Sialorrhea is an underrecognized nonmotor symptom that can affect up to 70% of patients with Parkinson’s disease, said co-investigator Ioana Cociasu, PhD, postdoctoral research fellow, Neurosciences Research Center, St. George’s University. The impact on quality of life increases with disease severity, she said.
The current study included 101 consecutive patients attending an advanced Parkinson’s disease disorders clinic. Researchers collected demographic data that included information on gender, age, age at Parkinson’s disease onset, and disease duration. They also gathered data on motor symptoms by assessing total levodopa equivalent daily dose (LEDD) and LEDD dopamine agonists. They also assessed results on the Unified Parkinson’s Disease Rating Scale (UPDRS) part III and the Hoehn and Yahr scale for on- and off-medication states.
Nonmotor functioning was assessed using the Non-Motor Symptoms Scale (NMSS) and Scales for Outcomes in Parkinson’s disease–autonomic dysfunction (SCOPA-AUT) questionnaire. Among patients with Parkinson’s disease, autonomic dysfunction can precede motor impairment and can involve orthostatic and postprandial hypotension, among other symptoms, the investigators noted.
Health status and quality of life were assessed using the Parkinson’s disease questionnaire–39 items (PDQ-39). The Radboud Oral Motor Inventory for PD (ROMP) was used to measure orofacial symptoms. ROMP is a self-administered questionnaire that evaluates speech, swallowing disturbances, and drooling of saliva. The Montreal Cognitive Assessment test was also used.
Investigators compared participants with sialorrhea to those without sialorrhea, described as droolers and nondroolers. Droolers were defined as those scoring higher than 1 on the UPDRS-II item 6. This signified slight but definite presence of saliva in the mouth and/or the possibility of nighttime drooling.
Greater impairment
Among the participants, 65 (64.4%) were classified as droolers, and 36 (35.6%) as nondroolers.
Patients with both Parkinson’s disease and sialorrhea were significantly more impaired in terms of motor functioning than those without sialorrhea. In these patients, the UPDRS-III was more severe in both the off- (P = .03) and on-states (P = .002), and they had less improvement with the levodopa challenge test (P = .007).
Droolers were also more severely affected by nonmotor problems. They had more severe speech dysfunction (P < .0001) and swallowing dysfunction (P < .05), and they had higher scores on the NMSS (P = .0008) and SCOPA-AUT (P = .003) and poorer quality-of-life scores on the PDQ-39 (P = .049).
To evaluate respiratory tract infections, the researchers used electronic health records. About 15.4% of the study population had had a documented respiratory infection since they were diagnosed with Parkinson’s disease.
Upper and lower respiratory tract infections were more frequent among droolers than nondroolers (P = .05).
“Infections might arise from swallowing disturbances leading to aspiration and drooling,” Dr. Morgante noted.
The drooling did not appear to affect cognition or sleep in these patients.
Treatment options?
Following the study presentation, session co-chair Philippe G. Damier, MD, PhD, professor of neurology, University Hospital, Nantes, France, asked about the best treatment for sialorrhea for these patients.
In general, those with milder disease might try chewing gum to improve swallowing; patients with more severe cases may benefit from botulinum toxin injections, said Dr. Cociasu. The treatment choice, she added, “very much depends on the severity of the sialorrhea.”
Botulinum toxin therapy involves injections into the salivary gland to reduce saliva production. It is typically administered about every 4 months.
The second session co-chair, Elena Moro, MD, PhD, director of the Movement Disorders Unit at Grenoble Alpes University, France, pointed out that chewing gum may be a swallowing hazard for patients with PD and severe dementia.
Asked by Dr. Moro whether patients with higher scores on balance and posture were more likely to have sialorrhea, Dr. Cociasu said she and her colleagues are currently looking into this.
Dr. Morgante said that the current study did not examine the effect of treatment on speech disorders associated with sialorrhea. “We are running another study now to understand the effect of treatment of sialorrhea on these features,” she said.
Dr. Morgante and Dr. Cociasu have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, new research shows. “Sialorrhea is not just a cosmetic problem,” study investigator Francesca Morgante, MD, associate professor of neurology, St. George’s University, London, told this news organization.
“We need to understand the relationship between sialorrhea and these speech and swallowing disturbances and whether treatment for sialorrhea improves that,” Dr. Morgante added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Underrecognized symptom
Sialorrhea is an underrecognized nonmotor symptom that can affect up to 70% of patients with Parkinson’s disease, said co-investigator Ioana Cociasu, PhD, postdoctoral research fellow, Neurosciences Research Center, St. George’s University. The impact on quality of life increases with disease severity, she said.
The current study included 101 consecutive patients attending an advanced Parkinson’s disease disorders clinic. Researchers collected demographic data that included information on gender, age, age at Parkinson’s disease onset, and disease duration. They also gathered data on motor symptoms by assessing total levodopa equivalent daily dose (LEDD) and LEDD dopamine agonists. They also assessed results on the Unified Parkinson’s Disease Rating Scale (UPDRS) part III and the Hoehn and Yahr scale for on- and off-medication states.
Nonmotor functioning was assessed using the Non-Motor Symptoms Scale (NMSS) and Scales for Outcomes in Parkinson’s disease–autonomic dysfunction (SCOPA-AUT) questionnaire. Among patients with Parkinson’s disease, autonomic dysfunction can precede motor impairment and can involve orthostatic and postprandial hypotension, among other symptoms, the investigators noted.
Health status and quality of life were assessed using the Parkinson’s disease questionnaire–39 items (PDQ-39). The Radboud Oral Motor Inventory for PD (ROMP) was used to measure orofacial symptoms. ROMP is a self-administered questionnaire that evaluates speech, swallowing disturbances, and drooling of saliva. The Montreal Cognitive Assessment test was also used.
Investigators compared participants with sialorrhea to those without sialorrhea, described as droolers and nondroolers. Droolers were defined as those scoring higher than 1 on the UPDRS-II item 6. This signified slight but definite presence of saliva in the mouth and/or the possibility of nighttime drooling.
Greater impairment
Among the participants, 65 (64.4%) were classified as droolers, and 36 (35.6%) as nondroolers.
Patients with both Parkinson’s disease and sialorrhea were significantly more impaired in terms of motor functioning than those without sialorrhea. In these patients, the UPDRS-III was more severe in both the off- (P = .03) and on-states (P = .002), and they had less improvement with the levodopa challenge test (P = .007).
Droolers were also more severely affected by nonmotor problems. They had more severe speech dysfunction (P < .0001) and swallowing dysfunction (P < .05), and they had higher scores on the NMSS (P = .0008) and SCOPA-AUT (P = .003) and poorer quality-of-life scores on the PDQ-39 (P = .049).
To evaluate respiratory tract infections, the researchers used electronic health records. About 15.4% of the study population had had a documented respiratory infection since they were diagnosed with Parkinson’s disease.
Upper and lower respiratory tract infections were more frequent among droolers than nondroolers (P = .05).
“Infections might arise from swallowing disturbances leading to aspiration and drooling,” Dr. Morgante noted.
The drooling did not appear to affect cognition or sleep in these patients.
Treatment options?
Following the study presentation, session co-chair Philippe G. Damier, MD, PhD, professor of neurology, University Hospital, Nantes, France, asked about the best treatment for sialorrhea for these patients.
In general, those with milder disease might try chewing gum to improve swallowing; patients with more severe cases may benefit from botulinum toxin injections, said Dr. Cociasu. The treatment choice, she added, “very much depends on the severity of the sialorrhea.”
Botulinum toxin therapy involves injections into the salivary gland to reduce saliva production. It is typically administered about every 4 months.
The second session co-chair, Elena Moro, MD, PhD, director of the Movement Disorders Unit at Grenoble Alpes University, France, pointed out that chewing gum may be a swallowing hazard for patients with PD and severe dementia.
Asked by Dr. Moro whether patients with higher scores on balance and posture were more likely to have sialorrhea, Dr. Cociasu said she and her colleagues are currently looking into this.
Dr. Morgante said that the current study did not examine the effect of treatment on speech disorders associated with sialorrhea. “We are running another study now to understand the effect of treatment of sialorrhea on these features,” she said.
Dr. Morgante and Dr. Cociasu have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, new research shows. “Sialorrhea is not just a cosmetic problem,” study investigator Francesca Morgante, MD, associate professor of neurology, St. George’s University, London, told this news organization.
“We need to understand the relationship between sialorrhea and these speech and swallowing disturbances and whether treatment for sialorrhea improves that,” Dr. Morgante added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Underrecognized symptom
Sialorrhea is an underrecognized nonmotor symptom that can affect up to 70% of patients with Parkinson’s disease, said co-investigator Ioana Cociasu, PhD, postdoctoral research fellow, Neurosciences Research Center, St. George’s University. The impact on quality of life increases with disease severity, she said.
The current study included 101 consecutive patients attending an advanced Parkinson’s disease disorders clinic. Researchers collected demographic data that included information on gender, age, age at Parkinson’s disease onset, and disease duration. They also gathered data on motor symptoms by assessing total levodopa equivalent daily dose (LEDD) and LEDD dopamine agonists. They also assessed results on the Unified Parkinson’s Disease Rating Scale (UPDRS) part III and the Hoehn and Yahr scale for on- and off-medication states.
Nonmotor functioning was assessed using the Non-Motor Symptoms Scale (NMSS) and Scales for Outcomes in Parkinson’s disease–autonomic dysfunction (SCOPA-AUT) questionnaire. Among patients with Parkinson’s disease, autonomic dysfunction can precede motor impairment and can involve orthostatic and postprandial hypotension, among other symptoms, the investigators noted.
Health status and quality of life were assessed using the Parkinson’s disease questionnaire–39 items (PDQ-39). The Radboud Oral Motor Inventory for PD (ROMP) was used to measure orofacial symptoms. ROMP is a self-administered questionnaire that evaluates speech, swallowing disturbances, and drooling of saliva. The Montreal Cognitive Assessment test was also used.
Investigators compared participants with sialorrhea to those without sialorrhea, described as droolers and nondroolers. Droolers were defined as those scoring higher than 1 on the UPDRS-II item 6. This signified slight but definite presence of saliva in the mouth and/or the possibility of nighttime drooling.
Greater impairment
Among the participants, 65 (64.4%) were classified as droolers, and 36 (35.6%) as nondroolers.
Patients with both Parkinson’s disease and sialorrhea were significantly more impaired in terms of motor functioning than those without sialorrhea. In these patients, the UPDRS-III was more severe in both the off- (P = .03) and on-states (P = .002), and they had less improvement with the levodopa challenge test (P = .007).
Droolers were also more severely affected by nonmotor problems. They had more severe speech dysfunction (P < .0001) and swallowing dysfunction (P < .05), and they had higher scores on the NMSS (P = .0008) and SCOPA-AUT (P = .003) and poorer quality-of-life scores on the PDQ-39 (P = .049).
To evaluate respiratory tract infections, the researchers used electronic health records. About 15.4% of the study population had had a documented respiratory infection since they were diagnosed with Parkinson’s disease.
Upper and lower respiratory tract infections were more frequent among droolers than nondroolers (P = .05).
“Infections might arise from swallowing disturbances leading to aspiration and drooling,” Dr. Morgante noted.
The drooling did not appear to affect cognition or sleep in these patients.
Treatment options?
Following the study presentation, session co-chair Philippe G. Damier, MD, PhD, professor of neurology, University Hospital, Nantes, France, asked about the best treatment for sialorrhea for these patients.
In general, those with milder disease might try chewing gum to improve swallowing; patients with more severe cases may benefit from botulinum toxin injections, said Dr. Cociasu. The treatment choice, she added, “very much depends on the severity of the sialorrhea.”
Botulinum toxin therapy involves injections into the salivary gland to reduce saliva production. It is typically administered about every 4 months.
The second session co-chair, Elena Moro, MD, PhD, director of the Movement Disorders Unit at Grenoble Alpes University, France, pointed out that chewing gum may be a swallowing hazard for patients with PD and severe dementia.
Asked by Dr. Moro whether patients with higher scores on balance and posture were more likely to have sialorrhea, Dr. Cociasu said she and her colleagues are currently looking into this.
Dr. Morgante said that the current study did not examine the effect of treatment on speech disorders associated with sialorrhea. “We are running another study now to understand the effect of treatment of sialorrhea on these features,” she said.
Dr. Morgante and Dr. Cociasu have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
From EAN 2021
Women with migraine are ‘high-risk’ patients during pregnancy
new research suggests. Although pregnancy is generally considered a “safe period” for women with migraine, “we actually found they have more diabetes, more hypertension, more blood clots, more complications during their delivery, and more postpartum complications,” said study investigator Nirit Lev, MD, PhD, head, department of neurology, Meir Medical Center, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University.
The results highlight the need for clinicians “to take people with migraines seriously” and reinforce the idea that migraine is not “just a headache,” said Dr. Lev.
Pregnant women with migraine should be considered high risk and have specialized neurologic follow-up during pregnancy and the postpartum period, she added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Prevalent, disabling
Migraine is one of the most prevalent and disabling neurologic disorders. Such disorders are major causes of death and disability.
In childhood, there’s no difference between the sexes in terms of migraine prevalence, but after puberty, migraine is about three times more common in women than men. Fluctuating levels of estrogen and progesterone likely explain these differences, said Dr. Lev.
The prevalence of migraine among females peaks during their reproductive years. Most female migraine patients report an improvement in headache symptoms during pregnancy, with some experiencing a “complete remission.” However, a minority report worsening of migraine when expecting a child, said Dr. Lev.
Some patients have their first aura during pregnancy. The most common migraine aura is visual, a problem with the visual field that can affect motor and sensory functioning, said Dr. Lev.
Managing migraine during pregnancy is “very complicated,” said Dr. Lev. She said the first-line treatment is paracetamol (acetaminophen) and stressed that taking opioids should be avoided.
Retrospective database study
For the study, the researchers retrospectively reviewed pregnancy and delivery records from a database of Clalit Medical Services, which has more than 4.5 million members and is the largest such database in Israel. They collected demographic data and information on mode of delivery, medical and obstetric complications, hospitalizations, emergency department visits, use of medications, laboratory reports, and medical consultations.
The study included 145,102 women who gave birth from 2014 to 2020.
Of these, 10,646 had migraine without aura, and 1,576 had migraine with aura. The migraine diagnoses, which were based on International Headache Society criteria and diagnostic codes, were made prior to pregnancy.
Dr. Lev noted that the number of patients with migraine is likely an underestimation because migraine is “not always diagnosed.”
Results showed that the risk for obstetric complications was higher among pregnant women with migraine, especially those with aura, in comparison with women without migraine. About 6.9% of patients with migraine without aura were admitted to high-risk hospital departments, compared with 6% of pregnant control patients who did not have migraine (P < .0001). For patients with migraine with aura, the risk for admissions was even higher (8.7%; P < .0001 vs. control patients and P < .03 vs. patients with migraine without aura) and was “very highly statistically significant,” said Dr. Lev.
Pregnant women with migraine were at significantly increased risk for gestational diabetes, hyperlipidemia, and being diagnosed with a psychiatric disorder (all P < .0001). These women were also more likely to experience preeclampsia and blood clots (P < .0001).
Unexpected finding
The finding that the risk for diabetes was higher was “unexpected,” inasmuch as older women with migraine are typically at increased risk for metabolic syndrome and higher body mass index, said Dr. Lev.
Migraine patients had significantly more consultations with family physicians, gynecologists, and neurologists (P < .0001). In addition, they were more likely to utilize emergency services; take more medications, mostly analgesics; and undergo more laboratory studies and brain imaging.
Those with aura had significantly more specialist consultations and took more medications compared with migraine patients without aura.
There was a statistically significant increase in the use of epidural anesthesia for migraine patients (40.5% of women without migraine; 45.7% of those with migraine accompanied by aura; and 47.5% of migraine patients without aura).
This was an “interesting” finding, said Dr. Lev. “We didn’t know what to expect; people with migraine are used to pain, so the question was, will they tolerate pain better or be more afraid of pain?”
Women with migraine also experienced more assisted deliveries with increased use of vacuums and forceps.
During the 3-month postpartum period, women with migraine sought more medical consultations and used more medications compared with control patients. They also underwent more lab examinations and more brain imaging during this period.
Dr. Lev noted that some of these evaluations may have been postponed because of the pregnancy.
Women with migraine also had a greater risk for postpartum depression, which Dr. Lev found “concerning.” She noted that depression is often underreported but is treatable. Women with migraine should be monitored for depression post partum, she said.
It’s unclear which factors contribute to the increased risk for pregnancy complications in women with migraine. Dr. Lev said she doesn’t believe it’s drug related.
“Although they’re taking more medications than people who don’t have migraine, we still are giving very low doses and only safe medicines, so I don’t think these increased risks are side effects,” she said.
She noted that women with migraine have more cardiovascular complications, including stroke and myocardial infarction, although these generally affect older patients.
Dr. Lev also noted that pain, especially chronic pain, can cause depression. “We know that people with migraine have more depression and anxiety, so maybe that also affects them during their pregnancy and after,” she said.
She suggested that pregnant women with migraine be considered high risk and be managed via specialized clinics.
Room for improvement
Commenting on the research, Lauren Doyle Strauss, DO, associate professor of neurology, Wake Forest University, Winston-Salem, N.C., who has written about the management of migraine during pregnancy, said studies such as this help raise awareness about pregnancy risks in migraine patients. Dr. Strauss did not attend the live presentation but is aware of the findings.
The increased use of epidurals during delivery among migraine patients in the study makes some sense, said Dr. Strauss. “It kind of shows a comfort level with medicines.”
She expressed concern that such research may be “skewed” because it includes patients with more severe migraine. If less severe cases were included in this research, “maybe there would still be higher risks, but not as high as what we have been finding in some of our studies,” she said.
