Mental Health

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

gmcoop/E+

At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

gmcoop/E+

At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

gmcoop/E+

At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.

Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.

While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.

Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.

Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.

Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.

Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.

Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.

The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.

Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.

Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.

While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.

Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.

Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.

Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.

Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.

Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.

The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.

Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

You have probably heard that determining the A(ntecedent)s, B(ehavior)s, and C(onsequence)s of a behavior is basic to counseling about oppositionality or aggression. But sorting out the As is especially important to going beyond disciplining a misbehavior to building insight for both parents and children.

Antecedents are of two types: triggers such as actions, words, or feelings that happen just before the behavior, and “setting events” that can occur intermittently hours or even days beforehand and lower the threshold for a trigger to cause a child to act out. Lack of sleep, hunger, or fatigue are common setting events that parents recognize and take into account as in “Oh, he missed his nap” to excuse a tantrum in younger children, but is less often considered or excused in older children in whom self-regulation is expected. Often, behavioral specialists in schools are asked to observe a child to identify the triggers and create a “functional behavioral assessment” based on what is observed.

While a functional behavioral assessment requires observations, invisible antecedents to consider include internal thoughts and feelings (meaning). A child feeling shame from a failed math test the day before may be on edge, then, when called on, may uncharacteristically talk back. The child may regard punishment for this “justified” response as unfair, accelerating anger. Feelings of shame or humiliation for failing one’s own standards (or perceived expectations of others the child cares about) are major setups for eliciting defiance.

Even more subtle are meanings the child creates for situations and people, whether real or imagined. A child’s behavior has meaning for the child and the family and can be initiated or maintained by that meaning. For example, a child may “live down” to what the family thinks of him/her; if you think I am bad, I will act badly.

Children may feel guilty about some real or imagined offense, such as divorce or death they think may be their fault, and act up with the family to elicit punishment as payment. When children feel conflicted in a relationship, such as a late adolescent feeling dependent on their mother when their age expectation is independence, they may act up expecting to be ejected from home when they are unable to gather the courage to voluntarily leave. This acting out may also occur with nonconflicted adults, who are actually safer targets. For example, school is often a safer place to express anger through aggression or bullying than home, the real source of the feelings, because family is the “lifeboat” of food and shelter they dare not upset.

Conflicted relationships may be present in blended families, especially if the ex speaks negatively about the other parent. The child of divorce, feeling himself composed of parts of each parent, has diminished self-esteem and anger on behalf of that side being put down. Marital conflict may set children up to feel they have to take sides to angrily defend the parent of like-gender by being oppositional to the other.

Just as we ponder whether the color blue looks the same to someone else, neurologically based differences in perception may make a child misinterpret or act inflexibly or explode in situations that seem normal to adults. While people joke about “being a little OCD,” for some children the distress caused by a change in routine, a messy room, a delayed bus, or loud music is enough to disrupt their functioning and coping enough to explode. Such hypersensitivity can be part of autism or obsessive compulsive disorder or a subthreshold variant. Children vary by age and individually in their ability to understand language, especially sarcastic humor, and often misinterpret it as insulting, threatening, or scary and act accordingly. While most common in children with autism, those with a language learning disability, intellectual disability, or who have English as a second language, or are anxious or vigilant may also take sarcasm the wrong way. Anxious children also may react aggressively from a “hostile bias attribution” of expecting the worst from others.

Another possible meaning of a behavior is that it is being used by the child to manage their feelings. I have found it useful to remind depressed children and parents that it “feels better to be mad than sad” as a reason for irritability. Anger can also push away a person whose otherwise sympathetic approach might release a collapse into tears the child can’t tolerate or would find embarrassing.

The meaning of a child’s misbehavior also resides in the minds of the adults. In addition to all the categories of meaning just described, a parent may be reminded by the child of someone else for whom the adult has strong or conflicted feelings (“projection”) such as a now-hated ex, a sibling of whom the adult is jealous, or a bully from childhood, thus eliciting a reaction falsely triggered by that connection rather than the actual child. Asking parents whom the child “takes after” may elicit such parental projections based on appearance, behavior, or temperament. Helping them pick a feature of the child to focus on to differentiate him/her can serve as an anchor to remind them to control these reactions. Other useful questions to detect meanings of behavior might include asking the child “What’s up with that?” or “What did that make you think/feel?” We can ask parents “How is that for you?” or “What do you think things will be like in 10 years?” to determine despair, mood disorders, or family discord contributing to maladaptive responses possibly maintaining unwanted behaviors.

Throughout life, putting feelings into words is the main way meanings that are contributing to misbehaviors or parenting dysfunction can be uncovered and shifted. For this, the child or adult must feel emotionally safe to talk with a person who conveys curiosity rather than judgment. Helping families explain that divorce is not the child’s fault; admit they also make mistakes; rebuild conflicted relationships through play or talking; identify hypersensitivities or triggers to avoid; and express confidence that the child is a good person, still young, and sure to do better over time, are all things we pediatricians can do to help sort out the meanings of behaviors.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Individuals with substance use disorders (SUDs) have a twofold increased risk for COVID-related hospitalization and death even after vaccination, new research shows.

Investigators analyzed data on over 10,000 vaccinated individuals with various SUDs and almost 600,000 vaccinated individuals without an SUD. They found about twice as many individuals with an SUD had a breakthrough COVID-19 infection as their counterparts without an SUD, at 7% versus 3.6%, respectively.

Worrisome phase

SUDs are “often associated with multiple comorbid conditions that are known risk factors for severe outcome of COVID-19 infection,” the investigators note.

Research published early in the pandemic showed patients with SUDs, including alcohol, cannabis, cocaine, opioid, and tobacco use disorders, were “at increased risk for COVID-19 infection and associated severe outcomes, especially among African Americans,” they add.

To date, no research has focused on the potential risk for COVID in individuals with SUDs following vaccination. In addition, although vaccines are “very effective,” breakthrough infections have been recorded, “highlighting the need to identify populations that might be most vulnerable, as we have entered a worrisome new phase of the pandemic,” the authors write.

For the study, researchers used a data analytics platform that included de-identified information from 63 health care organizations across the U.S. to estimate the risk for breakthrough COVID-19 among vaccinated patients with SUD (n = 30,183; mean age 59.3, 51.4% male, 63.2% White, 26.2% African American), compared with vaccinated individuals without SUDs (n = 549,189; mean age 54.7, 43.2% male, 63.4% White, 14.3% African American) between December 2020 and August 2021.

They also conducted statistical analyses to examine how the rate of breakthrough cases changed over that timeframe.

The cohorts were matched by demographics, adverse socioeconomic determinants of health, lifetime medical and psychiatric comorbidities, and vaccine type.

Among vaccinated SUD patients, three-quarters received the Pfizer-BioNTech vaccine, one-fifth received the Moderna vaccine, and 3.3% received the Johnson & Johnson vaccine.

In contrast, among the vaccinated non-SUD population, almost all (88.2%) received the Pfizer-BioNTech vaccine, 10% received Moderna, and only 1.2% received the Johnson & Johnson vaccine.
 

Underlying drivers

The prevalence of adverse socioeconomic determinants of health was higher in vaccinated individuals with SUDs compared to those without (7.9% vs. 1.2%, respectively). Moreover, vaccinated patients with SUD had a higher lifetime prevalence of all comorbidities as well as transplants (all Ps < .001).

The risk for breakthrough infection was significantly higher in vaccinated individuals with SUDs compared to those without (all Ps < .001).

After controlling for adverse socioeconomic determinants of health and comorbid medical conditions, the risk for breakthrough infection “no longer differed in SUD compared to non-SUD cohorts, except for patients with cannabis use disorder, who remained at significantly increased risk,” the authors report.

In both populations, the rate of breakthrough infections “steadily increased” between January and August 2021.

The risk for hospitalization and death was higher among those with breakthrough infections, compared with those in the matched cohort without breakthrough infections, but the risk for hospitalization and death were higher in the SUD compared with the non-SUD population.

In the SUD patients, after matching an array of demographic, socioeconomic, and medical factors as well as vaccine type, only cannabis use disorder was associated with a higher risk in African Americans, compared with matched Caucasians (HR = 1.63; 95% confidence interval, 1.06-2.51).

“When we adjusted the data to account for comorbidities and for socioeconomic background, we no longer saw a difference between those with substance use disorders and those without – the only exception to this was for people with cannabis use disorder,” said Dr. Volkow.

“This suggests that these factors, which are often associated with substance use disorders, are likely the underlying drivers for the increased risk,” she continued.

She added that it is important for other studies to investigate why individuals with cannabis use disorder had a higher risk for breakthrough infections.
 

Good news, bad news

Commenting for this news organization, Anna Lembke, MD, professor of psychiatry and behavioral sciences, Stanford (Calif.) University, said the study is important and contains good news and bad news.

The good news, she said, “is that, after controlling for comorbidities and socioeconomic variables, patients with SUDs are no more likely than patients without SUDs to get COVID after getting vaccinated, and the bad news is that if vaccinated patients with SUDs do get COVID, they’re more likely to end up hospitalized or die from it,” said Dr. Lembke, who was not involved with the study.

“The take-home message for clinicians is that if your vaccinated patient with an SUD gets COVID, be on the alert for a more complicated medical outcome and a higher risk of death,” warned Dr. Lembke.

This study was supported by the U.S. National Institute on Drug Abuse, the U.S. National Institute of Aging, and the Clinical and Translational Science Collaborative (CTSC) of Cleveland. No disclosures were listed on the original study. Dr. Lembke has disclosed no relevant financial relationships.

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

Individuals with substance use disorders (SUDs) have a twofold increased risk for COVID-related hospitalization and death even after vaccination, new research shows.

Investigators analyzed data on over 10,000 vaccinated individuals with various SUDs and almost 600,000 vaccinated individuals without an SUD. They found about twice as many individuals with an SUD had a breakthrough COVID-19 infection as their counterparts without an SUD, at 7% versus 3.6%, respectively.

Worrisome phase

SUDs are “often associated with multiple comorbid conditions that are known risk factors for severe outcome of COVID-19 infection,” the investigators note.

Research published early in the pandemic showed patients with SUDs, including alcohol, cannabis, cocaine, opioid, and tobacco use disorders, were “at increased risk for COVID-19 infection and associated severe outcomes, especially among African Americans,” they add.