Dr. Strauss said she feels the medical community should do a better job of identifying and diagnosing migraine. She said she would like to see migraine screening become a routine part of obstetric/gynecologic care. Doctors should counsel migraine patients who wish to become pregnant about potential risks, said Dr. Strauss. “We need to be up front in telling them when to seek care and when to report symptoms and not to wait for it to become super severe,” she said.
She also believes doctors should be “proactive” in helping patients develop a treatment plan before becoming pregnant, because the limited pain control options available for pregnant patients can take time to have an effect.
Also commenting on the study findings, Nina Riggins, MD, PhD, clinical associate professor of neurology at the University of California, San Francisco, said the study raises “important questions” and has “important aims.”
She believes the study reinforces the importance of collaboration between experts in primary care, obstetrics/gynecology, and neurology. However, she was surprised at some of the investigators’ assertions that there are no differences in migraine among prepubertal children and that the course of migraine for men is stable throughout their life span.
“There is literature that supports the view that the prevalence in boys is higher in prepuberty, and studies do show that migraine prevalence decreases in older adults – men and women,” she said.
There is still not enough evidence to determine that antiemetics and triptans are safe during pregnancy or that pregnant women with migraine should be taking acetylsalicylic acid, said Dr. Riggins.
The investigators, Dr. Strauss, and Dr. Riggins have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests. Although pregnancy is generally considered a “safe period” for women with migraine, “we actually found they have more diabetes, more hypertension, more blood clots, more complications during their delivery, and more postpartum complications,” said study investigator Nirit Lev, MD, PhD, head, department of neurology, Meir Medical Center, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University.
The results highlight the need for clinicians “to take people with migraines seriously” and reinforce the idea that migraine is not “just a headache,” said Dr. Lev.
Pregnant women with migraine should be considered high risk and have specialized neurologic follow-up during pregnancy and the postpartum period, she added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Prevalent, disabling
Migraine is one of the most prevalent and disabling neurologic disorders. Such disorders are major causes of death and disability.
In childhood, there’s no difference between the sexes in terms of migraine prevalence, but after puberty, migraine is about three times more common in women than men. Fluctuating levels of estrogen and progesterone likely explain these differences, said Dr. Lev.
The prevalence of migraine among females peaks during their reproductive years. Most female migraine patients report an improvement in headache symptoms during pregnancy, with some experiencing a “complete remission.” However, a minority report worsening of migraine when expecting a child, said Dr. Lev.
Some patients have their first aura during pregnancy. The most common migraine aura is visual, a problem with the visual field that can affect motor and sensory functioning, said Dr. Lev.
Managing migraine during pregnancy is “very complicated,” said Dr. Lev. She said the first-line treatment is paracetamol (acetaminophen) and stressed that taking opioids should be avoided.
Retrospective database study
For the study, the researchers retrospectively reviewed pregnancy and delivery records from a database of Clalit Medical Services, which has more than 4.5 million members and is the largest such database in Israel. They collected demographic data and information on mode of delivery, medical and obstetric complications, hospitalizations, emergency department visits, use of medications, laboratory reports, and medical consultations.
The study included 145,102 women who gave birth from 2014 to 2020.
Of these, 10,646 had migraine without aura, and 1,576 had migraine with aura. The migraine diagnoses, which were based on International Headache Society criteria and diagnostic codes, were made prior to pregnancy.
Dr. Lev noted that the number of patients with migraine is likely an underestimation because migraine is “not always diagnosed.”
Results showed that the risk for obstetric complications was higher among pregnant women with migraine, especially those with aura, in comparison with women without migraine. About 6.9% of patients with migraine without aura were admitted to high-risk hospital departments, compared with 6% of pregnant control patients who did not have migraine (P < .0001). For patients with migraine with aura, the risk for admissions was even higher (8.7%; P < .0001 vs. control patients and P < .03 vs. patients with migraine without aura) and was “very highly statistically significant,” said Dr. Lev.
Pregnant women with migraine were at significantly increased risk for gestational diabetes, hyperlipidemia, and being diagnosed with a psychiatric disorder (all P < .0001). These women were also more likely to experience preeclampsia and blood clots (P < .0001).
Unexpected finding
The finding that the risk for diabetes was higher was “unexpected,” inasmuch as older women with migraine are typically at increased risk for metabolic syndrome and higher body mass index, said Dr. Lev.
Migraine patients had significantly more consultations with family physicians, gynecologists, and neurologists (P < .0001). In addition, they were more likely to utilize emergency services; take more medications, mostly analgesics; and undergo more laboratory studies and brain imaging.
Those with aura had significantly more specialist consultations and took more medications compared with migraine patients without aura.
There was a statistically significant increase in the use of epidural anesthesia for migraine patients (40.5% of women without migraine; 45.7% of those with migraine accompanied by aura; and 47.5% of migraine patients without aura).
This was an “interesting” finding, said Dr. Lev. “We didn’t know what to expect; people with migraine are used to pain, so the question was, will they tolerate pain better or be more afraid of pain?”
Women with migraine also experienced more assisted deliveries with increased use of vacuums and forceps.
During the 3-month postpartum period, women with migraine sought more medical consultations and used more medications compared with control patients. They also underwent more lab examinations and more brain imaging during this period.
Dr. Lev noted that some of these evaluations may have been postponed because of the pregnancy.
Women with migraine also had a greater risk for postpartum depression, which Dr. Lev found “concerning.” She noted that depression is often underreported but is treatable. Women with migraine should be monitored for depression post partum, she said.
It’s unclear which factors contribute to the increased risk for pregnancy complications in women with migraine. Dr. Lev said she doesn’t believe it’s drug related.
“Although they’re taking more medications than people who don’t have migraine, we still are giving very low doses and only safe medicines, so I don’t think these increased risks are side effects,” she said.
She noted that women with migraine have more cardiovascular complications, including stroke and myocardial infarction, although these generally affect older patients.
Dr. Lev also noted that pain, especially chronic pain, can cause depression. “We know that people with migraine have more depression and anxiety, so maybe that also affects them during their pregnancy and after,” she said.
She suggested that pregnant women with migraine be considered high risk and be managed via specialized clinics.
Room for improvement
Commenting on the research, Lauren Doyle Strauss, DO, associate professor of neurology, Wake Forest University, Winston-Salem, N.C., who has written about the management of migraine during pregnancy, said studies such as this help raise awareness about pregnancy risks in migraine patients. Dr. Strauss did not attend the live presentation but is aware of the findings.
The increased use of epidurals during delivery among migraine patients in the study makes some sense, said Dr. Strauss. “It kind of shows a comfort level with medicines.”
She expressed concern that such research may be “skewed” because it includes patients with more severe migraine. If less severe cases were included in this research, “maybe there would still be higher risks, but not as high as what we have been finding in some of our studies,” she said.
Dr. Strauss said she feels the medical community should do a better job of identifying and diagnosing migraine. She said she would like to see migraine screening become a routine part of obstetric/gynecologic care. Doctors should counsel migraine patients who wish to become pregnant about potential risks, said Dr. Strauss. “We need to be up front in telling them when to seek care and when to report symptoms and not to wait for it to become super severe,” she said.
She also believes doctors should be “proactive” in helping patients develop a treatment plan before becoming pregnant, because the limited pain control options available for pregnant patients can take time to have an effect.
Also commenting on the study findings, Nina Riggins, MD, PhD, clinical associate professor of neurology at the University of California, San Francisco, said the study raises “important questions” and has “important aims.”
She believes the study reinforces the importance of collaboration between experts in primary care, obstetrics/gynecology, and neurology. However, she was surprised at some of the investigators’ assertions that there are no differences in migraine among prepubertal children and that the course of migraine for men is stable throughout their life span.
“There is literature that supports the view that the prevalence in boys is higher in prepuberty, and studies do show that migraine prevalence decreases in older adults – men and women,” she said.
There is still not enough evidence to determine that antiemetics and triptans are safe during pregnancy or that pregnant women with migraine should be taking acetylsalicylic acid, said Dr. Riggins.
The investigators, Dr. Strauss, and Dr. Riggins have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests. Although pregnancy is generally considered a “safe period” for women with migraine, “we actually found they have more diabetes, more hypertension, more blood clots, more complications during their delivery, and more postpartum complications,” said study investigator Nirit Lev, MD, PhD, head, department of neurology, Meir Medical Center, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University.
The results highlight the need for clinicians “to take people with migraines seriously” and reinforce the idea that migraine is not “just a headache,” said Dr. Lev.
Pregnant women with migraine should be considered high risk and have specialized neurologic follow-up during pregnancy and the postpartum period, she added.
The findings were presented at the 2021 Congress of the European Academy of Neurology.
Prevalent, disabling
Migraine is one of the most prevalent and disabling neurologic disorders. Such disorders are major causes of death and disability.
In childhood, there’s no difference between the sexes in terms of migraine prevalence, but after puberty, migraine is about three times more common in women than men. Fluctuating levels of estrogen and progesterone likely explain these differences, said Dr. Lev.
The prevalence of migraine among females peaks during their reproductive years. Most female migraine patients report an improvement in headache symptoms during pregnancy, with some experiencing a “complete remission.” However, a minority report worsening of migraine when expecting a child, said Dr. Lev.
Some patients have their first aura during pregnancy. The most common migraine aura is visual, a problem with the visual field that can affect motor and sensory functioning, said Dr. Lev.
Managing migraine during pregnancy is “very complicated,” said Dr. Lev. She said the first-line treatment is paracetamol (acetaminophen) and stressed that taking opioids should be avoided.
Retrospective database study
For the study, the researchers retrospectively reviewed pregnancy and delivery records from a database of Clalit Medical Services, which has more than 4.5 million members and is the largest such database in Israel. They collected demographic data and information on mode of delivery, medical and obstetric complications, hospitalizations, emergency department visits, use of medications, laboratory reports, and medical consultations.
The study included 145,102 women who gave birth from 2014 to 2020.
Of these, 10,646 had migraine without aura, and 1,576 had migraine with aura. The migraine diagnoses, which were based on International Headache Society criteria and diagnostic codes, were made prior to pregnancy.
Dr. Lev noted that the number of patients with migraine is likely an underestimation because migraine is “not always diagnosed.”
Results showed that the risk for obstetric complications was higher among pregnant women with migraine, especially those with aura, in comparison with women without migraine. About 6.9% of patients with migraine without aura were admitted to high-risk hospital departments, compared with 6% of pregnant control patients who did not have migraine (P < .0001). For patients with migraine with aura, the risk for admissions was even higher (8.7%; P < .0001 vs. control patients and P < .03 vs. patients with migraine without aura) and was “very highly statistically significant,” said Dr. Lev.
Pregnant women with migraine were at significantly increased risk for gestational diabetes, hyperlipidemia, and being diagnosed with a psychiatric disorder (all P < .0001). These women were also more likely to experience preeclampsia and blood clots (P < .0001).
Unexpected finding
The finding that the risk for diabetes was higher was “unexpected,” inasmuch as older women with migraine are typically at increased risk for metabolic syndrome and higher body mass index, said Dr. Lev.
Migraine patients had significantly more consultations with family physicians, gynecologists, and neurologists (P < .0001). In addition, they were more likely to utilize emergency services; take more medications, mostly analgesics; and undergo more laboratory studies and brain imaging.
Those with aura had significantly more specialist consultations and took more medications compared with migraine patients without aura.
There was a statistically significant increase in the use of epidural anesthesia for migraine patients (40.5% of women without migraine; 45.7% of those with migraine accompanied by aura; and 47.5% of migraine patients without aura).
This was an “interesting” finding, said Dr. Lev. “We didn’t know what to expect; people with migraine are used to pain, so the question was, will they tolerate pain better or be more afraid of pain?”
Women with migraine also experienced more assisted deliveries with increased use of vacuums and forceps.
During the 3-month postpartum period, women with migraine sought more medical consultations and used more medications compared with control patients. They also underwent more lab examinations and more brain imaging during this period.
Dr. Lev noted that some of these evaluations may have been postponed because of the pregnancy.
Women with migraine also had a greater risk for postpartum depression, which Dr. Lev found “concerning.” She noted that depression is often underreported but is treatable. Women with migraine should be monitored for depression post partum, she said.
It’s unclear which factors contribute to the increased risk for pregnancy complications in women with migraine. Dr. Lev said she doesn’t believe it’s drug related.
“Although they’re taking more medications than people who don’t have migraine, we still are giving very low doses and only safe medicines, so I don’t think these increased risks are side effects,” she said.
She noted that women with migraine have more cardiovascular complications, including stroke and myocardial infarction, although these generally affect older patients.
Dr. Lev also noted that pain, especially chronic pain, can cause depression. “We know that people with migraine have more depression and anxiety, so maybe that also affects them during their pregnancy and after,” she said.
She suggested that pregnant women with migraine be considered high risk and be managed via specialized clinics.
Room for improvement
Commenting on the research, Lauren Doyle Strauss, DO, associate professor of neurology, Wake Forest University, Winston-Salem, N.C., who has written about the management of migraine during pregnancy, said studies such as this help raise awareness about pregnancy risks in migraine patients. Dr. Strauss did not attend the live presentation but is aware of the findings.
The increased use of epidurals during delivery among migraine patients in the study makes some sense, said Dr. Strauss. “It kind of shows a comfort level with medicines.”
She expressed concern that such research may be “skewed” because it includes patients with more severe migraine. If less severe cases were included in this research, “maybe there would still be higher risks, but not as high as what we have been finding in some of our studies,” she said.
Dr. Strauss said she feels the medical community should do a better job of identifying and diagnosing migraine. She said she would like to see migraine screening become a routine part of obstetric/gynecologic care. Doctors should counsel migraine patients who wish to become pregnant about potential risks, said Dr. Strauss. “We need to be up front in telling them when to seek care and when to report symptoms and not to wait for it to become super severe,” she said.
She also believes doctors should be “proactive” in helping patients develop a treatment plan before becoming pregnant, because the limited pain control options available for pregnant patients can take time to have an effect.
Also commenting on the study findings, Nina Riggins, MD, PhD, clinical associate professor of neurology at the University of California, San Francisco, said the study raises “important questions” and has “important aims.”
She believes the study reinforces the importance of collaboration between experts in primary care, obstetrics/gynecology, and neurology. However, she was surprised at some of the investigators’ assertions that there are no differences in migraine among prepubertal children and that the course of migraine for men is stable throughout their life span.
“There is literature that supports the view that the prevalence in boys is higher in prepuberty, and studies do show that migraine prevalence decreases in older adults – men and women,” she said.
There is still not enough evidence to determine that antiemetics and triptans are safe during pregnancy or that pregnant women with migraine should be taking acetylsalicylic acid, said Dr. Riggins.
The investigators, Dr. Strauss, and Dr. Riggins have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
From EAN 2021
New data on COVID-19’s cognitive fallout
Investigators found cognitive changes, depression, and PTSD in infected patients, both in the subacute phase and 10 months after hospital discharge.
“We showed that cognitive and behavioral alterations are associated with COVID-19 infection within 2 months from hospital discharge and that they partially persist in the post-COVID phase,” study investigator Elisa Canu, PhD, neuroimaging research unit, division of neuroscience, IRCCS San Raffaele Scientific Institute, Milan, told a press briefing.
The findings were presented at the annual congress of the European Academy of Neurology.
Executive dysfunction
Previous research suggests about 30% of COVID-19 survivors have cognitive disturbances and 30%-40% have psychopathological disorders including anxiety and depression, said Dr. Canu.
These disturbances have been associated with the severity of acute-phase respiratory symptoms, infection-triggered neuroinflammation, cerebrovascular alterations, and/or neurodegeneration.
However, it’s unclear whether these disturbances persist in the post-COVID phase.
To investigate, the researchers explored cognitive and psychopathological features in 49 patients with confirmed COVID-19 admitted to a hospital ED. They examined these factors at 2 months (subacute phase) and at 10 months (post-COVID phase).
Participants had an average age of 61 years (age range, 40-75 years) and 73% were men. Most had at least one cardiovascular risk factor such as hypertension (55%), smoking (22%), and dyslipidemia (18%).
At hospital admission, 71% had an abnormal neurologic exam, 59% had hypogeusia (reduced sense of taste), 45% hyposmia (reduced sense of smell), 39% headache, and 20% confusion or drowsiness. During hospitalization, 27% had noninvasive ventilation.
In addition to cognitive and neurologic assessments, participants underwent MRI 2 months after hospital discharge. Researchers obtained data on gray matter, white matter, and total brain volume.
At 2 months post discharge, 53% of patients presented with at least one cognitive deficit. Many deficits related to executive function including difficulty planning, attention, and problem solving (16%).
However, some participants had memory issues (6%) or visuospatial disturbances (6%). Almost a quarter (23%) presented with a combination of symptoms related to executive dysfunction.
Low oxygen tied to more cognitive deficits
More than one-third of patients experienced symptoms of depression (16%) or PTSD (18%).
Patients younger than 50 years had more executive dysfunction, with these symptoms affecting 75% of younger patients. “Our explanation for that is that younger people had a milder clinical profile regarding COVID, so they were cared for at home,” said Dr. Canu.
While in hospital, patients may be on “continued alert” and receive structured interventions for cognitive and behavioral issues, she said.
More severe respiratory symptoms at hospital admission were significantly associated with deficits during the subacute phase (P = .002 for information processing).
“Low levels of oxygen in the brain could lead to confusion, headache, and brain fog, and cause the cognitive disturbances that we see,” said Dr. Canu.
White-matter hyperintensities were linked to cognitive deficits during this phase (P < .001 for verbal memory and delayed recall).
“These white-matter lesions are probably preexisting due to cardiovascular risk factors that were present in our population and may have amplified the memory disturbances we saw,” commented Dr. Canu.
The investigators did not find a significant relationship between cognitive performance and brain volume. Dr. Canu noted that cognitive and psychopathological disturbances are linked. For instance, she said, a patient with PTSD or depression may also have problems with attention or memory.
In the post-COVID phase, cognitive symptoms were reduced from 53% to 36%; again, the most common deficit was combined executive dysfunction symptoms. Depression persisted in 15% of patients and PTSD in 18%.
“We still don’t know if these alterations are a consequence of the infection,” said Dr. Canu. “And we don’t know whether the deficits are reversible or are part of a neurodegenerative process.”
The researchers plan to follow these patients further. “We definitely need longer follow-up and bigger populations, if possible, to see if these cognitive and psychopathological disturbances can improve in some way,” said Dr. Canu.
The study results underline the need for neuropsychological and neurologic monitoring in COVID patients. Cognitive stimulation training and physical activity, preferably outdoors, could be beneficial, Dr. Canu added.
A version of this article first appeared on Medscape.com.
Investigators found cognitive changes, depression, and PTSD in infected patients, both in the subacute phase and 10 months after hospital discharge.
“We showed that cognitive and behavioral alterations are associated with COVID-19 infection within 2 months from hospital discharge and that they partially persist in the post-COVID phase,” study investigator Elisa Canu, PhD, neuroimaging research unit, division of neuroscience, IRCCS San Raffaele Scientific Institute, Milan, told a press briefing.
The findings were presented at the annual congress of the European Academy of Neurology.
Executive dysfunction
Previous research suggests about 30% of COVID-19 survivors have cognitive disturbances and 30%-40% have psychopathological disorders including anxiety and depression, said Dr. Canu.
These disturbances have been associated with the severity of acute-phase respiratory symptoms, infection-triggered neuroinflammation, cerebrovascular alterations, and/or neurodegeneration.
However, it’s unclear whether these disturbances persist in the post-COVID phase.
To investigate, the researchers explored cognitive and psychopathological features in 49 patients with confirmed COVID-19 admitted to a hospital ED. They examined these factors at 2 months (subacute phase) and at 10 months (post-COVID phase).
Participants had an average age of 61 years (age range, 40-75 years) and 73% were men. Most had at least one cardiovascular risk factor such as hypertension (55%), smoking (22%), and dyslipidemia (18%).
At hospital admission, 71% had an abnormal neurologic exam, 59% had hypogeusia (reduced sense of taste), 45% hyposmia (reduced sense of smell), 39% headache, and 20% confusion or drowsiness. During hospitalization, 27% had noninvasive ventilation.
In addition to cognitive and neurologic assessments, participants underwent MRI 2 months after hospital discharge. Researchers obtained data on gray matter, white matter, and total brain volume.
At 2 months post discharge, 53% of patients presented with at least one cognitive deficit. Many deficits related to executive function including difficulty planning, attention, and problem solving (16%).
However, some participants had memory issues (6%) or visuospatial disturbances (6%). Almost a quarter (23%) presented with a combination of symptoms related to executive dysfunction.
Low oxygen tied to more cognitive deficits
More than one-third of patients experienced symptoms of depression (16%) or PTSD (18%).
Patients younger than 50 years had more executive dysfunction, with these symptoms affecting 75% of younger patients. “Our explanation for that is that younger people had a milder clinical profile regarding COVID, so they were cared for at home,” said Dr. Canu.
While in hospital, patients may be on “continued alert” and receive structured interventions for cognitive and behavioral issues, she said.
More severe respiratory symptoms at hospital admission were significantly associated with deficits during the subacute phase (P = .002 for information processing).
“Low levels of oxygen in the brain could lead to confusion, headache, and brain fog, and cause the cognitive disturbances that we see,” said Dr. Canu.
White-matter hyperintensities were linked to cognitive deficits during this phase (P < .001 for verbal memory and delayed recall).
“These white-matter lesions are probably preexisting due to cardiovascular risk factors that were present in our population and may have amplified the memory disturbances we saw,” commented Dr. Canu.
The investigators did not find a significant relationship between cognitive performance and brain volume. Dr. Canu noted that cognitive and psychopathological disturbances are linked. For instance, she said, a patient with PTSD or depression may also have problems with attention or memory.
In the post-COVID phase, cognitive symptoms were reduced from 53% to 36%; again, the most common deficit was combined executive dysfunction symptoms. Depression persisted in 15% of patients and PTSD in 18%.
“We still don’t know if these alterations are a consequence of the infection,” said Dr. Canu. “And we don’t know whether the deficits are reversible or are part of a neurodegenerative process.”
The researchers plan to follow these patients further. “We definitely need longer follow-up and bigger populations, if possible, to see if these cognitive and psychopathological disturbances can improve in some way,” said Dr. Canu.
The study results underline the need for neuropsychological and neurologic monitoring in COVID patients. Cognitive stimulation training and physical activity, preferably outdoors, could be beneficial, Dr. Canu added.
A version of this article first appeared on Medscape.com.
Investigators found cognitive changes, depression, and PTSD in infected patients, both in the subacute phase and 10 months after hospital discharge.
“We showed that cognitive and behavioral alterations are associated with COVID-19 infection within 2 months from hospital discharge and that they partially persist in the post-COVID phase,” study investigator Elisa Canu, PhD, neuroimaging research unit, division of neuroscience, IRCCS San Raffaele Scientific Institute, Milan, told a press briefing.
The findings were presented at the annual congress of the European Academy of Neurology.
Executive dysfunction
Previous research suggests about 30% of COVID-19 survivors have cognitive disturbances and 30%-40% have psychopathological disorders including anxiety and depression, said Dr. Canu.
These disturbances have been associated with the severity of acute-phase respiratory symptoms, infection-triggered neuroinflammation, cerebrovascular alterations, and/or neurodegeneration.
However, it’s unclear whether these disturbances persist in the post-COVID phase.
To investigate, the researchers explored cognitive and psychopathological features in 49 patients with confirmed COVID-19 admitted to a hospital ED. They examined these factors at 2 months (subacute phase) and at 10 months (post-COVID phase).
Participants had an average age of 61 years (age range, 40-75 years) and 73% were men. Most had at least one cardiovascular risk factor such as hypertension (55%), smoking (22%), and dyslipidemia (18%).
At hospital admission, 71% had an abnormal neurologic exam, 59% had hypogeusia (reduced sense of taste), 45% hyposmia (reduced sense of smell), 39% headache, and 20% confusion or drowsiness. During hospitalization, 27% had noninvasive ventilation.
In addition to cognitive and neurologic assessments, participants underwent MRI 2 months after hospital discharge. Researchers obtained data on gray matter, white matter, and total brain volume.
At 2 months post discharge, 53% of patients presented with at least one cognitive deficit. Many deficits related to executive function including difficulty planning, attention, and problem solving (16%).
However, some participants had memory issues (6%) or visuospatial disturbances (6%). Almost a quarter (23%) presented with a combination of symptoms related to executive dysfunction.
Low oxygen tied to more cognitive deficits
More than one-third of patients experienced symptoms of depression (16%) or PTSD (18%).
Patients younger than 50 years had more executive dysfunction, with these symptoms affecting 75% of younger patients. “Our explanation for that is that younger people had a milder clinical profile regarding COVID, so they were cared for at home,” said Dr. Canu.
While in hospital, patients may be on “continued alert” and receive structured interventions for cognitive and behavioral issues, she said.
More severe respiratory symptoms at hospital admission were significantly associated with deficits during the subacute phase (P = .002 for information processing).
“Low levels of oxygen in the brain could lead to confusion, headache, and brain fog, and cause the cognitive disturbances that we see,” said Dr. Canu.
White-matter hyperintensities were linked to cognitive deficits during this phase (P < .001 for verbal memory and delayed recall).
“These white-matter lesions are probably preexisting due to cardiovascular risk factors that were present in our population and may have amplified the memory disturbances we saw,” commented Dr. Canu.
The investigators did not find a significant relationship between cognitive performance and brain volume. Dr. Canu noted that cognitive and psychopathological disturbances are linked. For instance, she said, a patient with PTSD or depression may also have problems with attention or memory.
In the post-COVID phase, cognitive symptoms were reduced from 53% to 36%; again, the most common deficit was combined executive dysfunction symptoms. Depression persisted in 15% of patients and PTSD in 18%.
“We still don’t know if these alterations are a consequence of the infection,” said Dr. Canu. “And we don’t know whether the deficits are reversible or are part of a neurodegenerative process.”
The researchers plan to follow these patients further. “We definitely need longer follow-up and bigger populations, if possible, to see if these cognitive and psychopathological disturbances can improve in some way,” said Dr. Canu.
The study results underline the need for neuropsychological and neurologic monitoring in COVID patients. Cognitive stimulation training and physical activity, preferably outdoors, could be beneficial, Dr. Canu added.
A version of this article first appeared on Medscape.com.
Psychiatric fallout from long-COVID: How to prepare
As mounting evidence points to a significant psychiatric component of COVID-19, experts are concerned about an influx of survivors presenting with persistent mental health problems and how best to prepare.
Clinicians should be aware that patients who have had COVID frequently develop psychiatric symptoms, Silvia S. Martins, MD, PhD, associate professor of epidemiology, Columbia University, New York, said in an interview.
“There should be more screening of all patients recovering from a COVID infection for anxiety, posttraumatic stress disorder, and depression, as well as referral to services, including psychotherapy, and medication as needed,” said Dr. Martins, who, along with colleagues, uncovered a high rate of these symptoms in patients who had the disease.
The COVID-19 pandemic has taken an enormous social, emotional, and public health toll. It has disrupted lives and caused stress, fear, and uncertainty about loss of health and income, not to mention forced isolation.
In addition, a significant number of patients who contract COVID-19 continue to have symptoms after the acute phase of the illness. This post-COVID, or “long-haul,” syndrome isn’t well defined; experts cite a range of symptoms that persist for weeks or months.
These ongoing symptoms can include cough, fatigue, and chronic pain, as well as psychiatric complaints. As reported by this news organization, an observational study of more than 230,000 U.S. patient health records revealed that one in three COVID-19 survivors received a psychiatric or neurologic diagnosis within 6 months of contracting the virus.
The most common psychiatric diagnoses were anxiety disorders, mood disorders, substance misuse disorders, and insomnia.
Significant symptoms even in mild cases
Another study showed that even those with mild COVID-19 may experience psychiatric symptoms independently of previous psychiatric diagnoses. Results revealed that 26% of the sample of almost 900 patients reported depression, 22% reported anxiety, and 17% reported symptoms of posttraumatic stress 2 months after testing positive for the virus. This finding is important because the majority of individuals who contract COVID-19 have a mild case.
“We saw very high levels of clinically significant depression, anxiety, and posttraumatic stress symptoms in people who had mild disease,” study investigator João Mauricio Castaldelli-Maia, MD, PhD, postdoctoral fellow, department of epidemiology, Columbia University, said in an interview.
He attributed these symptoms in part to long periods of isolation, even from relatives in the same household, in cramped spaces typical of large cities such as São Paulo.
Social isolation can have a huge impact on persons who depend on social connections and relationships, Vivian Pender, MD, president of the American Psychiatric Association and clinical professor of psychiatry, Weill Cornell Medical Center, New York, said in an interview.
“The fact that we have not been able to see our colleagues, our friends, our family, and in the case of psychiatrists, even our patients has taken a toll on everyone, and that leads to more stress, more anxiety,” she said.
National surveys show that psychiatric symptoms occur after acute COVID. One survey revealed that over 50% of 3,900 respondents who had COVID reported having at least moderate symptoms of major depression.
Unique depression subtype?
Another survey, slated for publication later this year, shows that lead investigator Roy Perlis, MD, professor of psychiatry, Harvard Medical School, Boston, said in an interview.
This might suggest a neurobiological element. Researchers are speculating as to whether lingering psychiatric problems that occur after having COVID are linked to the psychosocial impact of the disease or to pathological processes, such as inflammation, that affect the brain.
Although rates of post-COVID psychiatric symptoms vary from study to study, “they seem to be pretty enduring,” noted Faith Gunning, PhD, vice chair of research, department of psychology, Weill Cornell Medicine, who specializes in clinical neuropsychology.
“So they’re not just a brief response” to getting sick, a fact that points to the possible need for treatment, she told this news organization. “In some of the work that’s starting to emerge, it does appear that the symptoms persist, at least for a relatively large subset of individuals.”
Although depression typically affects twice as many women as men, these new surveys show that, after COVID, “that difference is not so distinct,” said Dr. Gunning.
It’s unclear why this is, but it could be cause by financial stresses that may affect men to a greater extent, she added. “There is so much we’re still learning.”
Increased suicide risk?
Other researchers, including Leo Sher, MD, professor of psychiatry, Icahn School of Medicine at Mount Sinai, and director of inpatient psychiatry, James J. Peters Veterans Affairs Medical Center, both in New York, are concerned that higher rates of psychiatric symptoms among patients with long-haul COVID raise the risk for suicidal ideation and behavior.
Studies of suicidality in COVID-19 survivors “are urgently needed,” said Dr. Sher in an article published in the Monthly Journal of the Association of Physicians.
“We need to study what factors may increase suicide risk among the COVID-19 survivors during and after the recovery. We also need to investigate whether there is a long-term increased suicide risk among COVID-19 survivors,” Dr. Sher said.
COVID-19 is not unique among viral respiratory diseases in being associated with long-term mental health problems. Research shows that survivors of the 2003 outbreak of severe acute respiratory syndrome experienced increased psychological distress that persisted for at least a year, as did patients who in 2015 had Middle East respiratory syndrome coronavirus (MERS-CoV).
Some experts believe clinicians should screen patients for mental health symptoms after the acute phase of COVID and offer early and prolonged care.
“Early mental health intervention such as psychotherapy and supportive groups could play an important role in preventing incident mental health problems for post-COVID sufferers,” said Dr. Castaldelli-Maia.
A version of this article first appeared on Medscape.com.
As mounting evidence points to a significant psychiatric component of COVID-19, experts are concerned about an influx of survivors presenting with persistent mental health problems and how best to prepare.
Clinicians should be aware that patients who have had COVID frequently develop psychiatric symptoms, Silvia S. Martins, MD, PhD, associate professor of epidemiology, Columbia University, New York, said in an interview.
“There should be more screening of all patients recovering from a COVID infection for anxiety, posttraumatic stress disorder, and depression, as well as referral to services, including psychotherapy, and medication as needed,” said Dr. Martins, who, along with colleagues, uncovered a high rate of these symptoms in patients who had the disease.
The COVID-19 pandemic has taken an enormous social, emotional, and public health toll. It has disrupted lives and caused stress, fear, and uncertainty about loss of health and income, not to mention forced isolation.
In addition, a significant number of patients who contract COVID-19 continue to have symptoms after the acute phase of the illness. This post-COVID, or “long-haul,” syndrome isn’t well defined; experts cite a range of symptoms that persist for weeks or months.
These ongoing symptoms can include cough, fatigue, and chronic pain, as well as psychiatric complaints. As reported by this news organization, an observational study of more than 230,000 U.S. patient health records revealed that one in three COVID-19 survivors received a psychiatric or neurologic diagnosis within 6 months of contracting the virus.
The most common psychiatric diagnoses were anxiety disorders, mood disorders, substance misuse disorders, and insomnia.
Significant symptoms even in mild cases
Another study showed that even those with mild COVID-19 may experience psychiatric symptoms independently of previous psychiatric diagnoses. Results revealed that 26% of the sample of almost 900 patients reported depression, 22% reported anxiety, and 17% reported symptoms of posttraumatic stress 2 months after testing positive for the virus. This finding is important because the majority of individuals who contract COVID-19 have a mild case.
“We saw very high levels of clinically significant depression, anxiety, and posttraumatic stress symptoms in people who had mild disease,” study investigator João Mauricio Castaldelli-Maia, MD, PhD, postdoctoral fellow, department of epidemiology, Columbia University, said in an interview.
He attributed these symptoms in part to long periods of isolation, even from relatives in the same household, in cramped spaces typical of large cities such as São Paulo.
Social isolation can have a huge impact on persons who depend on social connections and relationships, Vivian Pender, MD, president of the American Psychiatric Association and clinical professor of psychiatry, Weill Cornell Medical Center, New York, said in an interview.
“The fact that we have not been able to see our colleagues, our friends, our family, and in the case of psychiatrists, even our patients has taken a toll on everyone, and that leads to more stress, more anxiety,” she said.
National surveys show that psychiatric symptoms occur after acute COVID. One survey revealed that over 50% of 3,900 respondents who had COVID reported having at least moderate symptoms of major depression.
Unique depression subtype?
Another survey, slated for publication later this year, shows that lead investigator Roy Perlis, MD, professor of psychiatry, Harvard Medical School, Boston, said in an interview.
This might suggest a neurobiological element. Researchers are speculating as to whether lingering psychiatric problems that occur after having COVID are linked to the psychosocial impact of the disease or to pathological processes, such as inflammation, that affect the brain.
Although rates of post-COVID psychiatric symptoms vary from study to study, “they seem to be pretty enduring,” noted Faith Gunning, PhD, vice chair of research, department of psychology, Weill Cornell Medicine, who specializes in clinical neuropsychology.
“So they’re not just a brief response” to getting sick, a fact that points to the possible need for treatment, she told this news organization. “In some of the work that’s starting to emerge, it does appear that the symptoms persist, at least for a relatively large subset of individuals.”
Although depression typically affects twice as many women as men, these new surveys show that, after COVID, “that difference is not so distinct,” said Dr. Gunning.
It’s unclear why this is, but it could be cause by financial stresses that may affect men to a greater extent, she added. “There is so much we’re still learning.”
Increased suicide risk?