To date, no research has focused on the potential risk for COVID in individuals with SUDs following vaccination. In addition, although vaccines are “very effective,” breakthrough infections have been recorded, “highlighting the need to identify populations that might be most vulnerable, as we have entered a worrisome new phase of the pandemic,” the authors write.

For the study, researchers used a data analytics platform that included de-identified information from 63 health care organizations across the U.S. to estimate the risk for breakthrough COVID-19 among vaccinated patients with SUD (n = 30,183; mean age 59.3, 51.4% male, 63.2% White, 26.2% African American), compared with vaccinated individuals without SUDs (n = 549,189; mean age 54.7, 43.2% male, 63.4% White, 14.3% African American) between December 2020 and August 2021.

They also conducted statistical analyses to examine how the rate of breakthrough cases changed over that timeframe.

The cohorts were matched by demographics, adverse socioeconomic determinants of health, lifetime medical and psychiatric comorbidities, and vaccine type.

Among vaccinated SUD patients, three-quarters received the Pfizer-BioNTech vaccine, one-fifth received the Moderna vaccine, and 3.3% received the Johnson & Johnson vaccine.

In contrast, among the vaccinated non-SUD population, almost all (88.2%) received the Pfizer-BioNTech vaccine, 10% received Moderna, and only 1.2% received the Johnson & Johnson vaccine.
 

Underlying drivers

The prevalence of adverse socioeconomic determinants of health was higher in vaccinated individuals with SUDs compared to those without (7.9% vs. 1.2%, respectively). Moreover, vaccinated patients with SUD had a higher lifetime prevalence of all comorbidities as well as transplants (all Ps < .001).

The risk for breakthrough infection was significantly higher in vaccinated individuals with SUDs compared to those without (all Ps < .001).

After controlling for adverse socioeconomic determinants of health and comorbid medical conditions, the risk for breakthrough infection “no longer differed in SUD compared to non-SUD cohorts, except for patients with cannabis use disorder, who remained at significantly increased risk,” the authors report.

In both populations, the rate of breakthrough infections “steadily increased” between January and August 2021.

The risk for hospitalization and death was higher among those with breakthrough infections, compared with those in the matched cohort without breakthrough infections, but the risk for hospitalization and death were higher in the SUD compared with the non-SUD population.

In the SUD patients, after matching an array of demographic, socioeconomic, and medical factors as well as vaccine type, only cannabis use disorder was associated with a higher risk in African Americans, compared with matched Caucasians (HR = 1.63; 95% confidence interval, 1.06-2.51).

“When we adjusted the data to account for comorbidities and for socioeconomic background, we no longer saw a difference between those with substance use disorders and those without – the only exception to this was for people with cannabis use disorder,” said Dr. Volkow.

“This suggests that these factors, which are often associated with substance use disorders, are likely the underlying drivers for the increased risk,” she continued.

She added that it is important for other studies to investigate why individuals with cannabis use disorder had a higher risk for breakthrough infections.
 

Good news, bad news

Commenting for this news organization, Anna Lembke, MD, professor of psychiatry and behavioral sciences, Stanford (Calif.) University, said the study is important and contains good news and bad news.

The good news, she said, “is that, after controlling for comorbidities and socioeconomic variables, patients with SUDs are no more likely than patients without SUDs to get COVID after getting vaccinated, and the bad news is that if vaccinated patients with SUDs do get COVID, they’re more likely to end up hospitalized or die from it,” said Dr. Lembke, who was not involved with the study.

“The take-home message for clinicians is that if your vaccinated patient with an SUD gets COVID, be on the alert for a more complicated medical outcome and a higher risk of death,” warned Dr. Lembke.

This study was supported by the U.S. National Institute on Drug Abuse, the U.S. National Institute of Aging, and the Clinical and Translational Science Collaborative (CTSC) of Cleveland. No disclosures were listed on the original study. Dr. Lembke has disclosed no relevant financial relationships.

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

Individuals with substance use disorders (SUDs) have a twofold increased risk for COVID-related hospitalization and death even after vaccination, new research shows.

Investigators analyzed data on over 10,000 vaccinated individuals with various SUDs and almost 600,000 vaccinated individuals without an SUD. They found about twice as many individuals with an SUD had a breakthrough COVID-19 infection as their counterparts without an SUD, at 7% versus 3.6%, respectively.

Worrisome phase

SUDs are “often associated with multiple comorbid conditions that are known risk factors for severe outcome of COVID-19 infection,” the investigators note.

Research published early in the pandemic showed patients with SUDs, including alcohol, cannabis, cocaine, opioid, and tobacco use disorders, were “at increased risk for COVID-19 infection and associated severe outcomes, especially among African Americans,” they add.

To date, no research has focused on the potential risk for COVID in individuals with SUDs following vaccination. In addition, although vaccines are “very effective,” breakthrough infections have been recorded, “highlighting the need to identify populations that might be most vulnerable, as we have entered a worrisome new phase of the pandemic,” the authors write.

For the study, researchers used a data analytics platform that included de-identified information from 63 health care organizations across the U.S. to estimate the risk for breakthrough COVID-19 among vaccinated patients with SUD (n = 30,183; mean age 59.3, 51.4% male, 63.2% White, 26.2% African American), compared with vaccinated individuals without SUDs (n = 549,189; mean age 54.7, 43.2% male, 63.4% White, 14.3% African American) between December 2020 and August 2021.

They also conducted statistical analyses to examine how the rate of breakthrough cases changed over that timeframe.

The cohorts were matched by demographics, adverse socioeconomic determinants of health, lifetime medical and psychiatric comorbidities, and vaccine type.

Among vaccinated SUD patients, three-quarters received the Pfizer-BioNTech vaccine, one-fifth received the Moderna vaccine, and 3.3% received the Johnson & Johnson vaccine.

In contrast, among the vaccinated non-SUD population, almost all (88.2%) received the Pfizer-BioNTech vaccine, 10% received Moderna, and only 1.2% received the Johnson & Johnson vaccine.
 

Underlying drivers

The prevalence of adverse socioeconomic determinants of health was higher in vaccinated individuals with SUDs compared to those without (7.9% vs. 1.2%, respectively). Moreover, vaccinated patients with SUD had a higher lifetime prevalence of all comorbidities as well as transplants (all Ps < .001).

The risk for breakthrough infection was significantly higher in vaccinated individuals with SUDs compared to those without (all Ps < .001).

After controlling for adverse socioeconomic determinants of health and comorbid medical conditions, the risk for breakthrough infection “no longer differed in SUD compared to non-SUD cohorts, except for patients with cannabis use disorder, who remained at significantly increased risk,” the authors report.

In both populations, the rate of breakthrough infections “steadily increased” between January and August 2021.

The risk for hospitalization and death was higher among those with breakthrough infections, compared with those in the matched cohort without breakthrough infections, but the risk for hospitalization and death were higher in the SUD compared with the non-SUD population.

In the SUD patients, after matching an array of demographic, socioeconomic, and medical factors as well as vaccine type, only cannabis use disorder was associated with a higher risk in African Americans, compared with matched Caucasians (HR = 1.63; 95% confidence interval, 1.06-2.51).

“When we adjusted the data to account for comorbidities and for socioeconomic background, we no longer saw a difference between those with substance use disorders and those without – the only exception to this was for people with cannabis use disorder,” said Dr. Volkow.

“This suggests that these factors, which are often associated with substance use disorders, are likely the underlying drivers for the increased risk,” she continued.

She added that it is important for other studies to investigate why individuals with cannabis use disorder had a higher risk for breakthrough infections.
 

Good news, bad news

Commenting for this news organization, Anna Lembke, MD, professor of psychiatry and behavioral sciences, Stanford (Calif.) University, said the study is important and contains good news and bad news.

The good news, she said, “is that, after controlling for comorbidities and socioeconomic variables, patients with SUDs are no more likely than patients without SUDs to get COVID after getting vaccinated, and the bad news is that if vaccinated patients with SUDs do get COVID, they’re more likely to end up hospitalized or die from it,” said Dr. Lembke, who was not involved with the study.

“The take-home message for clinicians is that if your vaccinated patient with an SUD gets COVID, be on the alert for a more complicated medical outcome and a higher risk of death,” warned Dr. Lembke.

This study was supported by the U.S. National Institute on Drug Abuse, the U.S. National Institute of Aging, and the Clinical and Translational Science Collaborative (CTSC) of Cleveland. No disclosures were listed on the original study. Dr. Lembke has disclosed no relevant financial relationships.

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

COVID-19 has killed Native Americans at twice the rate of White Americans, underscoring the health inequities and deep-rooted distrust tribal nations have of federal government entities.

And yet, Native Americans have the highest vaccination rates of any major racial or ethnic group in the United States. Like many other tribal nations, the Navajo had to embrace Western science to reclaim its social customs and ceremonies. “We’re a very social culture, so having to isolate really impacted our mental health,” said Mary Hasbah Roessel, MD, DLFAPA, a Navajo psychiatrist who is affiliated with Santa Fe Indian Hospital in New Mexico.

The Navajo nation occupies the largest Native American reservation in the United States, spanning New Mexico, Arizona, and Utah. As of mid-October, the nation had reported more than 34,000 COVID-19 cases and 1,400 deaths in its jurisdiction.

In an interview with this news organization, Dr. Roessel described the partnerships that mobilized a nation of more than 250,000 individuals to get vaccinated.

Question: Why has the death rate been so high in the Navajo nation?

Answer: A lot of health disparities before the pandemic were blatantly revealed during COVID. Only 40% of people on the reservation had running water. Having to stay home and isolate led to food insecurity. Further insecurity issues affected our ability to stay healthy, such as having good sanitation. There’s a lot of poverty, a high unemployment rate. Some people had to go to work off reservation and were potentially bringing the virus home. A lot of generations live in the same household. Elders were vulnerable to getting the infection, and there was little ability to isolate if someone wasn’t having symptoms. Hospitals nearby didn’t have ICUs.

Therefore, the rate of cases skyrocketed early on. We were disproportionately affected. The Navajo nation per capita had the highest rate of cases in any state.
 

Q: What changes took place within the Navajo nation to get people vaccinated? What role did the federal Indian Health Service have in promoting this?

A: There had to be a shift in acceptance of the vaccinations. I think what particularly helped the Navajo nation was seeing the IHS rise up and provide access for treatments and vaccinations early on.