Other researchers, including Leo Sher, MD, professor of psychiatry, Icahn School of Medicine at Mount Sinai, and director of inpatient psychiatry, James J. Peters Veterans Affairs Medical Center, both in New York, are concerned that higher rates of psychiatric symptoms among patients with long-haul COVID raise the risk for suicidal ideation and behavior.
Studies of suicidality in COVID-19 survivors “are urgently needed,” said Dr. Sher in an article published in the Monthly Journal of the Association of Physicians.
“We need to study what factors may increase suicide risk among the COVID-19 survivors during and after the recovery. We also need to investigate whether there is a long-term increased suicide risk among COVID-19 survivors,” Dr. Sher said.
COVID-19 is not unique among viral respiratory diseases in being associated with long-term mental health problems. Research shows that survivors of the 2003 outbreak of severe acute respiratory syndrome experienced increased psychological distress that persisted for at least a year, as did patients who in 2015 had Middle East respiratory syndrome coronavirus (MERS-CoV).
Some experts believe clinicians should screen patients for mental health symptoms after the acute phase of COVID and offer early and prolonged care.
“Early mental health intervention such as psychotherapy and supportive groups could play an important role in preventing incident mental health problems for post-COVID sufferers,” said Dr. Castaldelli-Maia.
A version of this article first appeared on Medscape.com.
As mounting evidence points to a significant psychiatric component of COVID-19, experts are concerned about an influx of survivors presenting with persistent mental health problems and how best to prepare.
Clinicians should be aware that patients who have had COVID frequently develop psychiatric symptoms, Silvia S. Martins, MD, PhD, associate professor of epidemiology, Columbia University, New York, said in an interview.
“There should be more screening of all patients recovering from a COVID infection for anxiety, posttraumatic stress disorder, and depression, as well as referral to services, including psychotherapy, and medication as needed,” said Dr. Martins, who, along with colleagues, uncovered a high rate of these symptoms in patients who had the disease.
The COVID-19 pandemic has taken an enormous social, emotional, and public health toll. It has disrupted lives and caused stress, fear, and uncertainty about loss of health and income, not to mention forced isolation.
In addition, a significant number of patients who contract COVID-19 continue to have symptoms after the acute phase of the illness. This post-COVID, or “long-haul,” syndrome isn’t well defined; experts cite a range of symptoms that persist for weeks or months.
These ongoing symptoms can include cough, fatigue, and chronic pain, as well as psychiatric complaints. As reported by this news organization, an observational study of more than 230,000 U.S. patient health records revealed that one in three COVID-19 survivors received a psychiatric or neurologic diagnosis within 6 months of contracting the virus.
The most common psychiatric diagnoses were anxiety disorders, mood disorders, substance misuse disorders, and insomnia.
Significant symptoms even in mild cases
Another study showed that even those with mild COVID-19 may experience psychiatric symptoms independently of previous psychiatric diagnoses. Results revealed that 26% of the sample of almost 900 patients reported depression, 22% reported anxiety, and 17% reported symptoms of posttraumatic stress 2 months after testing positive for the virus. This finding is important because the majority of individuals who contract COVID-19 have a mild case.
“We saw very high levels of clinically significant depression, anxiety, and posttraumatic stress symptoms in people who had mild disease,” study investigator João Mauricio Castaldelli-Maia, MD, PhD, postdoctoral fellow, department of epidemiology, Columbia University, said in an interview.
He attributed these symptoms in part to long periods of isolation, even from relatives in the same household, in cramped spaces typical of large cities such as São Paulo.
Social isolation can have a huge impact on persons who depend on social connections and relationships, Vivian Pender, MD, president of the American Psychiatric Association and clinical professor of psychiatry, Weill Cornell Medical Center, New York, said in an interview.
“The fact that we have not been able to see our colleagues, our friends, our family, and in the case of psychiatrists, even our patients has taken a toll on everyone, and that leads to more stress, more anxiety,” she said.
National surveys show that psychiatric symptoms occur after acute COVID. One survey revealed that over 50% of 3,900 respondents who had COVID reported having at least moderate symptoms of major depression.
Unique depression subtype?
Another survey, slated for publication later this year, shows that lead investigator Roy Perlis, MD, professor of psychiatry, Harvard Medical School, Boston, said in an interview.
This might suggest a neurobiological element. Researchers are speculating as to whether lingering psychiatric problems that occur after having COVID are linked to the psychosocial impact of the disease or to pathological processes, such as inflammation, that affect the brain.
Although rates of post-COVID psychiatric symptoms vary from study to study, “they seem to be pretty enduring,” noted Faith Gunning, PhD, vice chair of research, department of psychology, Weill Cornell Medicine, who specializes in clinical neuropsychology.
“So they’re not just a brief response” to getting sick, a fact that points to the possible need for treatment, she told this news organization. “In some of the work that’s starting to emerge, it does appear that the symptoms persist, at least for a relatively large subset of individuals.”
Although depression typically affects twice as many women as men, these new surveys show that, after COVID, “that difference is not so distinct,” said Dr. Gunning.
It’s unclear why this is, but it could be cause by financial stresses that may affect men to a greater extent, she added. “There is so much we’re still learning.”
Increased suicide risk?
Other researchers, including Leo Sher, MD, professor of psychiatry, Icahn School of Medicine at Mount Sinai, and director of inpatient psychiatry, James J. Peters Veterans Affairs Medical Center, both in New York, are concerned that higher rates of psychiatric symptoms among patients with long-haul COVID raise the risk for suicidal ideation and behavior.
Studies of suicidality in COVID-19 survivors “are urgently needed,” said Dr. Sher in an article published in the Monthly Journal of the Association of Physicians.
“We need to study what factors may increase suicide risk among the COVID-19 survivors during and after the recovery. We also need to investigate whether there is a long-term increased suicide risk among COVID-19 survivors,” Dr. Sher said.
COVID-19 is not unique among viral respiratory diseases in being associated with long-term mental health problems. Research shows that survivors of the 2003 outbreak of severe acute respiratory syndrome experienced increased psychological distress that persisted for at least a year, as did patients who in 2015 had Middle East respiratory syndrome coronavirus (MERS-CoV).
Some experts believe clinicians should screen patients for mental health symptoms after the acute phase of COVID and offer early and prolonged care.
“Early mental health intervention such as psychotherapy and supportive groups could play an important role in preventing incident mental health problems for post-COVID sufferers,” said Dr. Castaldelli-Maia.
A version of this article first appeared on Medscape.com.
Two key suicide risk factors identified in borderline personality disorder
Feelings of chronic emptiness and self-injury have been identified as two key risk factors for suicide attempts (SAs) in patients with borderline personality disorder (BPD), a new cross-sectional, nationally representative study suggests.
The findings also show lifetime and past-year SAs are common among patients with BPD, even when excluding self-injurious behaviors.
The results suggest that in addition to asking patients about self-harm during suicide risk screenings and assessments, clinicians should query them about “longstanding” feelings of emptiness, study investigator Carlos M. Grilo, PhD, professor of psychiatry and psychology, Yale University, New Haven, Conn., said in an interview.
Although related, chronic emptiness “is distinct and goes beyond feelings of sadness, loneliness, and hopelessness,” explained Dr. Grilo. he said.
The study was published online May 11 in JAMA Network Open.
Filling a research gap
While BPD and other psychiatric disorders are associated with suicide, the authors noted there is a “dearth of epidemiological research” examining the link between BPD and suicide.
Criteria for BPD diagnosis requires any five of the following criteria: relationships, affective instability, abandonment fear, anger, identity disturbance, emptiness, disassociation/paranoia, self-injurious behavior, and impulsivity, along with social-occupation dysfunction.
To determine SA risk with specific BPD diagnostic criteria, the investigators examined data on 36,309 individuals who participated in the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), conducted from 2012 to 2013.
During computer-assisted, face-to-face interviews, study participants answered questions based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) of the National Institute on Alcohol Abuse and Alcoholism.
This structured interview assesses a range of DSM-5–defined psychiatric disorders and their criteria. In addition to BPD, the AUDADIS-5 generates diagnoses for mood disorders, anxiety disorders, posttraumatic stress disorder, substance use disorders, antisocial personality disorder, schizotypal disorder, and conduct disorder.
During the interviews, respondents were asked if they had ever attempted suicide. For those who had, interviewers recorded the total number of lifetime attempts.
Participants also answered questions about childhood maltreatment including physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse by parents or caregivers and other adverse events occurring before the age of 18.
Childhood trauma common
Patients with BPD frequently report a history of childhood trauma, noted Dr. Grilo, adding that such trauma is associated with self-harm and suicide attempts. Sociodemographic information, including age, sex, and ethnicity/race, education level, and income, was also gathered.
Investigators examined data on suicide attempts using relatively stringent coding that required serious dysfunction in at least five BPD criteria.
Using this definition, investigators found the lifetime SA prevalence in patients with BPD was 30.4%, and 3.2% for past-year SAs. This compared with a rate of 3.7% for lifetime SAs and 0.2% for past-year SAs in those without a BPD diagnosis.
The authors examined SA rates using diagnostic codes in the NESARC-III that required seriously impaired function in only 1 or 2 BPD criteria. Rates were higher using the 5-criteria definition.
When the researchers excluded the BPD criterion of self-injurious behavior, the prevalence was 28.1% for lifetime and 3.0% for past-year SAs among the BPD group, with corresponding rates of 3.8% and 0.2% in those without a BPD diagnosis.
It’s important to look at this, said Dr. Grilo, as some patients with BPD who engage in self-harm have suicidal intent while others don’t.
“We tested whether BPD had heightened risk for suicide attempts if we eliminated the self-injurious criterion and we found that heightened risk was still there,” he explained.
Looking at individual criteria for BPD, a model that adjusted for sociodemographic characteristics, other psychiatric disorders, age at BPD onset, and history of childhood adverse events uncovered two criteria that were significantly associated with increased odds of SAs.
One was emptiness. For lifetime suicide attempts, the adjusted odds ratio (aOR) was 1.58 (95% confidence interval, 1.16-2.14) and for past-year attempts, the aOR was 1.99 (95% CI, 1.08-3.66).
The second was self-injurious behavior. For lifetime attempts, the aOR was 24.28 (95% CI, 16.83-32.03) and for past-year attempts, the aOR was 19.32 (95% CI, 5.22-71.58).
In a model in which all BPD-specific criteria were entered while excluding self-injurious behavior, the aORs for emptiness were 1.66 (95% CI, 1.23-2.24) for lifetime suicide attempts and 2.45 (95% CI, 1.18-5.08) for past year attempts.
Unlike another recent study that included more than 700 treatment-seeking patients with BPD who were followed for 10 years, the current study did not show significant associations with SAs for two other BPD criteria – identity disturbance and frantic attempts to avoid abandonment.
Dr. Grilo explained this might be because the earlier study included treatment-seeking patients instead of community cases, or because of differences in assessment interviews or other factors.
‘Compelling evidence’
“Our epidemiological sample has much broader generalizability and fewer potential confounds than the clinical treatment-seeking sample,” said Dr. Grilo.
However, he noted that the two studies “converge strongly and provide compelling evidence that BPD is associated with substantially heightened risk for suicide attempts over the lifetime.”
The two studies “also converge in finding that the presence of symptoms such as repeated self-harm and feelings of chronic emptiness are also associated with risk for suicide attempts.”
The new findings highlight the need to ask potentially at-risk patients about feelings of emptiness as well as self-injurious behaviors. Clinicians could, for example, ask: “Have you often felt like your life had no purpose or meaning?” or “Have you often felt empty inside?”
Limitations of the study include reliance on retrospective self-reports and use of lay interviewers, although these interviewers were trained and had an average of 5 years of experience conducting health-related surveys.
Although the study included a representative sample of U.S. adults, the sample did not include groups known to have high rates of suicide and self-harm behaviors, such as institutionalized, incarcerated, or homeless individuals.
In addition, the study did not evaluate severity and duration of BPD, although the authors noted they did adjust for age at BPD onset, this did not alter the findings.
Often misdiagnosed
Commenting on the study, John M. Oldham, MD, Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and past-president, American Psychiatric Association, and an expert on BPD, had high praise for the research.
BPD is often misdiagnosed, Dr. Oldham said in an interview. Many patients seek help from primary care doctors who may label the symptoms as an anxiety disorder or a mood disorder, he said.
Although medications can help treat some BPD symptoms, “the primary, core evidence-based treatment for BPD is psychotherapy,” said Dr. Oldham, who some years ago helped develop evidence-based practice guidelines for BPD.
“It’s a clear and very well-designed study, and I don’t see any major limitations or problems with it,” he said. “The authors kept their focus rigorously on their goals and they used really careful methodology.”
He noted the “huge” numbers of patients included in the data and the relatively large percentage of men (43.7%).
“There’s a general belief that it’s mostly females who have BPD, but that’s not true; it’s females who come to treatment,” said Dr. Oldham.
Requiring that all five criteria lead to seriously impaired functioning “is a much more rigorous diagnostic methodology” than requiring only one or two criteria to lead to such impairment, said Dr. Oldham. “This is really important” and makes it “a much stronger study.”
The finding that self-harm behavior was linked to suicide attempts isn’t that surprising as this association has been well documented, but the finding that chronic emptiness is also predictive of future suicide attempts “is news,” said Dr. Oldham.
“We have not paid enough attention to this criterion in the clinical world or in the research world.”
Dr. Oldham said one patient with BPD gave him an ideal metaphor for emptiness. “She said it’s like there’s just nobody home. Think of it as an empty house that may look fine on the outside but you go inside and nobody lives there; there’s no furniture; no favorite things; no photos; no possessions.”
The authors have “important messages we need to pay attention to, and the main one is to explore this sense of chronic ‘nobody home’ emptiness,” said Dr. Oldham.
Dr. Grilo has reported receiving research grants from the National Institutes of Health; serving as a consultant for Sunovion and Weight Watchers; receiving honoraria for lectures, continuing medical education activities, and presentations at scientific conferences; and receiving royalties from Guilford Press and Taylor & Francis, all outside the submitted work.
A version of this article first appeared on Medscape.com.
Feelings of chronic emptiness and self-injury have been identified as two key risk factors for suicide attempts (SAs) in patients with borderline personality disorder (BPD), a new cross-sectional, nationally representative study suggests.
The findings also show lifetime and past-year SAs are common among patients with BPD, even when excluding self-injurious behaviors.
The results suggest that in addition to asking patients about self-harm during suicide risk screenings and assessments, clinicians should query them about “longstanding” feelings of emptiness, study investigator Carlos M. Grilo, PhD, professor of psychiatry and psychology, Yale University, New Haven, Conn., said in an interview.
Although related, chronic emptiness “is distinct and goes beyond feelings of sadness, loneliness, and hopelessness,” explained Dr. Grilo. he said.
The study was published online May 11 in JAMA Network Open.
Filling a research gap
While BPD and other psychiatric disorders are associated with suicide, the authors noted there is a “dearth of epidemiological research” examining the link between BPD and suicide.
Criteria for BPD diagnosis requires any five of the following criteria: relationships, affective instability, abandonment fear, anger, identity disturbance, emptiness, disassociation/paranoia, self-injurious behavior, and impulsivity, along with social-occupation dysfunction.
To determine SA risk with specific BPD diagnostic criteria, the investigators examined data on 36,309 individuals who participated in the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), conducted from 2012 to 2013.
During computer-assisted, face-to-face interviews, study participants answered questions based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) of the National Institute on Alcohol Abuse and Alcoholism.
This structured interview assesses a range of DSM-5–defined psychiatric disorders and their criteria. In addition to BPD, the AUDADIS-5 generates diagnoses for mood disorders, anxiety disorders, posttraumatic stress disorder, substance use disorders, antisocial personality disorder, schizotypal disorder, and conduct disorder.
During the interviews, respondents were asked if they had ever attempted suicide. For those who had, interviewers recorded the total number of lifetime attempts.
Participants also answered questions about childhood maltreatment including physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse by parents or caregivers and other adverse events occurring before the age of 18.
Childhood trauma common
Patients with BPD frequently report a history of childhood trauma, noted Dr. Grilo, adding that such trauma is associated with self-harm and suicide attempts. Sociodemographic information, including age, sex, and ethnicity/race, education level, and income, was also gathered.
Investigators examined data on suicide attempts using relatively stringent coding that required serious dysfunction in at least five BPD criteria.
Using this definition, investigators found the lifetime SA prevalence in patients with BPD was 30.4%, and 3.2% for past-year SAs. This compared with a rate of 3.7% for lifetime SAs and 0.2% for past-year SAs in those without a BPD diagnosis.
The authors examined SA rates using diagnostic codes in the NESARC-III that required seriously impaired function in only 1 or 2 BPD criteria. Rates were higher using the 5-criteria definition.
When the researchers excluded the BPD criterion of self-injurious behavior, the prevalence was 28.1% for lifetime and 3.0% for past-year SAs among the BPD group, with corresponding rates of 3.8% and 0.2% in those without a BPD diagnosis.
It’s important to look at this, said Dr. Grilo, as some patients with BPD who engage in self-harm have suicidal intent while others don’t.
“We tested whether BPD had heightened risk for suicide attempts if we eliminated the self-injurious criterion and we found that heightened risk was still there,” he explained.
Looking at individual criteria for BPD, a model that adjusted for sociodemographic characteristics, other psychiatric disorders, age at BPD onset, and history of childhood adverse events uncovered two criteria that were significantly associated with increased odds of SAs.
One was emptiness. For lifetime suicide attempts, the adjusted odds ratio (aOR) was 1.58 (95% confidence interval, 1.16-2.14) and for past-year attempts, the aOR was 1.99 (95% CI, 1.08-3.66).
The second was self-injurious behavior. For lifetime attempts, the aOR was 24.28 (95% CI, 16.83-32.03) and for past-year attempts, the aOR was 19.32 (95% CI, 5.22-71.58).
In a model in which all BPD-specific criteria were entered while excluding self-injurious behavior, the aORs for emptiness were 1.66 (95% CI, 1.23-2.24) for lifetime suicide attempts and 2.45 (95% CI, 1.18-5.08) for past year attempts.
Unlike another recent study that included more than 700 treatment-seeking patients with BPD who were followed for 10 years, the current study did not show significant associations with SAs for two other BPD criteria – identity disturbance and frantic attempts to avoid abandonment.
Dr. Grilo explained this might be because the earlier study included treatment-seeking patients instead of community cases, or because of differences in assessment interviews or other factors.
‘Compelling evidence’
“Our epidemiological sample has much broader generalizability and fewer potential confounds than the clinical treatment-seeking sample,” said Dr. Grilo.
However, he noted that the two studies “converge strongly and provide compelling evidence that BPD is associated with substantially heightened risk for suicide attempts over the lifetime.”
The two studies “also converge in finding that the presence of symptoms such as repeated self-harm and feelings of chronic emptiness are also associated with risk for suicide attempts.”
The new findings highlight the need to ask potentially at-risk patients about feelings of emptiness as well as self-injurious behaviors. Clinicians could, for example, ask: “Have you often felt like your life had no purpose or meaning?” or “Have you often felt empty inside?”
Limitations of the study include reliance on retrospective self-reports and use of lay interviewers, although these interviewers were trained and had an average of 5 years of experience conducting health-related surveys.
Although the study included a representative sample of U.S. adults, the sample did not include groups known to have high rates of suicide and self-harm behaviors, such as institutionalized, incarcerated, or homeless individuals.
In addition, the study did not evaluate severity and duration of BPD, although the authors noted they did adjust for age at BPD onset, this did not alter the findings.
Often misdiagnosed
Commenting on the study, John M. Oldham, MD, Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and past-president, American Psychiatric Association, and an expert on BPD, had high praise for the research.
BPD is often misdiagnosed, Dr. Oldham said in an interview. Many patients seek help from primary care doctors who may label the symptoms as an anxiety disorder or a mood disorder, he said.
Although medications can help treat some BPD symptoms, “the primary, core evidence-based treatment for BPD is psychotherapy,” said Dr. Oldham, who some years ago helped develop evidence-based practice guidelines for BPD.
“It’s a clear and very well-designed study, and I don’t see any major limitations or problems with it,” he said. “The authors kept their focus rigorously on their goals and they used really careful methodology.”
He noted the “huge” numbers of patients included in the data and the relatively large percentage of men (43.7%).
“There’s a general belief that it’s mostly females who have BPD, but that’s not true; it’s females who come to treatment,” said Dr. Oldham.
Requiring that all five criteria lead to seriously impaired functioning “is a much more rigorous diagnostic methodology” than requiring only one or two criteria to lead to such impairment, said Dr. Oldham. “This is really important” and makes it “a much stronger study.”
The finding that self-harm behavior was linked to suicide attempts isn’t that surprising as this association has been well documented, but the finding that chronic emptiness is also predictive of future suicide attempts “is news,” said Dr. Oldham.
“We have not paid enough attention to this criterion in the clinical world or in the research world.”
Dr. Oldham said one patient with BPD gave him an ideal metaphor for emptiness. “She said it’s like there’s just nobody home. Think of it as an empty house that may look fine on the outside but you go inside and nobody lives there; there’s no furniture; no favorite things; no photos; no possessions.”
The authors have “important messages we need to pay attention to, and the main one is to explore this sense of chronic ‘nobody home’ emptiness,” said Dr. Oldham.
Dr. Grilo has reported receiving research grants from the National Institutes of Health; serving as a consultant for Sunovion and Weight Watchers; receiving honoraria for lectures, continuing medical education activities, and presentations at scientific conferences; and receiving royalties from Guilford Press and Taylor & Francis, all outside the submitted work.
A version of this article first appeared on Medscape.com.
Feelings of chronic emptiness and self-injury have been identified as two key risk factors for suicide attempts (SAs) in patients with borderline personality disorder (BPD), a new cross-sectional, nationally representative study suggests.
The findings also show lifetime and past-year SAs are common among patients with BPD, even when excluding self-injurious behaviors.
The results suggest that in addition to asking patients about self-harm during suicide risk screenings and assessments, clinicians should query them about “longstanding” feelings of emptiness, study investigator Carlos M. Grilo, PhD, professor of psychiatry and psychology, Yale University, New Haven, Conn., said in an interview.
Although related, chronic emptiness “is distinct and goes beyond feelings of sadness, loneliness, and hopelessness,” explained Dr. Grilo. he said.
The study was published online May 11 in JAMA Network Open.
Filling a research gap
While BPD and other psychiatric disorders are associated with suicide, the authors noted there is a “dearth of epidemiological research” examining the link between BPD and suicide.
Criteria for BPD diagnosis requires any five of the following criteria: relationships, affective instability, abandonment fear, anger, identity disturbance, emptiness, disassociation/paranoia, self-injurious behavior, and impulsivity, along with social-occupation dysfunction.
To determine SA risk with specific BPD diagnostic criteria, the investigators examined data on 36,309 individuals who participated in the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), conducted from 2012 to 2013.
During computer-assisted, face-to-face interviews, study participants answered questions based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) of the National Institute on Alcohol Abuse and Alcoholism.
This structured interview assesses a range of DSM-5–defined psychiatric disorders and their criteria. In addition to BPD, the AUDADIS-5 generates diagnoses for mood disorders, anxiety disorders, posttraumatic stress disorder, substance use disorders, antisocial personality disorder, schizotypal disorder, and conduct disorder.
During the interviews, respondents were asked if they had ever attempted suicide. For those who had, interviewers recorded the total number of lifetime attempts.
Participants also answered questions about childhood maltreatment including physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse by parents or caregivers and other adverse events occurring before the age of 18.
Childhood trauma common
Patients with BPD frequently report a history of childhood trauma, noted Dr. Grilo, adding that such trauma is associated with self-harm and suicide attempts. Sociodemographic information, including age, sex, and ethnicity/race, education level, and income, was also gathered.
Investigators examined data on suicide attempts using relatively stringent coding that required serious dysfunction in at least five BPD criteria.
Using this definition, investigators found the lifetime SA prevalence in patients with BPD was 30.4%, and 3.2% for past-year SAs. This compared with a rate of 3.7% for lifetime SAs and 0.2% for past-year SAs in those without a BPD diagnosis.
The authors examined SA rates using diagnostic codes in the NESARC-III that required seriously impaired function in only 1 or 2 BPD criteria. Rates were higher using the 5-criteria definition.
When the researchers excluded the BPD criterion of self-injurious behavior, the prevalence was 28.1% for lifetime and 3.0% for past-year SAs among the BPD group, with corresponding rates of 3.8% and 0.2% in those without a BPD diagnosis.
It’s important to look at this, said Dr. Grilo, as some patients with BPD who engage in self-harm have suicidal intent while others don’t.
“We tested whether BPD had heightened risk for suicide attempts if we eliminated the self-injurious criterion and we found that heightened risk was still there,” he explained.
Looking at individual criteria for BPD, a model that adjusted for sociodemographic characteristics, other psychiatric disorders, age at BPD onset, and history of childhood adverse events uncovered two criteria that were significantly associated with increased odds of SAs.
One was emptiness. For lifetime suicide attempts, the adjusted odds ratio (aOR) was 1.58 (95% confidence interval, 1.16-2.14) and for past-year attempts, the aOR was 1.99 (95% CI, 1.08-3.66).
The second was self-injurious behavior. For lifetime attempts, the aOR was 24.28 (95% CI, 16.83-32.03) and for past-year attempts, the aOR was 19.32 (95% CI, 5.22-71.58).
In a model in which all BPD-specific criteria were entered while excluding self-injurious behavior, the aORs for emptiness were 1.66 (95% CI, 1.23-2.24) for lifetime suicide attempts and 2.45 (95% CI, 1.18-5.08) for past year attempts.
Unlike another recent study that included more than 700 treatment-seeking patients with BPD who were followed for 10 years, the current study did not show significant associations with SAs for two other BPD criteria – identity disturbance and frantic attempts to avoid abandonment.
Dr. Grilo explained this might be because the earlier study included treatment-seeking patients instead of community cases, or because of differences in assessment interviews or other factors.
‘Compelling evidence’
“Our epidemiological sample has much broader generalizability and fewer potential confounds than the clinical treatment-seeking sample,” said Dr. Grilo.
However, he noted that the two studies “converge strongly and provide compelling evidence that BPD is associated with substantially heightened risk for suicide attempts over the lifetime.”
The two studies “also converge in finding that the presence of symptoms such as repeated self-harm and feelings of chronic emptiness are also associated with risk for suicide attempts.”
The new findings highlight the need to ask potentially at-risk patients about feelings of emptiness as well as self-injurious behaviors. Clinicians could, for example, ask: “Have you often felt like your life had no purpose or meaning?” or “Have you often felt empty inside?”
Limitations of the study include reliance on retrospective self-reports and use of lay interviewers, although these interviewers were trained and had an average of 5 years of experience conducting health-related surveys.
Although the study included a representative sample of U.S. adults, the sample did not include groups known to have high rates of suicide and self-harm behaviors, such as institutionalized, incarcerated, or homeless individuals.
In addition, the study did not evaluate severity and duration of BPD, although the authors noted they did adjust for age at BPD onset, this did not alter the findings.
Often misdiagnosed
Commenting on the study, John M. Oldham, MD, Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and past-president, American Psychiatric Association, and an expert on BPD, had high praise for the research.
BPD is often misdiagnosed, Dr. Oldham said in an interview. Many patients seek help from primary care doctors who may label the symptoms as an anxiety disorder or a mood disorder, he said.
Although medications can help treat some BPD symptoms, “the primary, core evidence-based treatment for BPD is psychotherapy,” said Dr. Oldham, who some years ago helped develop evidence-based practice guidelines for BPD.
“It’s a clear and very well-designed study, and I don’t see any major limitations or problems with it,” he said. “The authors kept their focus rigorously on their goals and they used really careful methodology.”
He noted the “huge” numbers of patients included in the data and the relatively large percentage of men (43.7%).
“There’s a general belief that it’s mostly females who have BPD, but that’s not true; it’s females who come to treatment,” said Dr. Oldham.
Requiring that all five criteria lead to seriously impaired functioning “is a much more rigorous diagnostic methodology” than requiring only one or two criteria to lead to such impairment, said Dr. Oldham. “This is really important” and makes it “a much stronger study.”
The finding that self-harm behavior was linked to suicide attempts isn’t that surprising as this association has been well documented, but the finding that chronic emptiness is also predictive of future suicide attempts “is news,” said Dr. Oldham.
“We have not paid enough attention to this criterion in the clinical world or in the research world.”
Dr. Oldham said one patient with BPD gave him an ideal metaphor for emptiness. “She said it’s like there’s just nobody home. Think of it as an empty house that may look fine on the outside but you go inside and nobody lives there; there’s no furniture; no favorite things; no photos; no possessions.”
The authors have “important messages we need to pay attention to, and the main one is to explore this sense of chronic ‘nobody home’ emptiness,” said Dr. Oldham.
Dr. Grilo has reported receiving research grants from the National Institutes of Health; serving as a consultant for Sunovion and Weight Watchers; receiving honoraria for lectures, continuing medical education activities, and presentations at scientific conferences; and receiving royalties from Guilford Press and Taylor & Francis, all outside the submitted work.
A version of this article first appeared on Medscape.com.
TMS ‘surprisingly effective’ for resistant depression
Treatment with transcranial magnetic stimulation (TMS) has a robust effect for patients with major depressive disorder (MDD), results from a large registry study show.
From patient self-reports and clinician assessments, investigators found that TMS was “surprisingly effective” and “an eye-opener” for these patients, lead investigator Harold A. Sackeim, PhD, professor of clinical psychology in psychiatry and radiology, Columbia University, New York, told this news organization.
“In a presumably treatment-resistant population, the efficacy compared favorably with virtually all pharmacologic treatments” tested in the studies, said Dr. Sackeim.
He noted that the registry from which the data were obtained “is the largest for any treatment of depression, period.” These positive results suggest TMS should be considered a first-line treatment for MDD, he added.
The study was presented at the virtual American Psychiatric Association 2021 Annual Meeting and was previously published in the Journal of Affective Disorders.
Real-world study
Results of randomized clinical trials have shown that TMS is effective for episodes of MDD. However, the investigators note that there is a need to characterize and identify patient- and treatment-related clinical outcomes.
The study included 5,010 adult patients who had received a primary diagnosis of MDD and were treated at 103 practices in the United States. Participants completed the nine-item Patient Health Questionnaire (PHQ-9) at baseline and at least one other time following a TMS treatment.
The average baseline PHQ-9 score was 19.8, indicating moderate to severe symptoms. This was also reflected in a smaller sample that included Clinical Global Impressions–Severity (CGI-S) ratings by clinicians, mostly psychiatrists.
About two-thirds of the study population were women. The average age was about 50 years. Participants typically received about 30 TMS sessions over 7 to 8 weeks.
TMS targets tissue in the dorsolateral prefrontal cortex. The standard protocol involves administering “fast” or high-frequency (10-Hz) stimulation on the left side. Sometimes, slow-frequency stimulation on the right side is added. About 57% of patients were treated on the left side, and 43% were treated on both sides. Each session involved delivery of about 3,000 pulses.
In the analysis of patient self-reports (PHQ-9), the response rate, which was defined as resolution of 50% or more of symptoms, was from 58% to 69%. The remission rate, defined as becoming asymptomatic or having minimal symptoms, ranged from 28% to 36%.
Results were about 5% higher in the “completer” sample, which included 3,814 patients who received at least 20 treatments and who completed a PHQ-9 assessment at the end the treatment course.
The number of completers in the analysis was “massive,” said Dr. Sackeim. It’s “ten times larger than in any previous TMS study; all randomized trials have a couple of hundred subjects at most, so this is whopping.”
The results provide “a full snapshot” of TMS in the “real-world” community instead of in the “highly controlled” environment of most studies, he added.
Gender differences
The analysis that included CGI-S clinician measures yielded higher outcome estimates – 79% to 83% for the response rate, and 47% to 63% for the remission rate.
Women tended to have better clinical outcomes. “It appears to me that around age 50 is where you see the difference,” said Dr. Sackeim. “Among women, it looks like the older they get, the better the outcome, whereas men are not showing that type of positive aging effect.”
This difference might be due to hormonal changes associated with menopause and the fact that older men with depression may have had a stroke or brain lesion. Dr. Sackeim said he plans to look more closely at outcomes of women in comparison with men.
This, said Dr. Sackeim, illustrates how rapidly the TMS field is evolving.
He noted that researchers are now personalizing the procedure by determining the optimal target for individual patients. Other investigators are testing different protocols.
In the current study, results tended to be better for those who received 4,000 or more pulses, said Dr. Sackeim. “There was an indication of a dose response effect in terms of how many pulses per session,” he said.
The authors note that the study’s PDQ-9 response and remission rates indicate that clinical outcomes are comparable to those of the seven antidepressants studied in Level 2 of the large Sequenced Treatment Alternatives to Relieve Depression (STAR-D) trial.
Initial data for relapse in the study population are “encouraging,” said Dr. Sackeim. “You don’t see the rapid relapse that you do when you discontinue some treatments, for example with ECT [electroconvulsive therapy].”
The “slower onset of action” over the course of several sessions “may induce longer benefit,” he added.
Expanded use warranted?
The intervention proved very safe. Side effects, including headaches, were minimal, and there were “virtually no cognitive effects,” said Dr. Sackeim.
Dr. Sackeim believes TMS, as it has evolved, “is an outstanding option for treatment-resistant depression, and it has a very bright future” and should not be reserved for patients with established treatment-resistant depression (TRD), which is the current U.S. Food and Drug Administration indication.
“Restricting it to TRD in my mind is probably a mistake. Why shouldn’t the patient who is just starting on their course of treatment for depression have this as a nonpharmacological option?” he said.
Limitations of the study included its open-label design and the fact that only patients’ age, gender, outcome scores, and TMS treatment parameters were recorded in the registry. Other clinical characteristics, including medication use, were unknown.
However, it’s presumed that most patients had TRD, because insurance reimbursement for TMS typically requires an extensive history of failed antidepressant treatment.
Commenting on the study for an interview, Mark George, MD, professor, and Layton McCurdy, endowed chair in psychiatry, the Medical University of South Carolina, Charleston, called the remission and response rates “remarkable.”
The study included a “huge sample size” of Americans suffering from depression “who have not responded to talking therapy or medications,” noted Dr. George.
“This real-world study shows how effective, safe, and important TMS is for depressed patients who do not respond to medications,” he said.
Neuronetics supported the NeuroStar Advanced Therapy System Clinical Outcomes Registry, analysis of the registry data, and the drafting of this manuscript. Dr. Sackeim serves as a scientific adviser to LivaNova PLC, MECTA Corporation, and Neuronetics. He receives honoraria and royalties from Elsevier and Oxford University Press. He is the inventor on nonremunerative U.S. patents for Focal Electrically Administered Seizure Therapy (FEAST), titration in the current domain in ECT, and the adjustment of current in ECT devices; each patent is held by the MECTA Corporation. He is also the originator of magnetic seizure therapy.
A version of this article first appeared on Medscape.com.
Treatment with transcranial magnetic stimulation (TMS) has a robust effect for patients with major depressive disorder (MDD), results from a large registry study show.
From patient self-reports and clinician assessments, investigators found that TMS was “surprisingly effective” and “an eye-opener” for these patients, lead investigator Harold A. Sackeim, PhD, professor of clinical psychology in psychiatry and radiology, Columbia University, New York, told this news organization.