With the IHS, we went into a disaster response mode with all-hands-on deck meetings. We had to figure out how we could access mass vaccination clinics. Partnering with the Navajo Department of Health, we did that right away with hospitals and small clinics across the Navajo nation. Casinos owned by tribal entities that closed during COVID reopened and were used as vaccination clinics.

Vaccinations were sent to us fairly quickly. I ended up getting vaccinated in December 2020, when it was first rolled out.

Native and Navajo individuals have been reluctant to rely on government services. Because IHS came through with the vaccines, COVID reduced that stigma to access its services. Even the Navajo Department of Health partnered with the Indian Health Service to provide culturally relevant campaigns that explain why the vaccine is valuable.

I think because people were so impacted, they saw something valuable with the vaccine. Given the education and access, people were ready to get vaccinated. They realized if a whole household got vaccinated, they could see early on that they could be social again.
 

Q: What cultural factors have been contributing to this positive development?

A: In our Navajo culture, we’ve dealt with monsters before. We talk about that in terms of how we teach our young people to be strong and resilient. We talked about this virus as being another monster we had to tackle and control. The teaching was along those lines. We’ve dealt with this before, and we can handle it. We’re resilient. Our culture is very strong in that way. So how do we do it? We have to partner; we have to embrace Western medicine to return back to the ceremonies we want to have again and be social again. We focus on positive things, so if we see something as potentially positive, such as the vaccine, we see that and know that’s something to help us come into our life again.

Q: I would expect that protecting elders in the tribe would be a big incentive in taking the vaccine.

A: Yes, we didn’t want to lose our language and culture, and we wanted to protect our elders. Having a way to do that was very important as well. They were among the first to get vaccinated.

Q: What is the current vaccination rate in the Navajo nation?

A: I think it’s in the upper 80th percentile. It’s very high.

Q: What have been the biggest takeaways so far, and what are your hopes for the future?

A: Even though the Navajo Nation has been impacted and devastated with the loss of elders and knowledge keepers, we still have our culture and ceremonies intact to the point that we know we can be resilient get through this difficult time.

Through collaborations with the federal and state governments and the clinics, we see that things are different now. Going forward, my hope is these partnerships will continue, that we’ll build those relationships and not be so siloed in our care. When the New Mexico Department of Health rolled out its first vaccination clinic, for example, we jumped on and saw how they did it. We were then able to do our own, collaborating with the state.

We also saw how important our culture was, how it helped our Navajo people through these difficult times.

Dr. Roessel, a distinguished fellow of the American Psychiatric Association, has special expertise in cultural psychiatry. Her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles.

References

American Public Media Research Lab. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” 2021 Mar 5.

Centers for Disease Control and Prevention. “Demographic Characteristics of People Receiving COVID-19 Vaccinations in the United States.” Data as of 2021 Oct 14.

Navajo Nation. Indian Health Service. U.S. Department of Health & Human Services.

The Navajo Nation’s Office of the President and Vice President. “11 New Cases, 32,735 Recoveries, and Six Recent Deaths Related to COVID-19.” 2021 Oct 13.

Navajo Nation Government web page.

COVID-19 has killed Native Americans at twice the rate of White Americans, underscoring the health inequities and deep-rooted distrust tribal nations have of federal government entities.

And yet, Native Americans have the highest vaccination rates of any major racial or ethnic group in the United States. Like many other tribal nations, the Navajo had to embrace Western science to reclaim its social customs and ceremonies. “We’re a very social culture, so having to isolate really impacted our mental health,” said Mary Hasbah Roessel, MD, DLFAPA, a Navajo psychiatrist who is affiliated with Santa Fe Indian Hospital in New Mexico.

The Navajo nation occupies the largest Native American reservation in the United States, spanning New Mexico, Arizona, and Utah. As of mid-October, the nation had reported more than 34,000 COVID-19 cases and 1,400 deaths in its jurisdiction.

In an interview with this news organization, Dr. Roessel described the partnerships that mobilized a nation of more than 250,000 individuals to get vaccinated.

Question: Why has the death rate been so high in the Navajo nation?

Answer: A lot of health disparities before the pandemic were blatantly revealed during COVID. Only 40% of people on the reservation had running water. Having to stay home and isolate led to food insecurity. Further insecurity issues affected our ability to stay healthy, such as having good sanitation. There’s a lot of poverty, a high unemployment rate. Some people had to go to work off reservation and were potentially bringing the virus home. A lot of generations live in the same household. Elders were vulnerable to getting the infection, and there was little ability to isolate if someone wasn’t having symptoms. Hospitals nearby didn’t have ICUs.

Therefore, the rate of cases skyrocketed early on. We were disproportionately affected. The Navajo nation per capita had the highest rate of cases in any state.
 

Q: What changes took place within the Navajo nation to get people vaccinated? What role did the federal Indian Health Service have in promoting this?

A: There had to be a shift in acceptance of the vaccinations. I think what particularly helped the Navajo nation was seeing the IHS rise up and provide access for treatments and vaccinations early on.

With the IHS, we went into a disaster response mode with all-hands-on deck meetings. We had to figure out how we could access mass vaccination clinics. Partnering with the Navajo Department of Health, we did that right away with hospitals and small clinics across the Navajo nation. Casinos owned by tribal entities that closed during COVID reopened and were used as vaccination clinics.

Vaccinations were sent to us fairly quickly. I ended up getting vaccinated in December 2020, when it was first rolled out.

Native and Navajo individuals have been reluctant to rely on government services. Because IHS came through with the vaccines, COVID reduced that stigma to access its services. Even the Navajo Department of Health partnered with the Indian Health Service to provide culturally relevant campaigns that explain why the vaccine is valuable.

I think because people were so impacted, they saw something valuable with the vaccine. Given the education and access, people were ready to get vaccinated. They realized if a whole household got vaccinated, they could see early on that they could be social again.
 

Q: What cultural factors have been contributing to this positive development?

A: In our Navajo culture, we’ve dealt with monsters before. We talk about that in terms of how we teach our young people to be strong and resilient. We talked about this virus as being another monster we had to tackle and control. The teaching was along those lines. We’ve dealt with this before, and we can handle it. We’re resilient. Our culture is very strong in that way. So how do we do it? We have to partner; we have to embrace Western medicine to return back to the ceremonies we want to have again and be social again. We focus on positive things, so if we see something as potentially positive, such as the vaccine, we see that and know that’s something to help us come into our life again.

Q: I would expect that protecting elders in the tribe would be a big incentive in taking the vaccine.

A: Yes, we didn’t want to lose our language and culture, and we wanted to protect our elders. Having a way to do that was very important as well. They were among the first to get vaccinated.

Q: What is the current vaccination rate in the Navajo nation?

A: I think it’s in the upper 80th percentile. It’s very high.

Q: What have been the biggest takeaways so far, and what are your hopes for the future?

A: Even though the Navajo Nation has been impacted and devastated with the loss of elders and knowledge keepers, we still have our culture and ceremonies intact to the point that we know we can be resilient get through this difficult time.

Through collaborations with the federal and state governments and the clinics, we see that things are different now. Going forward, my hope is these partnerships will continue, that we’ll build those relationships and not be so siloed in our care. When the New Mexico Department of Health rolled out its first vaccination clinic, for example, we jumped on and saw how they did it. We were then able to do our own, collaborating with the state.

We also saw how important our culture was, how it helped our Navajo people through these difficult times.

Dr. Roessel, a distinguished fellow of the American Psychiatric Association, has special expertise in cultural psychiatry. Her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles.

References

American Public Media Research Lab. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” 2021 Mar 5.

Centers for Disease Control and Prevention. “Demographic Characteristics of People Receiving COVID-19 Vaccinations in the United States.” Data as of 2021 Oct 14.

Navajo Nation. Indian Health Service. U.S. Department of Health & Human Services.

The Navajo Nation’s Office of the President and Vice President. “11 New Cases, 32,735 Recoveries, and Six Recent Deaths Related to COVID-19.” 2021 Oct 13.

Navajo Nation Government web page.

COVID-19 has killed Native Americans at twice the rate of White Americans, underscoring the health inequities and deep-rooted distrust tribal nations have of federal government entities.

And yet, Native Americans have the highest vaccination rates of any major racial or ethnic group in the United States. Like many other tribal nations, the Navajo had to embrace Western science to reclaim its social customs and ceremonies. “We’re a very social culture, so having to isolate really impacted our mental health,” said Mary Hasbah Roessel, MD, DLFAPA, a Navajo psychiatrist who is affiliated with Santa Fe Indian Hospital in New Mexico.

The Navajo nation occupies the largest Native American reservation in the United States, spanning New Mexico, Arizona, and Utah. As of mid-October, the nation had reported more than 34,000 COVID-19 cases and 1,400 deaths in its jurisdiction.

In an interview with this news organization, Dr. Roessel described the partnerships that mobilized a nation of more than 250,000 individuals to get vaccinated.

Question: Why has the death rate been so high in the Navajo nation?

Answer: A lot of health disparities before the pandemic were blatantly revealed during COVID. Only 40% of people on the reservation had running water. Having to stay home and isolate led to food insecurity. Further insecurity issues affected our ability to stay healthy, such as having good sanitation. There’s a lot of poverty, a high unemployment rate. Some people had to go to work off reservation and were potentially bringing the virus home. A lot of generations live in the same household. Elders were vulnerable to getting the infection, and there was little ability to isolate if someone wasn’t having symptoms. Hospitals nearby didn’t have ICUs.

Therefore, the rate of cases skyrocketed early on. We were disproportionately affected. The Navajo nation per capita had the highest rate of cases in any state.
 

Q: What changes took place within the Navajo nation to get people vaccinated? What role did the federal Indian Health Service have in promoting this?

A: There had to be a shift in acceptance of the vaccinations. I think what particularly helped the Navajo nation was seeing the IHS rise up and provide access for treatments and vaccinations early on.

With the IHS, we went into a disaster response mode with all-hands-on deck meetings. We had to figure out how we could access mass vaccination clinics. Partnering with the Navajo Department of Health, we did that right away with hospitals and small clinics across the Navajo nation. Casinos owned by tribal entities that closed during COVID reopened and were used as vaccination clinics.

Vaccinations were sent to us fairly quickly. I ended up getting vaccinated in December 2020, when it was first rolled out.

Native and Navajo individuals have been reluctant to rely on government services. Because IHS came through with the vaccines, COVID reduced that stigma to access its services. Even the Navajo Department of Health partnered with the Indian Health Service to provide culturally relevant campaigns that explain why the vaccine is valuable.

I think because people were so impacted, they saw something valuable with the vaccine. Given the education and access, people were ready to get vaccinated. They realized if a whole household got vaccinated, they could see early on that they could be social again.
 

Q: What cultural factors have been contributing to this positive development?

A: In our Navajo culture, we’ve dealt with monsters before. We talk about that in terms of how we teach our young people to be strong and resilient. We talked about this virus as being another monster we had to tackle and control. The teaching was along those lines. We’ve dealt with this before, and we can handle it. We’re resilient. Our culture is very strong in that way. So how do we do it? We have to partner; we have to embrace Western medicine to return back to the ceremonies we want to have again and be social again. We focus on positive things, so if we see something as potentially positive, such as the vaccine, we see that and know that’s something to help us come into our life again.

Q: I would expect that protecting elders in the tribe would be a big incentive in taking the vaccine.

A: Yes, we didn’t want to lose our language and culture, and we wanted to protect our elders. Having a way to do that was very important as well. They were among the first to get vaccinated.

Q: What is the current vaccination rate in the Navajo nation?

A: I think it’s in the upper 80th percentile. It’s very high.

Q: What have been the biggest takeaways so far, and what are your hopes for the future?

A: Even though the Navajo Nation has been impacted and devastated with the loss of elders and knowledge keepers, we still have our culture and ceremonies intact to the point that we know we can be resilient get through this difficult time.

Through collaborations with the federal and state governments and the clinics, we see that things are different now. Going forward, my hope is these partnerships will continue, that we’ll build those relationships and not be so siloed in our care. When the New Mexico Department of Health rolled out its first vaccination clinic, for example, we jumped on and saw how they did it. We were then able to do our own, collaborating with the state.

We also saw how important our culture was, how it helped our Navajo people through these difficult times.

Dr. Roessel, a distinguished fellow of the American Psychiatric Association, has special expertise in cultural psychiatry. Her childhood was spent growing up in the Navajo nation with her grandfather, who was a Navajo medicine man. Her psychiatric practice focuses on integrating Indigenous knowledge and principles.

References

American Public Media Research Lab. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” 2021 Mar 5.

Centers for Disease Control and Prevention. “Demographic Characteristics of People Receiving COVID-19 Vaccinations in the United States.” Data as of 2021 Oct 14.

Navajo Nation. Indian Health Service. U.S. Department of Health & Human Services.

The Navajo Nation’s Office of the President and Vice President. “11 New Cases, 32,735 Recoveries, and Six Recent Deaths Related to COVID-19.” 2021 Oct 13.

Navajo Nation Government web page.

Children in foster care are far more likely to be prescribed psychotropic medication, compared with children who are not in foster care, an analysis of Medicaid claims data shows.

Different rates of mental health disorders in these groups do not fully explain the “alarming trend,” which persists across psychotropic medication classes, said study author Rachael J. Keefe, MD, MPH.

Misdiagnosis, overprescribing, and frequent transitions to new doctors may contribute to this phenomenon, doctors suggested.

Dr. Keefe, with Baylor College of Medicine, Houston, and colleagues analyzed Medicaid claims data from two managed care organizations to compare the prevalence of psychotropic medication use among children in foster care versus children insured by Medicaid but not in foster care. The study focused on claims from the same region in southeast Texas between July 2014 and June 2016.

The researchers included 388,914 children in Medicaid and 8,426 children in foster care in their analysis. They excluded children with a seizure or epilepsy diagnosis.

About 8% of children not in foster care received psychotropic medications, compared with 35% of those in foster care.

Children in foster care were 27 times more likely to receive antipsychotic medication (21.2% of children in foster care vs. 0.8% of children not in foster care) and twice as likely to receive antianxiety medication (6% vs. 3%).

For children in foster care, the rate of alpha-agonist use was 15 times higher, the rate of antidepressant use was 13 times higher, the rate of mood stabilizer use was 26 times higher, and the rate of stimulant use was 6 times higher.

The researchers have a limited understanding of the full context in which these medications were prescribed, and psychotropic medications have a role in the treatment of children in foster care, Dr. Keefe acknowledged.

“We have to be careful not to have a knee-jerk reaction” and inappropriately withhold medication from children in foster care, she said in an interview.

But overprescribing has been a concern. Dr. Keefe leads a foster care clinical service at Texas Children’s Hospital in Houston.

“The overprescribing of psychotropic medications to children in foster care is something I feel every day in my clinical practice, but it’s different to see it on paper,” Dr. Keefe said in a news release highlighting the research, which she presented on Oct. 11 at the annual meeting of the American Academy of Pediatrics. “It’s especially shocking to see these dramatic differences in children of preschool and elementary age.”

Misdiagnosis can be a common problem among children in foster care, said Danielle Shaw, MD, a child and adolescent psychiatrist in Camarillo, Calif., during a question-and-answer period following the presentation.

“I see incorrect diagnoses very frequently,” Dr. Shaw said. “The history of trauma or [adverse childhood experiences] is not even included in the assessment. Mood lability from trauma is misdiagnosed as bipolar disorder, despite not meeting criteria. This will justify the use of antipsychotic medication and mood stabilizers. Flashbacks can be mistaken for a psychotic disorder, which again justifies the use of antipsychotic medication.”

Children in foster care have experienced numerous traumatic experiences that affect brain development and the hypothalamic-pituitary-adrenal axis, Dr. Keefe said.

“Although from previous research we know that children in foster care are more likely to carry mental health and developmental disorder diagnoses, this does not account for the significant difference in prescribing practices in this population,” Dr. Keefe said in an interview.

Although the study focused on data in Texas, Dr. Keefe expects similar patterns exist in other regions, based on anecdotal reports. “I work with foster care pediatricians across the country, and many have seen similar concerning trends within their own clinical practices,” she said.

The use of appropriate therapies, minimizing transitions between providers, improved record keeping, the development of deprescribing algorithms, and placement of children in foster care in long-term homes as early as possible are measures that potentially could reduce inappropriate psychotropic prescribing for children in foster care, Dr. Keefe suggested.

The research was funded by a Texas Medical Center Health Policy Research Grant. The study authors and Dr. Shaw had no relevant financial disclosures.

jremaly@mdedge.com

Children in foster care are far more likely to be prescribed psychotropic medication, compared with children who are not in foster care, an analysis of Medicaid claims data shows.

Different rates of mental health disorders in these groups do not fully explain the “alarming trend,” which persists across psychotropic medication classes, said study author Rachael J. Keefe, MD, MPH.

Misdiagnosis, overprescribing, and frequent transitions to new doctors may contribute to this phenomenon, doctors suggested.

Dr. Keefe, with Baylor College of Medicine, Houston, and colleagues analyzed Medicaid claims data from two managed care organizations to compare the prevalence of psychotropic medication use among children in foster care versus children insured by Medicaid but not in foster care. The study focused on claims from the same region in southeast Texas between July 2014 and June 2016.

The researchers included 388,914 children in Medicaid and 8,426 children in foster care in their analysis. They excluded children with a seizure or epilepsy diagnosis.

About 8% of children not in foster care received psychotropic medications, compared with 35% of those in foster care.

Children in foster care were 27 times more likely to receive antipsychotic medication (21.2% of children in foster care vs. 0.8% of children not in foster care) and twice as likely to receive antianxiety medication (6% vs. 3%).

For children in foster care, the rate of alpha-agonist use was 15 times higher, the rate of antidepressant use was 13 times higher, the rate of mood stabilizer use was 26 times higher, and the rate of stimulant use was 6 times higher.

The researchers have a limited understanding of the full context in which these medications were prescribed, and psychotropic medications have a role in the treatment of children in foster care, Dr. Keefe acknowledged.

“We have to be careful not to have a knee-jerk reaction” and inappropriately withhold medication from children in foster care, she said in an interview.

But overprescribing has been a concern. Dr. Keefe leads a foster care clinical service at Texas Children’s Hospital in Houston.

“The overprescribing of psychotropic medications to children in foster care is something I feel every day in my clinical practice, but it’s different to see it on paper,” Dr. Keefe said in a news release highlighting the research, which she presented on Oct. 11 at the annual meeting of the American Academy of Pediatrics. “It’s especially shocking to see these dramatic differences in children of preschool and elementary age.”

Misdiagnosis can be a common problem among children in foster care, said Danielle Shaw, MD, a child and adolescent psychiatrist in Camarillo, Calif., during a question-and-answer period following the presentation.

“I see incorrect diagnoses very frequently,” Dr. Shaw said. “The history of trauma or [adverse childhood experiences] is not even included in the assessment. Mood lability from trauma is misdiagnosed as bipolar disorder, despite not meeting criteria. This will justify the use of antipsychotic medication and mood stabilizers. Flashbacks can be mistaken for a psychotic disorder, which again justifies the use of antipsychotic medication.”

Children in foster care have experienced numerous traumatic experiences that affect brain development and the hypothalamic-pituitary-adrenal axis, Dr. Keefe said.

“Although from previous research we know that children in foster care are more likely to carry mental health and developmental disorder diagnoses, this does not account for the significant difference in prescribing practices in this population,” Dr. Keefe said in an interview.

Although the study focused on data in Texas, Dr. Keefe expects similar patterns exist in other regions, based on anecdotal reports. “I work with foster care pediatricians across the country, and many have seen similar concerning trends within their own clinical practices,” she said.

The use of appropriate therapies, minimizing transitions between providers, improved record keeping, the development of deprescribing algorithms, and placement of children in foster care in long-term homes as early as possible are measures that potentially could reduce inappropriate psychotropic prescribing for children in foster care, Dr. Keefe suggested.

The research was funded by a Texas Medical Center Health Policy Research Grant. The study authors and Dr. Shaw had no relevant financial disclosures.

jremaly@mdedge.com

Children in foster care are far more likely to be prescribed psychotropic medication, compared with children who are not in foster care, an analysis of Medicaid claims data shows.

Different rates of mental health disorders in these groups do not fully explain the “alarming trend,” which persists across psychotropic medication classes, said study author Rachael J. Keefe, MD, MPH.

Misdiagnosis, overprescribing, and frequent transitions to new doctors may contribute to this phenomenon, doctors suggested.