“In a presumably treatment-resistant population, the efficacy compared favorably with virtually all pharmacologic treatments” tested in the studies, said Dr. Sackeim.
He noted that the registry from which the data were obtained “is the largest for any treatment of depression, period.” These positive results suggest TMS should be considered a first-line treatment for MDD, he added.
The study was presented at the virtual American Psychiatric Association 2021 Annual Meeting and was previously published in the Journal of Affective Disorders.
Real-world study
Results of randomized clinical trials have shown that TMS is effective for episodes of MDD. However, the investigators note that there is a need to characterize and identify patient- and treatment-related clinical outcomes.
The study included 5,010 adult patients who had received a primary diagnosis of MDD and were treated at 103 practices in the United States. Participants completed the nine-item Patient Health Questionnaire (PHQ-9) at baseline and at least one other time following a TMS treatment.
The average baseline PHQ-9 score was 19.8, indicating moderate to severe symptoms. This was also reflected in a smaller sample that included Clinical Global Impressions–Severity (CGI-S) ratings by clinicians, mostly psychiatrists.
About two-thirds of the study population were women. The average age was about 50 years. Participants typically received about 30 TMS sessions over 7 to 8 weeks.
TMS targets tissue in the dorsolateral prefrontal cortex. The standard protocol involves administering “fast” or high-frequency (10-Hz) stimulation on the left side. Sometimes, slow-frequency stimulation on the right side is added. About 57% of patients were treated on the left side, and 43% were treated on both sides. Each session involved delivery of about 3,000 pulses.
In the analysis of patient self-reports (PHQ-9), the response rate, which was defined as resolution of 50% or more of symptoms, was from 58% to 69%. The remission rate, defined as becoming asymptomatic or having minimal symptoms, ranged from 28% to 36%.
Results were about 5% higher in the “completer” sample, which included 3,814 patients who received at least 20 treatments and who completed a PHQ-9 assessment at the end the treatment course.
The number of completers in the analysis was “massive,” said Dr. Sackeim. It’s “ten times larger than in any previous TMS study; all randomized trials have a couple of hundred subjects at most, so this is whopping.”
The results provide “a full snapshot” of TMS in the “real-world” community instead of in the “highly controlled” environment of most studies, he added.
Gender differences
The analysis that included CGI-S clinician measures yielded higher outcome estimates – 79% to 83% for the response rate, and 47% to 63% for the remission rate.
Women tended to have better clinical outcomes. “It appears to me that around age 50 is where you see the difference,” said Dr. Sackeim. “Among women, it looks like the older they get, the better the outcome, whereas men are not showing that type of positive aging effect.”
This difference might be due to hormonal changes associated with menopause and the fact that older men with depression may have had a stroke or brain lesion. Dr. Sackeim said he plans to look more closely at outcomes of women in comparison with men.
This, said Dr. Sackeim, illustrates how rapidly the TMS field is evolving.
He noted that researchers are now personalizing the procedure by determining the optimal target for individual patients. Other investigators are testing different protocols.
In the current study, results tended to be better for those who received 4,000 or more pulses, said Dr. Sackeim. “There was an indication of a dose response effect in terms of how many pulses per session,” he said.
The authors note that the study’s PDQ-9 response and remission rates indicate that clinical outcomes are comparable to those of the seven antidepressants studied in Level 2 of the large Sequenced Treatment Alternatives to Relieve Depression (STAR-D) trial.
Initial data for relapse in the study population are “encouraging,” said Dr. Sackeim. “You don’t see the rapid relapse that you do when you discontinue some treatments, for example with ECT [electroconvulsive therapy].”
The “slower onset of action” over the course of several sessions “may induce longer benefit,” he added.
Expanded use warranted?
The intervention proved very safe. Side effects, including headaches, were minimal, and there were “virtually no cognitive effects,” said Dr. Sackeim.
Dr. Sackeim believes TMS, as it has evolved, “is an outstanding option for treatment-resistant depression, and it has a very bright future” and should not be reserved for patients with established treatment-resistant depression (TRD), which is the current U.S. Food and Drug Administration indication.
“Restricting it to TRD in my mind is probably a mistake. Why shouldn’t the patient who is just starting on their course of treatment for depression have this as a nonpharmacological option?” he said.
Limitations of the study included its open-label design and the fact that only patients’ age, gender, outcome scores, and TMS treatment parameters were recorded in the registry. Other clinical characteristics, including medication use, were unknown.
However, it’s presumed that most patients had TRD, because insurance reimbursement for TMS typically requires an extensive history of failed antidepressant treatment.
Commenting on the study for an interview, Mark George, MD, professor, and Layton McCurdy, endowed chair in psychiatry, the Medical University of South Carolina, Charleston, called the remission and response rates “remarkable.”
The study included a “huge sample size” of Americans suffering from depression “who have not responded to talking therapy or medications,” noted Dr. George.
“This real-world study shows how effective, safe, and important TMS is for depressed patients who do not respond to medications,” he said.
Neuronetics supported the NeuroStar Advanced Therapy System Clinical Outcomes Registry, analysis of the registry data, and the drafting of this manuscript. Dr. Sackeim serves as a scientific adviser to LivaNova PLC, MECTA Corporation, and Neuronetics. He receives honoraria and royalties from Elsevier and Oxford University Press. He is the inventor on nonremunerative U.S. patents for Focal Electrically Administered Seizure Therapy (FEAST), titration in the current domain in ECT, and the adjustment of current in ECT devices; each patent is held by the MECTA Corporation. He is also the originator of magnetic seizure therapy.
A version of this article first appeared on Medscape.com.
Treatment with transcranial magnetic stimulation (TMS) has a robust effect for patients with major depressive disorder (MDD), results from a large registry study show.
From patient self-reports and clinician assessments, investigators found that TMS was “surprisingly effective” and “an eye-opener” for these patients, lead investigator Harold A. Sackeim, PhD, professor of clinical psychology in psychiatry and radiology, Columbia University, New York, told this news organization.
“In a presumably treatment-resistant population, the efficacy compared favorably with virtually all pharmacologic treatments” tested in the studies, said Dr. Sackeim.
He noted that the registry from which the data were obtained “is the largest for any treatment of depression, period.” These positive results suggest TMS should be considered a first-line treatment for MDD, he added.
The study was presented at the virtual American Psychiatric Association 2021 Annual Meeting and was previously published in the Journal of Affective Disorders.
Real-world study
Results of randomized clinical trials have shown that TMS is effective for episodes of MDD. However, the investigators note that there is a need to characterize and identify patient- and treatment-related clinical outcomes.
The study included 5,010 adult patients who had received a primary diagnosis of MDD and were treated at 103 practices in the United States. Participants completed the nine-item Patient Health Questionnaire (PHQ-9) at baseline and at least one other time following a TMS treatment.
The average baseline PHQ-9 score was 19.8, indicating moderate to severe symptoms. This was also reflected in a smaller sample that included Clinical Global Impressions–Severity (CGI-S) ratings by clinicians, mostly psychiatrists.
About two-thirds of the study population were women. The average age was about 50 years. Participants typically received about 30 TMS sessions over 7 to 8 weeks.
TMS targets tissue in the dorsolateral prefrontal cortex. The standard protocol involves administering “fast” or high-frequency (10-Hz) stimulation on the left side. Sometimes, slow-frequency stimulation on the right side is added. About 57% of patients were treated on the left side, and 43% were treated on both sides. Each session involved delivery of about 3,000 pulses.
In the analysis of patient self-reports (PHQ-9), the response rate, which was defined as resolution of 50% or more of symptoms, was from 58% to 69%. The remission rate, defined as becoming asymptomatic or having minimal symptoms, ranged from 28% to 36%.
Results were about 5% higher in the “completer” sample, which included 3,814 patients who received at least 20 treatments and who completed a PHQ-9 assessment at the end the treatment course.
The number of completers in the analysis was “massive,” said Dr. Sackeim. It’s “ten times larger than in any previous TMS study; all randomized trials have a couple of hundred subjects at most, so this is whopping.”
The results provide “a full snapshot” of TMS in the “real-world” community instead of in the “highly controlled” environment of most studies, he added.
Gender differences
The analysis that included CGI-S clinician measures yielded higher outcome estimates – 79% to 83% for the response rate, and 47% to 63% for the remission rate.
Women tended to have better clinical outcomes. “It appears to me that around age 50 is where you see the difference,” said Dr. Sackeim. “Among women, it looks like the older they get, the better the outcome, whereas men are not showing that type of positive aging effect.”
This difference might be due to hormonal changes associated with menopause and the fact that older men with depression may have had a stroke or brain lesion. Dr. Sackeim said he plans to look more closely at outcomes of women in comparison with men.
This, said Dr. Sackeim, illustrates how rapidly the TMS field is evolving.
He noted that researchers are now personalizing the procedure by determining the optimal target for individual patients. Other investigators are testing different protocols.
In the current study, results tended to be better for those who received 4,000 or more pulses, said Dr. Sackeim. “There was an indication of a dose response effect in terms of how many pulses per session,” he said.
The authors note that the study’s PDQ-9 response and remission rates indicate that clinical outcomes are comparable to those of the seven antidepressants studied in Level 2 of the large Sequenced Treatment Alternatives to Relieve Depression (STAR-D) trial.
Initial data for relapse in the study population are “encouraging,” said Dr. Sackeim. “You don’t see the rapid relapse that you do when you discontinue some treatments, for example with ECT [electroconvulsive therapy].”
The “slower onset of action” over the course of several sessions “may induce longer benefit,” he added.
Expanded use warranted?
The intervention proved very safe. Side effects, including headaches, were minimal, and there were “virtually no cognitive effects,” said Dr. Sackeim.
Dr. Sackeim believes TMS, as it has evolved, “is an outstanding option for treatment-resistant depression, and it has a very bright future” and should not be reserved for patients with established treatment-resistant depression (TRD), which is the current U.S. Food and Drug Administration indication.
“Restricting it to TRD in my mind is probably a mistake. Why shouldn’t the patient who is just starting on their course of treatment for depression have this as a nonpharmacological option?” he said.
Limitations of the study included its open-label design and the fact that only patients’ age, gender, outcome scores, and TMS treatment parameters were recorded in the registry. Other clinical characteristics, including medication use, were unknown.
However, it’s presumed that most patients had TRD, because insurance reimbursement for TMS typically requires an extensive history of failed antidepressant treatment.
Commenting on the study for an interview, Mark George, MD, professor, and Layton McCurdy, endowed chair in psychiatry, the Medical University of South Carolina, Charleston, called the remission and response rates “remarkable.”
The study included a “huge sample size” of Americans suffering from depression “who have not responded to talking therapy or medications,” noted Dr. George.
“This real-world study shows how effective, safe, and important TMS is for depressed patients who do not respond to medications,” he said.
Neuronetics supported the NeuroStar Advanced Therapy System Clinical Outcomes Registry, analysis of the registry data, and the drafting of this manuscript. Dr. Sackeim serves as a scientific adviser to LivaNova PLC, MECTA Corporation, and Neuronetics. He receives honoraria and royalties from Elsevier and Oxford University Press. He is the inventor on nonremunerative U.S. patents for Focal Electrically Administered Seizure Therapy (FEAST), titration in the current domain in ECT, and the adjustment of current in ECT devices; each patent is held by the MECTA Corporation. He is also the originator of magnetic seizure therapy.
A version of this article first appeared on Medscape.com.
Opioid addiction meds may curb growing problem of kratom dependence
Medications typically used to treat opioid use disorder (OUD) may* also be effective for the growing public health problem of kratom addiction, new research shows.
Results of a comprehensive literature review and an expert survey suggest buprenorphine, naltrexone, and methadone may be effective for patients seeking help for kratom addiction, and if further research confirms these findings, the indication for OUD medications could potentially be expanded to include moderate-to-severe kratom addiction, study investigator Saeed Ahmed, MD, medical director of West Ridge Center at Rutland Regional Medical Center, Rutland, Vermont, said in an interview.
Dr. Ahmed, who practices general psychiatry and addiction psychiatry, presented the findings at the virtual American Psychiatric Association 2021 Annual Meeting.
Emerging public health problem
Kratom can be ingested in pill or capsule form or as an extract. Its leaves can be chewed or dried and powdered to make a tea. It can also be incorporated into topical creams, balms, or tinctures.
Products containing the substance are “readily available and legal for sale in many states and cities in the U.S.,” said Dr. Ahmed, adding that it can be purchased online or at local smoke shops and is increasingly used by individuals to self-treat a variety of conditions including pain, anxiety, and mood conditions and as an opioid substitute.
As reported by this news organization, a 2018 analysis conducted by the U.S. Food and Drug Administration showed kratom is, in fact, an opioid, a finding that garnered significant push-back from the American Kratom Association.
Kratom addiction is an “emerging public health problem,” said Dr. Ahmed, adding that in recent years the number of calls to poison control centers across the country has increased 52-fold – from one per month to two per day. He believes misinformation through social media has helped fuel its use.
Kratom use, the investigators note, can lead to muscle pain, weight loss, insomnia, hallucinations and, in some cases (particularly when combined with synthetic opioids or benzodiazepines), it can lead to respiratory depression, seizures, coma, and death.
In addition,
To investigate, the researchers conducted a systematic literature search for cases pertaining to maintenance treatment for kratom dependence. They also tapped into case reports and scientific posters from reliable online sources and conference proceedings. In addition, they conducted a survey of members from the American Society of Addiction Medicine (ASAM).
The researchers found 14 reports of long-term management of kratom addiction, half of which did not involve an OUD. It’s important to exclude OUDs to avoid possible confounding.
In most cases, buprenorphine was used, but in a few cases naltrexone or methadone were prescribed. All cases had a favorable outcome. Dr. Ahmed noted that buprenorphine maintenance doses appear to be lower than those required to effectively treat OUD.
With a response rate of 11.5% (82 respondents) the ASAM survey results showed 82.6% of respondents (n = 57) had experience managing KUD, including 27.5% (n = 19) who had kratom addiction only. Of these, 89.5% (n = 17-19), used buprenorphine to manage KUD and of these, 6 combined it with talk therapy.
Dr. Ahmed cautioned that the included cases varied significantly in terms of relevant data, including kratom dose and route of administration, toxicology screening used to monitor abstinence, and duration of maintenance follow-up.
Despite these limitations, the review and survey underscore the importance of including moderate to severe kratom dependence as an indication for current OUD medications, the researchers note.
Including kratom addiction as an indication for these medications is important, especially for patients who are heavily addicted, to meet DSM-5 diagnostic criteria for moderate or severe SUD, they add.
In addition, the researchers recommend that clinicians consider referring patients with moderate to severe kratom dependence for counseling or enrollment in 12-step addiction treatment programs.
A separate diagnosis?
Dr. Ahmed said he would like to see kratom dependence included in the DSM-5 as a separate entity because it is a botanical with properties similar to, but different from, traditional opioids.
“This will not only help to better inform clinicians about a diagnostic criteria encompassing problematic use and facilitate screening, but it will also pave the way for treatments to be explored for this diagnosable condition,” he said. Dr. Ahmed pointed to a review published in the Wisconsin Medical Journal earlier this year that explored potential treatments for kratom dependence.
Commenting on the study for an interview, Petros Levounis, MD, professor and chair, department of psychiatry, and associate dean for professional development, Rutgers New Jersey Medical School, Newark, said the authors “have done a great job reviewing the literature and asking experts” about kratom addiction treatment.
“The punchline of their study is that kratom behaves very much like an opioid and is treated like an opioid.”
Dr. Levounis noted that kratom dependence is so new that experts don’t know much about it. However, he added, emerging evidence suggests that kratom “should be considered an opioid more than anything else,” but specified that he does not believe it warrants its own diagnosis.
He noted that individual opioids don’t have their own diagnostic category and that opioid use disorder is an umbrella term that covers all of these drugs.
Dr. Ahmed and Dr. Levounis have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
*Updated 5/18/2021
Medications typically used to treat opioid use disorder (OUD) may* also be effective for the growing public health problem of kratom addiction, new research shows.
Results of a comprehensive literature review and an expert survey suggest buprenorphine, naltrexone, and methadone may be effective for patients seeking help for kratom addiction, and if further research confirms these findings, the indication for OUD medications could potentially be expanded to include moderate-to-severe kratom addiction, study investigator Saeed Ahmed, MD, medical director of West Ridge Center at Rutland Regional Medical Center, Rutland, Vermont, said in an interview.
Dr. Ahmed, who practices general psychiatry and addiction psychiatry, presented the findings at the virtual American Psychiatric Association 2021 Annual Meeting.
Emerging public health problem
Kratom can be ingested in pill or capsule form or as an extract. Its leaves can be chewed or dried and powdered to make a tea. It can also be incorporated into topical creams, balms, or tinctures.
Products containing the substance are “readily available and legal for sale in many states and cities in the U.S.,” said Dr. Ahmed, adding that it can be purchased online or at local smoke shops and is increasingly used by individuals to self-treat a variety of conditions including pain, anxiety, and mood conditions and as an opioid substitute.
As reported by this news organization, a 2018 analysis conducted by the U.S. Food and Drug Administration showed kratom is, in fact, an opioid, a finding that garnered significant push-back from the American Kratom Association.
Kratom addiction is an “emerging public health problem,” said Dr. Ahmed, adding that in recent years the number of calls to poison control centers across the country has increased 52-fold – from one per month to two per day. He believes misinformation through social media has helped fuel its use.
Kratom use, the investigators note, can lead to muscle pain, weight loss, insomnia, hallucinations and, in some cases (particularly when combined with synthetic opioids or benzodiazepines), it can lead to respiratory depression, seizures, coma, and death.