Dr. Keefe, with Baylor College of Medicine, Houston, and colleagues analyzed Medicaid claims data from two managed care organizations to compare the prevalence of psychotropic medication use among children in foster care versus children insured by Medicaid but not in foster care. The study focused on claims from the same region in southeast Texas between July 2014 and June 2016.

The researchers included 388,914 children in Medicaid and 8,426 children in foster care in their analysis. They excluded children with a seizure or epilepsy diagnosis.

About 8% of children not in foster care received psychotropic medications, compared with 35% of those in foster care.

Children in foster care were 27 times more likely to receive antipsychotic medication (21.2% of children in foster care vs. 0.8% of children not in foster care) and twice as likely to receive antianxiety medication (6% vs. 3%).

For children in foster care, the rate of alpha-agonist use was 15 times higher, the rate of antidepressant use was 13 times higher, the rate of mood stabilizer use was 26 times higher, and the rate of stimulant use was 6 times higher.

The researchers have a limited understanding of the full context in which these medications were prescribed, and psychotropic medications have a role in the treatment of children in foster care, Dr. Keefe acknowledged.

“We have to be careful not to have a knee-jerk reaction” and inappropriately withhold medication from children in foster care, she said in an interview.

But overprescribing has been a concern. Dr. Keefe leads a foster care clinical service at Texas Children’s Hospital in Houston.

“The overprescribing of psychotropic medications to children in foster care is something I feel every day in my clinical practice, but it’s different to see it on paper,” Dr. Keefe said in a news release highlighting the research, which she presented on Oct. 11 at the annual meeting of the American Academy of Pediatrics. “It’s especially shocking to see these dramatic differences in children of preschool and elementary age.”

Misdiagnosis can be a common problem among children in foster care, said Danielle Shaw, MD, a child and adolescent psychiatrist in Camarillo, Calif., during a question-and-answer period following the presentation.

“I see incorrect diagnoses very frequently,” Dr. Shaw said. “The history of trauma or [adverse childhood experiences] is not even included in the assessment. Mood lability from trauma is misdiagnosed as bipolar disorder, despite not meeting criteria. This will justify the use of antipsychotic medication and mood stabilizers. Flashbacks can be mistaken for a psychotic disorder, which again justifies the use of antipsychotic medication.”

Children in foster care have experienced numerous traumatic experiences that affect brain development and the hypothalamic-pituitary-adrenal axis, Dr. Keefe said.

“Although from previous research we know that children in foster care are more likely to carry mental health and developmental disorder diagnoses, this does not account for the significant difference in prescribing practices in this population,” Dr. Keefe said in an interview.

Although the study focused on data in Texas, Dr. Keefe expects similar patterns exist in other regions, based on anecdotal reports. “I work with foster care pediatricians across the country, and many have seen similar concerning trends within their own clinical practices,” she said.

The use of appropriate therapies, minimizing transitions between providers, improved record keeping, the development of deprescribing algorithms, and placement of children in foster care in long-term homes as early as possible are measures that potentially could reduce inappropriate psychotropic prescribing for children in foster care, Dr. Keefe suggested.

The research was funded by a Texas Medical Center Health Policy Research Grant. The study authors and Dr. Shaw had no relevant financial disclosures.

jremaly@mdedge.com

Transgender and nonbinary young people experienced less depression and fewer suicidal thoughts after a year of gender-affirming care with hormones or puberty blockers, according to new research.

“Given the high rates of adverse mental health comorbidities, these data provide critical evidence that expansion of gender-affirming care can save lives,” said David J. Inwards-Breland, MD, MPH, chief of adolescent and young adult medicine and codirector of the Center for Gender-Affirming Care at Rady Children’s Hospital in San Diego, during his presentation.

The findings, presented October 11 at the American Academy of Pediatrics 2021 National Conference, were not at all surprising to Cora Breuner, MD, MPH, professor of pediatrics at Seattle Children’s Hospital.

“The younger we can provide gender-affirming care, the less likely they’re going to have depression, and then the negative outcomes from untreated depression, which includes suicide intent or even suicide completion,” Dr. Breuner told this news organization. “It’s so obvious that we are saving lives by providing gender-affirming care.”

For their study, Dr. Inwards-Breland and his colleagues tracked depression, anxiety, and suicidality in 104 trans and nonbinary people 13 to 21 years of age who received care at the Seattle Children’s gender clinic between August 2017 and June 2018.

The study population consisted of 63 transgender male or male participants, 27 transgender female or female participants, 10 nonbinary participants, and four participants who had not defined their gender identity. Of this cohort, 62.5% were receiving mental health therapy, and 34.7% reported some substance use.

Participants completed the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) at baseline and then at 3, 6, and 12 months. The researchers defined severe depression and severe anxiety as a score of 10 or greater on either scale.

At baseline, 56.7% of the participants had moderate to severe depression, 43.3% reported thoughts of self-harm or suicidal in the previous 2 weeks, and 50.0% had moderate to severe anxiety.

After 12 months of care, participants experienced a 60% decrease in depression (adjusted odds ratio, 0.4) and a 73% decrease in suicidality (aOR, 0.27), after adjustment for temporal trends and sex assigned at birth, race/ethnicity, level of parental support, ongoing mental health therapy, substance use, and victimization, including bullying, interpersonal violence, neglect, and abuse.

Although the decline in depression and suicidality after gender-affirming treatment was not a surprise, “those drops are huge,” Dr. Inwards-Breland said in an interview.

He said he attributes the improvement to a health care system that “affirms who these young people are” and enables changes that allow their outward appearance to reflect “who they know they are inside.”

There were no significant changes in anxiety during the study period. “Anxiety, I think, is just a little harder to treat, and it takes a little longer to treat,” he explained. And a lot of factors can trigger anxiety, and those can continue during treatment.

The slow pace of changes to gender identity can have an effect on people’s moods. “Since they’re not happening quickly, these young people are still being misgendered, they’re still seeing the body that they don’t feel like they should have, and they have to go to school and go out in public. I think that continues to fuel anxiety with a lot of these young people.”

Family support is important in reducing depression and suicidal thoughts in this population. Parents will often see positive changes after their child receives gender-affirming care, which can help contribute to positive changes in parents’ attitudes, Dr. Inwards-Breland said.

Such changes reinforce “that protective factor of connectedness with family,” he noted. “Families are crucial for any health care, and if there’s that connectedness with families, we know that, clinically, patients do better.”
 

Balancing risks

Although there are risks associated with gender-affirming hormones and puberty blockers, the risks of not receiving treatment must also be considered.

“Our young people are killing themselves,” he said. “Our young people are developing severe eating disorders that are killing them. Our young people are increasing their substance abuse, homelessness, depression. The list just goes on.”

For trans-masculine and nonbinary masculine patients, the potential permanent changes of hormone therapy include a deeper voice, hair growth, enlargement of the clitoris, and, in some patients, the development of male pattern baldness. In trans and nonbinary feminine patients, potential long-term effects include breast development and an increased risk for fertility issues.

The consent forms required for young people who want gender-affirming hormones or puberty blockers are extensive, with every possible reversible and irreversible effect described in detail, Dr. Breuner said.

“Parents sign them because they want their child to stay alive,” she explained. “When you compare the cost of someone who has severe debilitating depression and dying by suicide with some of the risks associated with gender-affirming hormone therapy, that’s a no-brainer to me.”

This study is limited by the fact that screening tests, not diagnostic tests, were used to identify depression, anxiety, and suicidality, and the fact that the use of antidepression or antianxiety medications was not taken into account, Dr. Inwards-Breland acknowledged.

“I think future studies should look at a mental health evaluation and diagnosis by a mental health provider,” he added. And mental health, gender dysphoria, suicidality, and self-harm should be tracked over the course of treatment.

He also acknowledged the study’s selection bias. All participants sought care at a multidisciplinary gender clinic, so were likely to be privileged and to have supportive families. “There’s a good chance that if we had more trans and nonbinary youth of color, we may have different findings,” he said.

More qualitative research is needed to assess the effect of gender-affirming therapy on the mental health of these patients, Dr. Breuner said.

“Being able to finally come into who you think you are and enjoy expressing who you are in a gender-affirming way has to be positive in such a way that you’re not depressed anymore,” she added. “It has to be tragic for people who cannot stand the body they’re in and cannot talk about it to anybody or express themselves without fear of recourse, to the point that they would be so devastated that they’d want to die by suicide.”

This research was funded by the Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Development and Port Authority. Dr. Inwards-Breland and Dr. Breuner have disclosed no relevant financial relationships.

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

Transgender and nonbinary young people experienced less depression and fewer suicidal thoughts after a year of gender-affirming care with hormones or puberty blockers, according to new research.

“Given the high rates of adverse mental health comorbidities, these data provide critical evidence that expansion of gender-affirming care can save lives,” said David J. Inwards-Breland, MD, MPH, chief of adolescent and young adult medicine and codirector of the Center for Gender-Affirming Care at Rady Children’s Hospital in San Diego, during his presentation.

The findings, presented October 11 at the American Academy of Pediatrics 2021 National Conference, were not at all surprising to Cora Breuner, MD, MPH, professor of pediatrics at Seattle Children’s Hospital.

“The younger we can provide gender-affirming care, the less likely they’re going to have depression, and then the negative outcomes from untreated depression, which includes suicide intent or even suicide completion,” Dr. Breuner told this news organization. “It’s so obvious that we are saving lives by providing gender-affirming care.”

For their study, Dr. Inwards-Breland and his colleagues tracked depression, anxiety, and suicidality in 104 trans and nonbinary people 13 to 21 years of age who received care at the Seattle Children’s gender clinic between August 2017 and June 2018.

The study population consisted of 63 transgender male or male participants, 27 transgender female or female participants, 10 nonbinary participants, and four participants who had not defined their gender identity. Of this cohort, 62.5% were receiving mental health therapy, and 34.7% reported some substance use.

Participants completed the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) at baseline and then at 3, 6, and 12 months. The researchers defined severe depression and severe anxiety as a score of 10 or greater on either scale.

At baseline, 56.7% of the participants had moderate to severe depression, 43.3% reported thoughts of self-harm or suicidal in the previous 2 weeks, and 50.0% had moderate to severe anxiety.

After 12 months of care, participants experienced a 60% decrease in depression (adjusted odds ratio, 0.4) and a 73% decrease in suicidality (aOR, 0.27), after adjustment for temporal trends and sex assigned at birth, race/ethnicity, level of parental support, ongoing mental health therapy, substance use, and victimization, including bullying, interpersonal violence, neglect, and abuse.

Although the decline in depression and suicidality after gender-affirming treatment was not a surprise, “those drops are huge,” Dr. Inwards-Breland said in an interview.

He said he attributes the improvement to a health care system that “affirms who these young people are” and enables changes that allow their outward appearance to reflect “who they know they are inside.”

There were no significant changes in anxiety during the study period. “Anxiety, I think, is just a little harder to treat, and it takes a little longer to treat,” he explained. And a lot of factors can trigger anxiety, and those can continue during treatment.

The slow pace of changes to gender identity can have an effect on people’s moods. “Since they’re not happening quickly, these young people are still being misgendered, they’re still seeing the body that they don’t feel like they should have, and they have to go to school and go out in public. I think that continues to fuel anxiety with a lot of these young people.”

Family support is important in reducing depression and suicidal thoughts in this population. Parents will often see positive changes after their child receives gender-affirming care, which can help contribute to positive changes in parents’ attitudes, Dr. Inwards-Breland said.

Such changes reinforce “that protective factor of connectedness with family,” he noted. “Families are crucial for any health care, and if there’s that connectedness with families, we know that, clinically, patients do better.”
 

Balancing risks

Although there are risks associated with gender-affirming hormones and puberty blockers, the risks of not receiving treatment must also be considered.

“Our young people are killing themselves,” he said. “Our young people are developing severe eating disorders that are killing them. Our young people are increasing their substance abuse, homelessness, depression. The list just goes on.”

For trans-masculine and nonbinary masculine patients, the potential permanent changes of hormone therapy include a deeper voice, hair growth, enlargement of the clitoris, and, in some patients, the development of male pattern baldness. In trans and nonbinary feminine patients, potential long-term effects include breast development and an increased risk for fertility issues.

The consent forms required for young people who want gender-affirming hormones or puberty blockers are extensive, with every possible reversible and irreversible effect described in detail, Dr. Breuner said.

“Parents sign them because they want their child to stay alive,” she explained. “When you compare the cost of someone who has severe debilitating depression and dying by suicide with some of the risks associated with gender-affirming hormone therapy, that’s a no-brainer to me.”

This study is limited by the fact that screening tests, not diagnostic tests, were used to identify depression, anxiety, and suicidality, and the fact that the use of antidepression or antianxiety medications was not taken into account, Dr. Inwards-Breland acknowledged.

“I think future studies should look at a mental health evaluation and diagnosis by a mental health provider,” he added. And mental health, gender dysphoria, suicidality, and self-harm should be tracked over the course of treatment.

He also acknowledged the study’s selection bias. All participants sought care at a multidisciplinary gender clinic, so were likely to be privileged and to have supportive families. “There’s a good chance that if we had more trans and nonbinary youth of color, we may have different findings,” he said.

More qualitative research is needed to assess the effect of gender-affirming therapy on the mental health of these patients, Dr. Breuner said.

“Being able to finally come into who you think you are and enjoy expressing who you are in a gender-affirming way has to be positive in such a way that you’re not depressed anymore,” she added. “It has to be tragic for people who cannot stand the body they’re in and cannot talk about it to anybody or express themselves without fear of recourse, to the point that they would be so devastated that they’d want to die by suicide.”

This research was funded by the Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Development and Port Authority. Dr. Inwards-Breland and Dr. Breuner have disclosed no relevant financial relationships.

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

Transgender and nonbinary young people experienced less depression and fewer suicidal thoughts after a year of gender-affirming care with hormones or puberty blockers, according to new research.

“Given the high rates of adverse mental health comorbidities, these data provide critical evidence that expansion of gender-affirming care can save lives,” said David J. Inwards-Breland, MD, MPH, chief of adolescent and young adult medicine and codirector of the Center for Gender-Affirming Care at Rady Children’s Hospital in San Diego, during his presentation.

The findings, presented October 11 at the American Academy of Pediatrics 2021 National Conference, were not at all surprising to Cora Breuner, MD, MPH, professor of pediatrics at Seattle Children’s Hospital.

“The younger we can provide gender-affirming care, the less likely they’re going to have depression, and then the negative outcomes from untreated depression, which includes suicide intent or even suicide completion,” Dr. Breuner told this news organization. “It’s so obvious that we are saving lives by providing gender-affirming care.”

For their study, Dr. Inwards-Breland and his colleagues tracked depression, anxiety, and suicidality in 104 trans and nonbinary people 13 to 21 years of age who received care at the Seattle Children’s gender clinic between August 2017 and June 2018.

The study population consisted of 63 transgender male or male participants, 27 transgender female or female participants, 10 nonbinary participants, and four participants who had not defined their gender identity. Of this cohort, 62.5% were receiving mental health therapy, and 34.7% reported some substance use.

Participants completed the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) at baseline and then at 3, 6, and 12 months. The researchers defined severe depression and severe anxiety as a score of 10 or greater on either scale.

At baseline, 56.7% of the participants had moderate to severe depression, 43.3% reported thoughts of self-harm or suicidal in the previous 2 weeks, and 50.0% had moderate to severe anxiety.

After 12 months of care, participants experienced a 60% decrease in depression (adjusted odds ratio, 0.4) and a 73% decrease in suicidality (aOR, 0.27), after adjustment for temporal trends and sex assigned at birth, race/ethnicity, level of parental support, ongoing mental health therapy, substance use, and victimization, including bullying, interpersonal violence, neglect, and abuse.

Although the decline in depression and suicidality after gender-affirming treatment was not a surprise, “those drops are huge,” Dr. Inwards-Breland said in an interview.

He said he attributes the improvement to a health care system that “affirms who these young people are” and enables changes that allow their outward appearance to reflect “who they know they are inside.”

There were no significant changes in anxiety during the study period. “Anxiety, I think, is just a little harder to treat, and it takes a little longer to treat,” he explained. And a lot of factors can trigger anxiety, and those can continue during treatment.

The slow pace of changes to gender identity can have an effect on people’s moods. “Since they’re not happening quickly, these young people are still being misgendered, they’re still seeing the body that they don’t feel like they should have, and they have to go to school and go out in public. I think that continues to fuel anxiety with a lot of these young people.”

Family support is important in reducing depression and suicidal thoughts in this population. Parents will often see positive changes after their child receives gender-affirming care, which can help contribute to positive changes in parents’ attitudes, Dr. Inwards-Breland said.

Such changes reinforce “that protective factor of connectedness with family,” he noted. “Families are crucial for any health care, and if there’s that connectedness with families, we know that, clinically, patients do better.”
 

Balancing risks

Although there are risks associated with gender-affirming hormones and puberty blockers, the risks of not receiving treatment must also be considered.

“Our young people are killing themselves,” he said. “Our young people are developing severe eating disorders that are killing them. Our young people are increasing their substance abuse, homelessness, depression. The list just goes on.”

For trans-masculine and nonbinary masculine patients, the potential permanent changes of hormone therapy include a deeper voice, hair growth, enlargement of the clitoris, and, in some patients, the development of male pattern baldness. In trans and nonbinary feminine patients, potential long-term effects include breast development and an increased risk for fertility issues.

The consent forms required for young people who want gender-affirming hormones or puberty blockers are extensive, with every possible reversible and irreversible effect described in detail, Dr. Breuner said.

“Parents sign them because they want their child to stay alive,” she explained. “When you compare the cost of someone who has severe debilitating depression and dying by suicide with some of the risks associated with gender-affirming hormone therapy, that’s a no-brainer to me.”

This study is limited by the fact that screening tests, not diagnostic tests, were used to identify depression, anxiety, and suicidality, and the fact that the use of antidepression or antianxiety medications was not taken into account, Dr. Inwards-Breland acknowledged.

“I think future studies should look at a mental health evaluation and diagnosis by a mental health provider,” he added. And mental health, gender dysphoria, suicidality, and self-harm should be tracked over the course of treatment.

He also acknowledged the study’s selection bias. All participants sought care at a multidisciplinary gender clinic, so were likely to be privileged and to have supportive families. “There’s a good chance that if we had more trans and nonbinary youth of color, we may have different findings,” he said.

More qualitative research is needed to assess the effect of gender-affirming therapy on the mental health of these patients, Dr. Breuner said.

“Being able to finally come into who you think you are and enjoy expressing who you are in a gender-affirming way has to be positive in such a way that you’re not depressed anymore,” she added. “It has to be tragic for people who cannot stand the body they’re in and cannot talk about it to anybody or express themselves without fear of recourse, to the point that they would be so devastated that they’d want to die by suicide.”

This research was funded by the Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Development and Port Authority. Dr. Inwards-Breland and Dr. Breuner have disclosed no relevant financial relationships.

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

Given that approximately 9.5% of youth aged 13-17 in the United States identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ),¹ it is likely that a general pediatrician or pediatric subspecialist is going to encounter at least one LGBTQ patient during the course of the average workweek. By having an easy way to identify these patients and store this data in a user-friendly manner, you can ensure that your practice is LGBTQ friendly and an affirming environment for all sexual- and gender-minority youth.

One way to do this is to look over any paper or electronic forms your practice uses and make sure that they provide patients and families a range of options to identify themselves. For example, you could provide more options for gender, other than male or female, including a nonbinary or “other” (with a free text line) option. This allows your patients to give you an accurate description of what their affirmed gender is. Instead of having a space for mother’s name and father’s name, you could list these fields as “parent/guardian #1” and “parent/guardian #2.” These labels allow for more inclusivity and to reflect the diverse makeup of modern families. Providing a space for a patient to put the name and pronouns that they use allows your staff to make sure that you are calling a patient by the correct name and using the correct pronouns.

Within your EMR, there may be editable fields that allow for you or your staff to list the patient’s affirmed name and pronouns. Making this small change allows any staff member who accesses the chart to have that information displayed correctly for them and reduces the chances of staff misgendering or dead-naming a patient. Underscoring the importance of this, Sequeira et al. found that in a sample of youth from a gender clinic, only 9% of those adolescents reported that they were asked their name/pronouns outside of the gender clinic.² If those fields are not there, you may check with your IT staff or your EMR vendor to see if these fields may be added in. However, staff needs to make sure that they check with the child/adolescent first to discern with whom the patient has discussed their gender identity. If you were to put a patient’s affirmed name into the chart and then call the patient by that name in front of the parent/guardian, the parent/guardian may look at you quizzically about why you are calling their child by that name. This could then cause an uncomfortable conversation in the exam room or result in harm to the patient after the visit.