In addition,
To investigate, the researchers conducted a systematic literature search for cases pertaining to maintenance treatment for kratom dependence. They also tapped into case reports and scientific posters from reliable online sources and conference proceedings. In addition, they conducted a survey of members from the American Society of Addiction Medicine (ASAM).
The researchers found 14 reports of long-term management of kratom addiction, half of which did not involve an OUD. It’s important to exclude OUDs to avoid possible confounding.
In most cases, buprenorphine was used, but in a few cases naltrexone or methadone were prescribed. All cases had a favorable outcome. Dr. Ahmed noted that buprenorphine maintenance doses appear to be lower than those required to effectively treat OUD.
With a response rate of 11.5% (82 respondents) the ASAM survey results showed 82.6% of respondents (n = 57) had experience managing KUD, including 27.5% (n = 19) who had kratom addiction only. Of these, 89.5% (n = 17-19), used buprenorphine to manage KUD and of these, 6 combined it with talk therapy.
Dr. Ahmed cautioned that the included cases varied significantly in terms of relevant data, including kratom dose and route of administration, toxicology screening used to monitor abstinence, and duration of maintenance follow-up.
Despite these limitations, the review and survey underscore the importance of including moderate to severe kratom dependence as an indication for current OUD medications, the researchers note.
Including kratom addiction as an indication for these medications is important, especially for patients who are heavily addicted, to meet DSM-5 diagnostic criteria for moderate or severe SUD, they add.
In addition, the researchers recommend that clinicians consider referring patients with moderate to severe kratom dependence for counseling or enrollment in 12-step addiction treatment programs.
A separate diagnosis?
Dr. Ahmed said he would like to see kratom dependence included in the DSM-5 as a separate entity because it is a botanical with properties similar to, but different from, traditional opioids.
“This will not only help to better inform clinicians about a diagnostic criteria encompassing problematic use and facilitate screening, but it will also pave the way for treatments to be explored for this diagnosable condition,” he said. Dr. Ahmed pointed to a review published in the Wisconsin Medical Journal earlier this year that explored potential treatments for kratom dependence.
Commenting on the study for an interview, Petros Levounis, MD, professor and chair, department of psychiatry, and associate dean for professional development, Rutgers New Jersey Medical School, Newark, said the authors “have done a great job reviewing the literature and asking experts” about kratom addiction treatment.
“The punchline of their study is that kratom behaves very much like an opioid and is treated like an opioid.”
Dr. Levounis noted that kratom dependence is so new that experts don’t know much about it. However, he added, emerging evidence suggests that kratom “should be considered an opioid more than anything else,” but specified that he does not believe it warrants its own diagnosis.
He noted that individual opioids don’t have their own diagnostic category and that opioid use disorder is an umbrella term that covers all of these drugs.
Dr. Ahmed and Dr. Levounis have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
*Updated 5/18/2021
Medications typically used to treat opioid use disorder (OUD) may* also be effective for the growing public health problem of kratom addiction, new research shows.
Results of a comprehensive literature review and an expert survey suggest buprenorphine, naltrexone, and methadone may be effective for patients seeking help for kratom addiction, and if further research confirms these findings, the indication for OUD medications could potentially be expanded to include moderate-to-severe kratom addiction, study investigator Saeed Ahmed, MD, medical director of West Ridge Center at Rutland Regional Medical Center, Rutland, Vermont, said in an interview.
Dr. Ahmed, who practices general psychiatry and addiction psychiatry, presented the findings at the virtual American Psychiatric Association 2021 Annual Meeting.
Emerging public health problem
Kratom can be ingested in pill or capsule form or as an extract. Its leaves can be chewed or dried and powdered to make a tea. It can also be incorporated into topical creams, balms, or tinctures.
Products containing the substance are “readily available and legal for sale in many states and cities in the U.S.,” said Dr. Ahmed, adding that it can be purchased online or at local smoke shops and is increasingly used by individuals to self-treat a variety of conditions including pain, anxiety, and mood conditions and as an opioid substitute.
As reported by this news organization, a 2018 analysis conducted by the U.S. Food and Drug Administration showed kratom is, in fact, an opioid, a finding that garnered significant push-back from the American Kratom Association.
Kratom addiction is an “emerging public health problem,” said Dr. Ahmed, adding that in recent years the number of calls to poison control centers across the country has increased 52-fold – from one per month to two per day. He believes misinformation through social media has helped fuel its use.
Kratom use, the investigators note, can lead to muscle pain, weight loss, insomnia, hallucinations and, in some cases (particularly when combined with synthetic opioids or benzodiazepines), it can lead to respiratory depression, seizures, coma, and death.
In addition,
To investigate, the researchers conducted a systematic literature search for cases pertaining to maintenance treatment for kratom dependence. They also tapped into case reports and scientific posters from reliable online sources and conference proceedings. In addition, they conducted a survey of members from the American Society of Addiction Medicine (ASAM).
The researchers found 14 reports of long-term management of kratom addiction, half of which did not involve an OUD. It’s important to exclude OUDs to avoid possible confounding.
In most cases, buprenorphine was used, but in a few cases naltrexone or methadone were prescribed. All cases had a favorable outcome. Dr. Ahmed noted that buprenorphine maintenance doses appear to be lower than those required to effectively treat OUD.
With a response rate of 11.5% (82 respondents) the ASAM survey results showed 82.6% of respondents (n = 57) had experience managing KUD, including 27.5% (n = 19) who had kratom addiction only. Of these, 89.5% (n = 17-19), used buprenorphine to manage KUD and of these, 6 combined it with talk therapy.
Dr. Ahmed cautioned that the included cases varied significantly in terms of relevant data, including kratom dose and route of administration, toxicology screening used to monitor abstinence, and duration of maintenance follow-up.
Despite these limitations, the review and survey underscore the importance of including moderate to severe kratom dependence as an indication for current OUD medications, the researchers note.
Including kratom addiction as an indication for these medications is important, especially for patients who are heavily addicted, to meet DSM-5 diagnostic criteria for moderate or severe SUD, they add.
In addition, the researchers recommend that clinicians consider referring patients with moderate to severe kratom dependence for counseling or enrollment in 12-step addiction treatment programs.
A separate diagnosis?
Dr. Ahmed said he would like to see kratom dependence included in the DSM-5 as a separate entity because it is a botanical with properties similar to, but different from, traditional opioids.
“This will not only help to better inform clinicians about a diagnostic criteria encompassing problematic use and facilitate screening, but it will also pave the way for treatments to be explored for this diagnosable condition,” he said. Dr. Ahmed pointed to a review published in the Wisconsin Medical Journal earlier this year that explored potential treatments for kratom dependence.
Commenting on the study for an interview, Petros Levounis, MD, professor and chair, department of psychiatry, and associate dean for professional development, Rutgers New Jersey Medical School, Newark, said the authors “have done a great job reviewing the literature and asking experts” about kratom addiction treatment.
“The punchline of their study is that kratom behaves very much like an opioid and is treated like an opioid.”
Dr. Levounis noted that kratom dependence is so new that experts don’t know much about it. However, he added, emerging evidence suggests that kratom “should be considered an opioid more than anything else,” but specified that he does not believe it warrants its own diagnosis.
He noted that individual opioids don’t have their own diagnostic category and that opioid use disorder is an umbrella term that covers all of these drugs.
Dr. Ahmed and Dr. Levounis have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
*Updated 5/18/2021
Structural racism tied to psychosis risk in Black people
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Parental attitudes to kids’ sexual orientation: Unexpected findings
For gay and lesbian individuals, consistency in parents’ attitudes toward their child’s sexual orientation, even when they are negative, is an important factor in positive mental health outcomes, new research shows.
Study investigator Matthew Verdun, MS, a licensed marriage and family therapist and doctoral student at the Chicago School of Professional Psychology at Los Angeles, California, found that gays and lesbians whose parents were not supportive of their sexual orientation could still have good outcomes.
The findings were presented at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
High rates of mental illness
Research shows that members of the gay and lesbian community experience higher rates of mental illness and substance use disorders and that psychological well-being declines during periods close to when sexual orientation is disclosed.
Mr. Verdun referred to a theory in the literature of homosexual identity formation that describes how individuals go through six stages: confusion, comparison, tolerance, acceptance, pride, and synthesis.
Research shows a U-shaped relationship between subjective reports of well-being at these six stages. The lowest rates occur during the identity comparison and identity tolerance stages.
“Those stages roughly correspond with the time when people would disclose their sexual orientation to parents and family members. The time when a person discloses is probably one of the most anxious times in their life; it’s also where their rate of well-being is the lowest,” said Mr. Verdun.
Mr. Verdun said he “wanted to know what happens when a parent is supportive or rejecting at that moment, but also what happens over time.”
To determine whether parental support affects depression, anxiety, or substance abuse in members of the gay and lesbian community, Mr. Verdun studied 175 individuals who self-identified as gay or lesbian (77 males and 98 females) and were recruited via social media. Most (70.3%) were of White race or ethnicity.
Participants completed surveys asking about their parents’ initial and current level of support regarding their sexual orientation. They also completed the nine-item Patient Health Questionnaire (PHQ-9), the seven-item General Anxiety Disorder (GAD-7), and the 20-item Drug Abuse Screening Tool (DAST-20).
The investigators categorized participants into one of three groups on the basis of parental support:
- Consistently positive.
- Negative to positive.
- Consistently negative.
A fourth group, positive to negative, was excluded from the analysis because it was too small.
Mr. Verdun was unable analyze results for substance abuse. “The DAST-20 results violated the assumption of homogeneity of variances, which meant the analysis could result in error,” he explained.
Analyses for the PHQ-9 and GAD-7 showed that the consistently positive group had the lowest symptom scores.
“People whose parents were accepting had the lowest scores for anxiety and depression,” said Mr. Verdun.
For both the PHQ and GAD, the findings were significant (P < .05) for the consistently positive and the consistently negative groups in comparison with the negative to positive group.
The difference between the consistently positive and the consistently negative groups was not statistically significant.
Surprise finding
Previous research has shown that current levels of parental support relate to better mental health, so Mr. Verdun initially thought children whose parents were consistently supportive or those whose parents became supportive over time would have the best mental health outcomes.
“But, interestingly, what I found was that people whose parents vacillated between being accepting and rejecting over time actually had significantly more mental health symptoms at the time of the assessment than people whose parents were consistently accepting or consistently rejecting,” he said.
Although the study provided evidence of better outcomes for those with consistently unsupportive parents, Mr. Verdun believes some hypotheses are worthy of further research.
One is that people with unsupportive parents receive support elsewhere and could, for example, turn to peers, teachers, or other community members, including faith leaders, and that symptoms of mental illness may improve with such support, said Mr. Verdun.
These individuals may also develop ways to “buffer their mental health symptoms,” possibly by cultivating meaningful relationships “where they’re seen as a complete and total person, not just in terms of their sexual orientation,” he said.
Gay and lesbian individuals may also benefit from “healing activities,” which might include engagement and involvement in their community, such as performing volunteer work and learning about the history of their community, said Mr. Verdun.
Mental health providers can play a role in creating a positive environment by referring patients to support groups, to centers that cater to gays and lesbians, to faith communities, or by encouraging recreational activities, said Mr. Verdun.
Clinicians can also help gay and lesbian patients determine how and when to safely disclose their sexual orientation, he said.
The study did not include bisexual or transsexual individuals because processes of identifying sexual orientation differ for those persons, said Mr. Verdun.
“I would like to conduct future research that includes bisexual, trans people, and intersectional groups within the LGBTQIA [lesbian, gay, bisexual, transgender, queer, intersex, asexual] community,” he said.
Important research
Commenting on the study, Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, said the work is “extremely important and that it has the potential to lead to clinical guidance.”
The finding that levels of depression and anxiety were lower in children whose parents were accepting of their sexual orientation is not surprising, said Dr. Borenstein. “It’s common sense, but it’s always good to have such a finding demonstrate it,” he said.
Parents who understand this relationship may be better able to help their child who is depressed or anxious, he added.
Dr. Borenstein agreed that further research is needed regarding the finding of benefits from consistent parenting, even when that parenting involves rejection.
Such research might uncover “what types of other supports these individuals have that allow for lower levels of depression and anxiety,” he said.
“For this population, the risk of mental health issues is higher, and the risk of suicide is higher, so anything we can do to provide support and improved treatment is extremely important,” he said.
A version of this article first appeared on Medscape.com.
For gay and lesbian individuals, consistency in parents’ attitudes toward their child’s sexual orientation, even when they are negative, is an important factor in positive mental health outcomes, new research shows.
Study investigator Matthew Verdun, MS, a licensed marriage and family therapist and doctoral student at the Chicago School of Professional Psychology at Los Angeles, California, found that gays and lesbians whose parents were not supportive of their sexual orientation could still have good outcomes.
The findings were presented at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
High rates of mental illness
Research shows that members of the gay and lesbian community experience higher rates of mental illness and substance use disorders and that psychological well-being declines during periods close to when sexual orientation is disclosed.
Mr. Verdun referred to a theory in the literature of homosexual identity formation that describes how individuals go through six stages: confusion, comparison, tolerance, acceptance, pride, and synthesis.
Research shows a U-shaped relationship between subjective reports of well-being at these six stages. The lowest rates occur during the identity comparison and identity tolerance stages.
“Those stages roughly correspond with the time when people would disclose their sexual orientation to parents and family members. The time when a person discloses is probably one of the most anxious times in their life; it’s also where their rate of well-being is the lowest,” said Mr. Verdun.
Mr. Verdun said he “wanted to know what happens when a parent is supportive or rejecting at that moment, but also what happens over time.”
To determine whether parental support affects depression, anxiety, or substance abuse in members of the gay and lesbian community, Mr. Verdun studied 175 individuals who self-identified as gay or lesbian (77 males and 98 females) and were recruited via social media. Most (70.3%) were of White race or ethnicity.
Participants completed surveys asking about their parents’ initial and current level of support regarding their sexual orientation. They also completed the nine-item Patient Health Questionnaire (PHQ-9), the seven-item General Anxiety Disorder (GAD-7), and the 20-item Drug Abuse Screening Tool (DAST-20).
The investigators categorized participants into one of three groups on the basis of parental support:
- Consistently positive.
- Negative to positive.
- Consistently negative.
A fourth group, positive to negative, was excluded from the analysis because it was too small.
Mr. Verdun was unable analyze results for substance abuse. “The DAST-20 results violated the assumption of homogeneity of variances, which meant the analysis could result in error,” he explained.
Analyses for the PHQ-9 and GAD-7 showed that the consistently positive group had the lowest symptom scores.
“People whose parents were accepting had the lowest scores for anxiety and depression,” said Mr. Verdun.
For both the PHQ and GAD, the findings were significant (P < .05) for the consistently positive and the consistently negative groups in comparison with the negative to positive group.
The difference between the consistently positive and the consistently negative groups was not statistically significant.
Surprise finding
Previous research has shown that current levels of parental support relate to better mental health, so Mr. Verdun initially thought children whose parents were consistently supportive or those whose parents became supportive over time would have the best mental health outcomes.
“But, interestingly, what I found was that people whose parents vacillated between being accepting and rejecting over time actually had significantly more mental health symptoms at the time of the assessment than people whose parents were consistently accepting or consistently rejecting,” he said.
Although the study provided evidence of better outcomes for those with consistently unsupportive parents, Mr. Verdun believes some hypotheses are worthy of further research.
One is that people with unsupportive parents receive support elsewhere and could, for example, turn to peers, teachers, or other community members, including faith leaders, and that symptoms of mental illness may improve with such support, said Mr. Verdun.
These individuals may also develop ways to “buffer their mental health symptoms,” possibly by cultivating meaningful relationships “where they’re seen as a complete and total person, not just in terms of their sexual orientation,” he said.
Gay and lesbian individuals may also benefit from “healing activities,” which might include engagement and involvement in their community, such as performing volunteer work and learning about the history of their community, said Mr. Verdun.
Mental health providers can play a role in creating a positive environment by referring patients to support groups, to centers that cater to gays and lesbians, to faith communities, or by encouraging recreational activities, said Mr. Verdun.
Clinicians can also help gay and lesbian patients determine how and when to safely disclose their sexual orientation, he said.
The study did not include bisexual or transsexual individuals because processes of identifying sexual orientation differ for those persons, said Mr. Verdun.
“I would like to conduct future research that includes bisexual, trans people, and intersectional groups within the LGBTQIA [lesbian, gay, bisexual, transgender, queer, intersex, asexual] community,” he said.
Important research
Commenting on the study, Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, said the work is “extremely important and that it has the potential to lead to clinical guidance.”
The finding that levels of depression and anxiety were lower in children whose parents were accepting of their sexual orientation is not surprising, said Dr. Borenstein. “It’s common sense, but it’s always good to have such a finding demonstrate it,” he said.
Parents who understand this relationship may be better able to help their child who is depressed or anxious, he added.
Dr. Borenstein agreed that further research is needed regarding the finding of benefits from consistent parenting, even when that parenting involves rejection.
Such research might uncover “what types of other supports these individuals have that allow for lower levels of depression and anxiety,” he said.
“For this population, the risk of mental health issues is higher, and the risk of suicide is higher, so anything we can do to provide support and improved treatment is extremely important,” he said.
A version of this article first appeared on Medscape.com.
For gay and lesbian individuals, consistency in parents’ attitudes toward their child’s sexual orientation, even when they are negative, is an important factor in positive mental health outcomes, new research shows.
Study investigator Matthew Verdun, MS, a licensed marriage and family therapist and doctoral student at the Chicago School of Professional Psychology at Los Angeles, California, found that gays and lesbians whose parents were not supportive of their sexual orientation could still have good outcomes.
The findings were presented at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
High rates of mental illness
Research shows that members of the gay and lesbian community experience higher rates of mental illness and substance use disorders and that psychological well-being declines during periods close to when sexual orientation is disclosed.