It is not just good clinical practice to ensure that you use a patient’s affirmed name and pronouns. Russell et al. looked at the relationship between depressive symptoms and suicidal ideation and whether an adolescent’s name/pronouns were used in the context of their home, school, work, and/or friend group. They found that use of an adolescent’s affirmed name in at least one of these contexts was associated with a decrease in depressive symptoms and a 29% decrease in suicidal ideation.³ Therefore, the use of an adolescent’s affirmed name and pronouns in your office contributes to the overall mental well-being of your patients.

Fortunately, there are many guides to help you and your practice be successful at implementing some of these changes. The Gay, Lesbian, Bisexual and Transgender Health Access Project put together its “Community Standards of Practice for the Provision of Quality Health Care Services to Lesbian, Gay, Bisexual, and Transgender Clients” to aid practices in developing environments that are LGBTQ affirming. The National LGBTQIA+ Health Education Center, a part of the Fenway Institute, has a series of learning modules that you and your staff can view for interactive training and tips for best practices. These resources offer pediatricians and their practices free resources to improve their policies and procedures. By instituting these small changes, you can ensure that your practice continues to be an affirming environment for your LGBTQ children and adolescents.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Conran KJ. LGBT youth population in the United States, UCLA School of Law, Williams Institute, 2020 Sep.

2. Sequeira GM et al. Affirming transgender youths’ names and pronouns in the electronic medical record. JAMA Pediatr. 2020;174(5):501-3.

3. Russell ST et al. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018;63(4):503-5.

Given that approximately 9.5% of youth aged 13-17 in the United States identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ),¹ it is likely that a general pediatrician or pediatric subspecialist is going to encounter at least one LGBTQ patient during the course of the average workweek. By having an easy way to identify these patients and store this data in a user-friendly manner, you can ensure that your practice is LGBTQ friendly and an affirming environment for all sexual- and gender-minority youth.

One way to do this is to look over any paper or electronic forms your practice uses and make sure that they provide patients and families a range of options to identify themselves. For example, you could provide more options for gender, other than male or female, including a nonbinary or “other” (with a free text line) option. This allows your patients to give you an accurate description of what their affirmed gender is. Instead of having a space for mother’s name and father’s name, you could list these fields as “parent/guardian #1” and “parent/guardian #2.” These labels allow for more inclusivity and to reflect the diverse makeup of modern families. Providing a space for a patient to put the name and pronouns that they use allows your staff to make sure that you are calling a patient by the correct name and using the correct pronouns.

Within your EMR, there may be editable fields that allow for you or your staff to list the patient’s affirmed name and pronouns. Making this small change allows any staff member who accesses the chart to have that information displayed correctly for them and reduces the chances of staff misgendering or dead-naming a patient. Underscoring the importance of this, Sequeira et al. found that in a sample of youth from a gender clinic, only 9% of those adolescents reported that they were asked their name/pronouns outside of the gender clinic.² If those fields are not there, you may check with your IT staff or your EMR vendor to see if these fields may be added in. However, staff needs to make sure that they check with the child/adolescent first to discern with whom the patient has discussed their gender identity. If you were to put a patient’s affirmed name into the chart and then call the patient by that name in front of the parent/guardian, the parent/guardian may look at you quizzically about why you are calling their child by that name. This could then cause an uncomfortable conversation in the exam room or result in harm to the patient after the visit.

It is not just good clinical practice to ensure that you use a patient’s affirmed name and pronouns. Russell et al. looked at the relationship between depressive symptoms and suicidal ideation and whether an adolescent’s name/pronouns were used in the context of their home, school, work, and/or friend group. They found that use of an adolescent’s affirmed name in at least one of these contexts was associated with a decrease in depressive symptoms and a 29% decrease in suicidal ideation.³ Therefore, the use of an adolescent’s affirmed name and pronouns in your office contributes to the overall mental well-being of your patients.

Fortunately, there are many guides to help you and your practice be successful at implementing some of these changes. The Gay, Lesbian, Bisexual and Transgender Health Access Project put together its “Community Standards of Practice for the Provision of Quality Health Care Services to Lesbian, Gay, Bisexual, and Transgender Clients” to aid practices in developing environments that are LGBTQ affirming. The National LGBTQIA+ Health Education Center, a part of the Fenway Institute, has a series of learning modules that you and your staff can view for interactive training and tips for best practices. These resources offer pediatricians and their practices free resources to improve their policies and procedures. By instituting these small changes, you can ensure that your practice continues to be an affirming environment for your LGBTQ children and adolescents.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Conran KJ. LGBT youth population in the United States, UCLA School of Law, Williams Institute, 2020 Sep.

2. Sequeira GM et al. Affirming transgender youths’ names and pronouns in the electronic medical record. JAMA Pediatr. 2020;174(5):501-3.

3. Russell ST et al. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018;63(4):503-5.

Given that approximately 9.5% of youth aged 13-17 in the United States identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ),¹ it is likely that a general pediatrician or pediatric subspecialist is going to encounter at least one LGBTQ patient during the course of the average workweek. By having an easy way to identify these patients and store this data in a user-friendly manner, you can ensure that your practice is LGBTQ friendly and an affirming environment for all sexual- and gender-minority youth.

One way to do this is to look over any paper or electronic forms your practice uses and make sure that they provide patients and families a range of options to identify themselves. For example, you could provide more options for gender, other than male or female, including a nonbinary or “other” (with a free text line) option. This allows your patients to give you an accurate description of what their affirmed gender is. Instead of having a space for mother’s name and father’s name, you could list these fields as “parent/guardian #1” and “parent/guardian #2.” These labels allow for more inclusivity and to reflect the diverse makeup of modern families. Providing a space for a patient to put the name and pronouns that they use allows your staff to make sure that you are calling a patient by the correct name and using the correct pronouns.

Within your EMR, there may be editable fields that allow for you or your staff to list the patient’s affirmed name and pronouns. Making this small change allows any staff member who accesses the chart to have that information displayed correctly for them and reduces the chances of staff misgendering or dead-naming a patient. Underscoring the importance of this, Sequeira et al. found that in a sample of youth from a gender clinic, only 9% of those adolescents reported that they were asked their name/pronouns outside of the gender clinic.² If those fields are not there, you may check with your IT staff or your EMR vendor to see if these fields may be added in. However, staff needs to make sure that they check with the child/adolescent first to discern with whom the patient has discussed their gender identity. If you were to put a patient’s affirmed name into the chart and then call the patient by that name in front of the parent/guardian, the parent/guardian may look at you quizzically about why you are calling their child by that name. This could then cause an uncomfortable conversation in the exam room or result in harm to the patient after the visit.

It is not just good clinical practice to ensure that you use a patient’s affirmed name and pronouns. Russell et al. looked at the relationship between depressive symptoms and suicidal ideation and whether an adolescent’s name/pronouns were used in the context of their home, school, work, and/or friend group. They found that use of an adolescent’s affirmed name in at least one of these contexts was associated with a decrease in depressive symptoms and a 29% decrease in suicidal ideation.³ Therefore, the use of an adolescent’s affirmed name and pronouns in your office contributes to the overall mental well-being of your patients.

Fortunately, there are many guides to help you and your practice be successful at implementing some of these changes. The Gay, Lesbian, Bisexual and Transgender Health Access Project put together its “Community Standards of Practice for the Provision of Quality Health Care Services to Lesbian, Gay, Bisexual, and Transgender Clients” to aid practices in developing environments that are LGBTQ affirming. The National LGBTQIA+ Health Education Center, a part of the Fenway Institute, has a series of learning modules that you and your staff can view for interactive training and tips for best practices. These resources offer pediatricians and their practices free resources to improve their policies and procedures. By instituting these small changes, you can ensure that your practice continues to be an affirming environment for your LGBTQ children and adolescents.
 

Dr. Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

References

1. Conran KJ. LGBT youth population in the United States, UCLA School of Law, Williams Institute, 2020 Sep.

2. Sequeira GM et al. Affirming transgender youths’ names and pronouns in the electronic medical record. JAMA Pediatr. 2020;174(5):501-3.

3. Russell ST et al. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. J Adolesc Health. 2018;63(4):503-5.

It’s well known that levels of anxiety and depression in youth are on the rise. While some of this increase may be because of other things, such as a lowering of the threshold for what counts as clinically relevant symptoms and decreased stigma when it comes to seeking out mental health services, there seems little debate that the number of children and adolescents who are actually struggling with their mental health is taking a sharp turn for the worse.

What is much less certain are the causes behind this surge. The answer to this important question will likely defy a clear answer from a definitive study. In its place then are a number of different theories that have been circulated and discussed. Each comes with some evidence to support the hypothesis, but none seems able to make a truly compelling argument as the single driving force behind this trend. This column briefly describes and examines some of the factors that may be contributing to the rise in anxiety and depression while providing some explanation for why each factor is unlikely to be the sole culprit.

Some of the biggest suggested causes for the rise in child and adolescent mental health problems include the following:

• COVID. Multiple studies have documented increases in mood and anxiety associated with the pandemic, which in turn, may be because of a number of factors such as social isolation, loss of family members, family financial stressors, and many other contributors.¹ Yet, while it certainly makes sense that COVID is a powerful instigator of mood and anxiety problems, there is good evidence that the upward tic in emotional-behavioral problems began well before the COVID pandemic.²
• Smartphones. In 2017, psychologist Jean Twenge penned a provocative essay in the Atlantic with the title “Have Smartphones Destroyed a Generation?” and the basic answer was yes.³ The foundation for this conclusion was the tracking between the rise in mood and anxiety problems and the meteoric rise of smartphone use in youth. None of these associations, however, can be proven as casual, and more experimental data on the link between smartphone usage and mental health have been inconsistent.
• Bullying. The toxic effect of bullying and, in particular, online or “cyberbullying” has frequently been brought up as a potential cause. Yet while the negative effects of bullying have been well documented, there is evidence that overall bullying has actually decreased over recent years.⁴

These three factors have arguably been the most discussed, but a few others also probably deserve mention.