Mr. Verdun referred to a theory in the literature of homosexual identity formation that describes how individuals go through six stages: confusion, comparison, tolerance, acceptance, pride, and synthesis.
Research shows a U-shaped relationship between subjective reports of well-being at these six stages. The lowest rates occur during the identity comparison and identity tolerance stages.
“Those stages roughly correspond with the time when people would disclose their sexual orientation to parents and family members. The time when a person discloses is probably one of the most anxious times in their life; it’s also where their rate of well-being is the lowest,” said Mr. Verdun.
Mr. Verdun said he “wanted to know what happens when a parent is supportive or rejecting at that moment, but also what happens over time.”
To determine whether parental support affects depression, anxiety, or substance abuse in members of the gay and lesbian community, Mr. Verdun studied 175 individuals who self-identified as gay or lesbian (77 males and 98 females) and were recruited via social media. Most (70.3%) were of White race or ethnicity.
Participants completed surveys asking about their parents’ initial and current level of support regarding their sexual orientation. They also completed the nine-item Patient Health Questionnaire (PHQ-9), the seven-item General Anxiety Disorder (GAD-7), and the 20-item Drug Abuse Screening Tool (DAST-20).
The investigators categorized participants into one of three groups on the basis of parental support:
- Consistently positive.
- Negative to positive.
- Consistently negative.
A fourth group, positive to negative, was excluded from the analysis because it was too small.
Mr. Verdun was unable analyze results for substance abuse. “The DAST-20 results violated the assumption of homogeneity of variances, which meant the analysis could result in error,” he explained.
Analyses for the PHQ-9 and GAD-7 showed that the consistently positive group had the lowest symptom scores.
“People whose parents were accepting had the lowest scores for anxiety and depression,” said Mr. Verdun.
For both the PHQ and GAD, the findings were significant (P < .05) for the consistently positive and the consistently negative groups in comparison with the negative to positive group.
The difference between the consistently positive and the consistently negative groups was not statistically significant.
Surprise finding
Previous research has shown that current levels of parental support relate to better mental health, so Mr. Verdun initially thought children whose parents were consistently supportive or those whose parents became supportive over time would have the best mental health outcomes.
“But, interestingly, what I found was that people whose parents vacillated between being accepting and rejecting over time actually had significantly more mental health symptoms at the time of the assessment than people whose parents were consistently accepting or consistently rejecting,” he said.
Although the study provided evidence of better outcomes for those with consistently unsupportive parents, Mr. Verdun believes some hypotheses are worthy of further research.
One is that people with unsupportive parents receive support elsewhere and could, for example, turn to peers, teachers, or other community members, including faith leaders, and that symptoms of mental illness may improve with such support, said Mr. Verdun.
These individuals may also develop ways to “buffer their mental health symptoms,” possibly by cultivating meaningful relationships “where they’re seen as a complete and total person, not just in terms of their sexual orientation,” he said.
Gay and lesbian individuals may also benefit from “healing activities,” which might include engagement and involvement in their community, such as performing volunteer work and learning about the history of their community, said Mr. Verdun.
Mental health providers can play a role in creating a positive environment by referring patients to support groups, to centers that cater to gays and lesbians, to faith communities, or by encouraging recreational activities, said Mr. Verdun.
Clinicians can also help gay and lesbian patients determine how and when to safely disclose their sexual orientation, he said.
The study did not include bisexual or transsexual individuals because processes of identifying sexual orientation differ for those persons, said Mr. Verdun.
“I would like to conduct future research that includes bisexual, trans people, and intersectional groups within the LGBTQIA [lesbian, gay, bisexual, transgender, queer, intersex, asexual] community,” he said.
Important research
Commenting on the study, Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, said the work is “extremely important and that it has the potential to lead to clinical guidance.”
The finding that levels of depression and anxiety were lower in children whose parents were accepting of their sexual orientation is not surprising, said Dr. Borenstein. “It’s common sense, but it’s always good to have such a finding demonstrate it,” he said.
Parents who understand this relationship may be better able to help their child who is depressed or anxious, he added.
Dr. Borenstein agreed that further research is needed regarding the finding of benefits from consistent parenting, even when that parenting involves rejection.
Such research might uncover “what types of other supports these individuals have that allow for lower levels of depression and anxiety,” he said.
“For this population, the risk of mental health issues is higher, and the risk of suicide is higher, so anything we can do to provide support and improved treatment is extremely important,” he said.
A version of this article first appeared on Medscape.com.
Police contact tied to elevated anxiety in young Black adults
Young Black adults who witness or experience police violence have significantly elevated levels of anxiety, new research shows.
In the first study to quantify the impact of police contact anxiety, investigators found it was associated with moderately severe anxiety levels in this group of individuals, highlighting the need to screen for exposure to police violence in this patient population, study investigator Robert O. Motley Jr, PhD, manager of the Race & Opportunity Lab at Washington University in St. Louis, said in an interview.
“If you’re working in an institution and providing clinical care, mental health care, or behavior health care, these additional measures should be included to get a much more holistic view of the exposure of these individuals in terms of traumatic events. These assessments can inform your decisions around care,” Dr. Motley added.
The findings were presented at the annual meeting of the American Psychiatric Association.
‘Alarming’ rates of exposure
Evidence shows anxiety disorders are among the most prevalent conditions for Black people aged 18-29 years – an age group described as “emergent adulthood” because these individuals haven’t yet taken on full responsibilities of adulthood.
Research shows Black emergent adults are three to four times more likely than other ethnic groups to be exposed to actual or threatened nonfatal police violence, said Dr. Motley. “So they didn’t die, but were exposed to force, which could be things like police yelling at them, hitting or kicking them, pointing a gun at them, or tasing them.”
These individuals are also two to three times more likely to experience exposure to fatal police violence, and to be unarmed and killed, said Dr. Motley.
Evidence shows a clear link between exposure to stressful or traumatic events and anxiety disorders, but there has been little research examining the relationship between exposure to police violence and anxiety disorders among Black emergent adults, he said.
To assess the prevalence and correlates of “police contact anxiety” the investigators used computer-assisted surveys to collect data from 300 young Black college students in St. Louis who had been exposed to police violence at some point in their lives. The mean age of the sample was 20.4 years and included an equal number of men and women.
Work status for the previous year showed almost one-quarter (23.6%) were unemployed and about half worked part time. Almost two-thirds (62.6%) had an annual income of less than $10,000.
Respondents reported they had personally experienced police violence almost twice (a mean of 1.89) during their lifetime. The mean number of times they witnessed police using force against someone else was 7.82. Respondents also reported they had watched videos showing police use of force on the internet or television an average of 34.5 times.
This, said Dr. Motley, isn’t surprising given the growing number of young adults – of all races – who are using social media platforms to upload and share videos.
The researchers also looked at witnessing community violence, unrelated to police violence. Here, respondents had an average of 10.9 exposures.
Protectors or predators?
To examine the impact of police contact anxiety caused either by direct experience, or as a result of witnessing, or seeing a video of police use of violence in the past 30 days, the researchers created a “police contact anxiety” scale.
Respondents were asked six questions pertaining specifically to experiences during, or in anticipation of, police contact and its effects on anxiety levels.
For each of the six questions, participants rated the severity of anxiety on a scale of 0 (least severe) to 3 (most severe) for each exposure type. The final score had a potential range of 0-24.
Results showed police contact anxiety was moderately severe for all three exposure types with scores ranging from 13 to 14.
Ordinary least square regression analyses showed that, compared with unemployed participants, those who worked full time were less likely to have higher police contact anxiety as a result of seeing a video of police use of force (P < .05) – a finding Dr. Motley said was not surprising.
Employment, he noted, promotes individual self-efficacy, social participation, and mental health, which may provide a “buffer” to the effects of watching videos of police violence.
Dr. Motley noted that police officers “have been entrusted to serve and protect” the community, but “rarely face consequences when they use force against Black emergent adults; they’re rarely held accountable.”
These young Black adults “may perceive police officers as more of a threat to personal safety instead of a protector of it.”
Additional bivariate analyses showed that males had significantly higher scores than females for police contact anxiety because of witnessing police use of force.
This, too, was not surprising since males are exposed to more violence in general, said Dr. Motley.
It’s important to replicate the findings using a much larger and more diverse sample, he said. His next research project will be to collect data from a nationally representative sample of emerging adults across different ethnic groups and examining a range of different variables.
Commenting on the findings, Jeffrey Borenstein, MD, president and CEO of the Brain & Behavior Research Foundation and editor in chief of Psychiatric News, called it “outstanding.”
“This is a very important issue,” said Dr. Borenstein, who moderated a press briefing that featured the study.
“We know anxiety is an extremely important condition and symptom, across the board for all groups, and often anxiety isn’t evaluated in the way that it needs to be. This is a great study that will lead to further research in this important area,” he added.
The study was funded by the National Institute on Minority Health and Health Disparities. Dr. Motley and Dr. Borenstein have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Young Black adults who witness or experience police violence have significantly elevated levels of anxiety, new research shows.
In the first study to quantify the impact of police contact anxiety, investigators found it was associated with moderately severe anxiety levels in this group of individuals, highlighting the need to screen for exposure to police violence in this patient population, study investigator Robert O. Motley Jr, PhD, manager of the Race & Opportunity Lab at Washington University in St. Louis, said in an interview.
“If you’re working in an institution and providing clinical care, mental health care, or behavior health care, these additional measures should be included to get a much more holistic view of the exposure of these individuals in terms of traumatic events. These assessments can inform your decisions around care,” Dr. Motley added.
The findings were presented at the annual meeting of the American Psychiatric Association.
‘Alarming’ rates of exposure
Evidence shows anxiety disorders are among the most prevalent conditions for Black people aged 18-29 years – an age group described as “emergent adulthood” because these individuals haven’t yet taken on full responsibilities of adulthood.
Research shows Black emergent adults are three to four times more likely than other ethnic groups to be exposed to actual or threatened nonfatal police violence, said Dr. Motley. “So they didn’t die, but were exposed to force, which could be things like police yelling at them, hitting or kicking them, pointing a gun at them, or tasing them.”
These individuals are also two to three times more likely to experience exposure to fatal police violence, and to be unarmed and killed, said Dr. Motley.
Evidence shows a clear link between exposure to stressful or traumatic events and anxiety disorders, but there has been little research examining the relationship between exposure to police violence and anxiety disorders among Black emergent adults, he said.
To assess the prevalence and correlates of “police contact anxiety” the investigators used computer-assisted surveys to collect data from 300 young Black college students in St. Louis who had been exposed to police violence at some point in their lives. The mean age of the sample was 20.4 years and included an equal number of men and women.
Work status for the previous year showed almost one-quarter (23.6%) were unemployed and about half worked part time. Almost two-thirds (62.6%) had an annual income of less than $10,000.
Respondents reported they had personally experienced police violence almost twice (a mean of 1.89) during their lifetime. The mean number of times they witnessed police using force against someone else was 7.82. Respondents also reported they had watched videos showing police use of force on the internet or television an average of 34.5 times.
This, said Dr. Motley, isn’t surprising given the growing number of young adults – of all races – who are using social media platforms to upload and share videos.
The researchers also looked at witnessing community violence, unrelated to police violence. Here, respondents had an average of 10.9 exposures.
Protectors or predators?
To examine the impact of police contact anxiety caused either by direct experience, or as a result of witnessing, or seeing a video of police use of violence in the past 30 days, the researchers created a “police contact anxiety” scale.
Respondents were asked six questions pertaining specifically to experiences during, or in anticipation of, police contact and its effects on anxiety levels.
For each of the six questions, participants rated the severity of anxiety on a scale of 0 (least severe) to 3 (most severe) for each exposure type. The final score had a potential range of 0-24.
Results showed police contact anxiety was moderately severe for all three exposure types with scores ranging from 13 to 14.
Ordinary least square regression analyses showed that, compared with unemployed participants, those who worked full time were less likely to have higher police contact anxiety as a result of seeing a video of police use of force (P < .05) – a finding Dr. Motley said was not surprising.
Employment, he noted, promotes individual self-efficacy, social participation, and mental health, which may provide a “buffer” to the effects of watching videos of police violence.
Dr. Motley noted that police officers “have been entrusted to serve and protect” the community, but “rarely face consequences when they use force against Black emergent adults; they’re rarely held accountable.”
These young Black adults “may perceive police officers as more of a threat to personal safety instead of a protector of it.”
Additional bivariate analyses showed that males had significantly higher scores than females for police contact anxiety because of witnessing police use of force.
This, too, was not surprising since males are exposed to more violence in general, said Dr. Motley.
It’s important to replicate the findings using a much larger and more diverse sample, he said. His next research project will be to collect data from a nationally representative sample of emerging adults across different ethnic groups and examining a range of different variables.
Commenting on the findings, Jeffrey Borenstein, MD, president and CEO of the Brain & Behavior Research Foundation and editor in chief of Psychiatric News, called it “outstanding.”
“This is a very important issue,” said Dr. Borenstein, who moderated a press briefing that featured the study.
“We know anxiety is an extremely important condition and symptom, across the board for all groups, and often anxiety isn’t evaluated in the way that it needs to be. This is a great study that will lead to further research in this important area,” he added.
The study was funded by the National Institute on Minority Health and Health Disparities. Dr. Motley and Dr. Borenstein have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Young Black adults who witness or experience police violence have significantly elevated levels of anxiety, new research shows.
In the first study to quantify the impact of police contact anxiety, investigators found it was associated with moderately severe anxiety levels in this group of individuals, highlighting the need to screen for exposure to police violence in this patient population, study investigator Robert O. Motley Jr, PhD, manager of the Race & Opportunity Lab at Washington University in St. Louis, said in an interview.
“If you’re working in an institution and providing clinical care, mental health care, or behavior health care, these additional measures should be included to get a much more holistic view of the exposure of these individuals in terms of traumatic events. These assessments can inform your decisions around care,” Dr. Motley added.
The findings were presented at the annual meeting of the American Psychiatric Association.
‘Alarming’ rates of exposure
Evidence shows anxiety disorders are among the most prevalent conditions for Black people aged 18-29 years – an age group described as “emergent adulthood” because these individuals haven’t yet taken on full responsibilities of adulthood.
Research shows Black emergent adults are three to four times more likely than other ethnic groups to be exposed to actual or threatened nonfatal police violence, said Dr. Motley. “So they didn’t die, but were exposed to force, which could be things like police yelling at them, hitting or kicking them, pointing a gun at them, or tasing them.”
These individuals are also two to three times more likely to experience exposure to fatal police violence, and to be unarmed and killed, said Dr. Motley.
Evidence shows a clear link between exposure to stressful or traumatic events and anxiety disorders, but there has been little research examining the relationship between exposure to police violence and anxiety disorders among Black emergent adults, he said.
To assess the prevalence and correlates of “police contact anxiety” the investigators used computer-assisted surveys to collect data from 300 young Black college students in St. Louis who had been exposed to police violence at some point in their lives. The mean age of the sample was 20.4 years and included an equal number of men and women.
Work status for the previous year showed almost one-quarter (23.6%) were unemployed and about half worked part time. Almost two-thirds (62.6%) had an annual income of less than $10,000.
Respondents reported they had personally experienced police violence almost twice (a mean of 1.89) during their lifetime. The mean number of times they witnessed police using force against someone else was 7.82. Respondents also reported they had watched videos showing police use of force on the internet or television an average of 34.5 times.
This, said Dr. Motley, isn’t surprising given the growing number of young adults – of all races – who are using social media platforms to upload and share videos.
The researchers also looked at witnessing community violence, unrelated to police violence. Here, respondents had an average of 10.9 exposures.
Protectors or predators?
To examine the impact of police contact anxiety caused either by direct experience, or as a result of witnessing, or seeing a video of police use of violence in the past 30 days, the researchers created a “police contact anxiety” scale.
Respondents were asked six questions pertaining specifically to experiences during, or in anticipation of, police contact and its effects on anxiety levels.
For each of the six questions, participants rated the severity of anxiety on a scale of 0 (least severe) to 3 (most severe) for each exposure type. The final score had a potential range of 0-24.
Results showed police contact anxiety was moderately severe for all three exposure types with scores ranging from 13 to 14.
Ordinary least square regression analyses showed that, compared with unemployed participants, those who worked full time were less likely to have higher police contact anxiety as a result of seeing a video of police use of force (P < .05) – a finding Dr. Motley said was not surprising.
Employment, he noted, promotes individual self-efficacy, social participation, and mental health, which may provide a “buffer” to the effects of watching videos of police violence.
Dr. Motley noted that police officers “have been entrusted to serve and protect” the community, but “rarely face consequences when they use force against Black emergent adults; they’re rarely held accountable.”
These young Black adults “may perceive police officers as more of a threat to personal safety instead of a protector of it.”
Additional bivariate analyses showed that males had significantly higher scores than females for police contact anxiety because of witnessing police use of force.
This, too, was not surprising since males are exposed to more violence in general, said Dr. Motley.
It’s important to replicate the findings using a much larger and more diverse sample, he said. His next research project will be to collect data from a nationally representative sample of emerging adults across different ethnic groups and examining a range of different variables.
Commenting on the findings, Jeffrey Borenstein, MD, president and CEO of the Brain & Behavior Research Foundation and editor in chief of Psychiatric News, called it “outstanding.”
“This is a very important issue,” said Dr. Borenstein, who moderated a press briefing that featured the study.
“We know anxiety is an extremely important condition and symptom, across the board for all groups, and often anxiety isn’t evaluated in the way that it needs to be. This is a great study that will lead to further research in this important area,” he added.
The study was funded by the National Institute on Minority Health and Health Disparities. Dr. Motley and Dr. Borenstein have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.