• Helicopter parenting. Critics of this common and increasingly popular approach to parenting are concerned that all the parental hovering and stepping in convey the message that the world is a very dangerous place while depriving children of opportunities to gain the exposure and competence they need to succeed. The critique is certainly logical and even has been supported in some studies but lacks the needed evidence for a more definitive conclusion.⁵
• Medications. Of course there will be stories blaming the mental health treatment itself, rather than the reasons people seek treatment, for this disturbing trend. And while it is always important to consider that medications can be part of the problem rather than the solution, the majority of evidence points overall to a lack of treatment rather than too much. A recent important study, for example, found that the peak of suicidal thoughts and behaviors occurred a month before medications were started, rather than after.⁶
• Cannabis. While there seems to be a lot of geographic variability with regard to whether or not the number of youth using cannabis is increasing or not, it’s clear that the product now being consumed is considerably stronger than what was used in decades past. This high-potency cannabis now being used has been shown to increase the risk for later mental health problems including psychosis and suicidal behavior.⁷ Unfortunately, these risks are not being heard as a powerful industry fights to increase their market share.

Putting all this together, it seems likely that a tidy and simple explanation for the alarming increase in youth mental health problems will be hard to pin down. It’s also worth pointing out that many of the above factors could work in a synergistic manner. For example, helicopter parenting may be keeping kids more confined to their rooms where they interact more and more on their phones and are exposed to higher amounts of online bullying, all of which has been magnified recently with the COVID pandemic. Obviously, understanding the causes behind this surge is much more than an academic exercise as the amount of stress and suffering rises and treatment resources get overwhelmed. In the meantime, addressing all of the above factors in both primary and specialty care is worthwhile in an effort to reverse this worrying and wide-ranging pattern.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. He is the author of the 2021 book, “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

References

1. Hawes MT et al. Psychol Med. 2021;13:1-9.

2. Twenge JM et al. J Abnorm Psych. 2019;128(3):185-99.

3. Twenge JM. Have Smartphones Destroyed a Generation? The Atlantic. 2017:September.

4. Rettew DC. Bullying: An update. Child Psych Clin North Am. 2021; in press.

5. Van Der Bruggen CO et al. J Child Psychol Psychiatry. 2008;49(12):1257-69.

6. Lagerberg T et al. Selective serotonin reuptake inhibitors and suicidal behaviour: A population-based cohort study. Neuropsychopharmacology 2021 Sep 24.

7. Gobbi G et al. JAMA Psychiatry. 2019;76(4):426-34.

It’s well known that levels of anxiety and depression in youth are on the rise. While some of this increase may be because of other things, such as a lowering of the threshold for what counts as clinically relevant symptoms and decreased stigma when it comes to seeking out mental health services, there seems little debate that the number of children and adolescents who are actually struggling with their mental health is taking a sharp turn for the worse.

What is much less certain are the causes behind this surge. The answer to this important question will likely defy a clear answer from a definitive study. In its place then are a number of different theories that have been circulated and discussed. Each comes with some evidence to support the hypothesis, but none seems able to make a truly compelling argument as the single driving force behind this trend. This column briefly describes and examines some of the factors that may be contributing to the rise in anxiety and depression while providing some explanation for why each factor is unlikely to be the sole culprit.

Some of the biggest suggested causes for the rise in child and adolescent mental health problems include the following:

• COVID. Multiple studies have documented increases in mood and anxiety associated with the pandemic, which in turn, may be because of a number of factors such as social isolation, loss of family members, family financial stressors, and many other contributors.¹ Yet, while it certainly makes sense that COVID is a powerful instigator of mood and anxiety problems, there is good evidence that the upward tic in emotional-behavioral problems began well before the COVID pandemic.²
• Smartphones. In 2017, psychologist Jean Twenge penned a provocative essay in the Atlantic with the title “Have Smartphones Destroyed a Generation?” and the basic answer was yes.³ The foundation for this conclusion was the tracking between the rise in mood and anxiety problems and the meteoric rise of smartphone use in youth. None of these associations, however, can be proven as casual, and more experimental data on the link between smartphone usage and mental health have been inconsistent.
• Bullying. The toxic effect of bullying and, in particular, online or “cyberbullying” has frequently been brought up as a potential cause. Yet while the negative effects of bullying have been well documented, there is evidence that overall bullying has actually decreased over recent years.⁴

These three factors have arguably been the most discussed, but a few others also probably deserve mention.

• Helicopter parenting. Critics of this common and increasingly popular approach to parenting are concerned that all the parental hovering and stepping in convey the message that the world is a very dangerous place while depriving children of opportunities to gain the exposure and competence they need to succeed. The critique is certainly logical and even has been supported in some studies but lacks the needed evidence for a more definitive conclusion.⁵
• Medications. Of course there will be stories blaming the mental health treatment itself, rather than the reasons people seek treatment, for this disturbing trend. And while it is always important to consider that medications can be part of the problem rather than the solution, the majority of evidence points overall to a lack of treatment rather than too much. A recent important study, for example, found that the peak of suicidal thoughts and behaviors occurred a month before medications were started, rather than after.⁶
• Cannabis. While there seems to be a lot of geographic variability with regard to whether or not the number of youth using cannabis is increasing or not, it’s clear that the product now being consumed is considerably stronger than what was used in decades past. This high-potency cannabis now being used has been shown to increase the risk for later mental health problems including psychosis and suicidal behavior.⁷ Unfortunately, these risks are not being heard as a powerful industry fights to increase their market share.

Putting all this together, it seems likely that a tidy and simple explanation for the alarming increase in youth mental health problems will be hard to pin down. It’s also worth pointing out that many of the above factors could work in a synergistic manner. For example, helicopter parenting may be keeping kids more confined to their rooms where they interact more and more on their phones and are exposed to higher amounts of online bullying, all of which has been magnified recently with the COVID pandemic. Obviously, understanding the causes behind this surge is much more than an academic exercise as the amount of stress and suffering rises and treatment resources get overwhelmed. In the meantime, addressing all of the above factors in both primary and specialty care is worthwhile in an effort to reverse this worrying and wide-ranging pattern.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. He is the author of the 2021 book, “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

References

1. Hawes MT et al. Psychol Med. 2021;13:1-9.

2. Twenge JM et al. J Abnorm Psych. 2019;128(3):185-99.

3. Twenge JM. Have Smartphones Destroyed a Generation? The Atlantic. 2017:September.

4. Rettew DC. Bullying: An update. Child Psych Clin North Am. 2021; in press.

5. Van Der Bruggen CO et al. J Child Psychol Psychiatry. 2008;49(12):1257-69.

6. Lagerberg T et al. Selective serotonin reuptake inhibitors and suicidal behaviour: A population-based cohort study. Neuropsychopharmacology 2021 Sep 24.

7. Gobbi G et al. JAMA Psychiatry. 2019;76(4):426-34.

It’s well known that levels of anxiety and depression in youth are on the rise. While some of this increase may be because of other things, such as a lowering of the threshold for what counts as clinically relevant symptoms and decreased stigma when it comes to seeking out mental health services, there seems little debate that the number of children and adolescents who are actually struggling with their mental health is taking a sharp turn for the worse.

What is much less certain are the causes behind this surge. The answer to this important question will likely defy a clear answer from a definitive study. In its place then are a number of different theories that have been circulated and discussed. Each comes with some evidence to support the hypothesis, but none seems able to make a truly compelling argument as the single driving force behind this trend. This column briefly describes and examines some of the factors that may be contributing to the rise in anxiety and depression while providing some explanation for why each factor is unlikely to be the sole culprit.

Some of the biggest suggested causes for the rise in child and adolescent mental health problems include the following:

• COVID. Multiple studies have documented increases in mood and anxiety associated with the pandemic, which in turn, may be because of a number of factors such as social isolation, loss of family members, family financial stressors, and many other contributors.¹ Yet, while it certainly makes sense that COVID is a powerful instigator of mood and anxiety problems, there is good evidence that the upward tic in emotional-behavioral problems began well before the COVID pandemic.²
• Smartphones. In 2017, psychologist Jean Twenge penned a provocative essay in the Atlantic with the title “Have Smartphones Destroyed a Generation?” and the basic answer was yes.³ The foundation for this conclusion was the tracking between the rise in mood and anxiety problems and the meteoric rise of smartphone use in youth. None of these associations, however, can be proven as casual, and more experimental data on the link between smartphone usage and mental health have been inconsistent.
• Bullying. The toxic effect of bullying and, in particular, online or “cyberbullying” has frequently been brought up as a potential cause. Yet while the negative effects of bullying have been well documented, there is evidence that overall bullying has actually decreased over recent years.⁴

These three factors have arguably been the most discussed, but a few others also probably deserve mention.

• Helicopter parenting. Critics of this common and increasingly popular approach to parenting are concerned that all the parental hovering and stepping in convey the message that the world is a very dangerous place while depriving children of opportunities to gain the exposure and competence they need to succeed. The critique is certainly logical and even has been supported in some studies but lacks the needed evidence for a more definitive conclusion.⁵
• Medications. Of course there will be stories blaming the mental health treatment itself, rather than the reasons people seek treatment, for this disturbing trend. And while it is always important to consider that medications can be part of the problem rather than the solution, the majority of evidence points overall to a lack of treatment rather than too much. A recent important study, for example, found that the peak of suicidal thoughts and behaviors occurred a month before medications were started, rather than after.⁶
• Cannabis. While there seems to be a lot of geographic variability with regard to whether or not the number of youth using cannabis is increasing or not, it’s clear that the product now being consumed is considerably stronger than what was used in decades past. This high-potency cannabis now being used has been shown to increase the risk for later mental health problems including psychosis and suicidal behavior.⁷ Unfortunately, these risks are not being heard as a powerful industry fights to increase their market share.

Putting all this together, it seems likely that a tidy and simple explanation for the alarming increase in youth mental health problems will be hard to pin down. It’s also worth pointing out that many of the above factors could work in a synergistic manner. For example, helicopter parenting may be keeping kids more confined to their rooms where they interact more and more on their phones and are exposed to higher amounts of online bullying, all of which has been magnified recently with the COVID pandemic. Obviously, understanding the causes behind this surge is much more than an academic exercise as the amount of stress and suffering rises and treatment resources get overwhelmed. In the meantime, addressing all of the above factors in both primary and specialty care is worthwhile in an effort to reverse this worrying and wide-ranging pattern.

Dr. Rettew is a child and adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Ore. He is the author of the 2021 book, “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

References

1. Hawes MT et al. Psychol Med. 2021;13:1-9.

2. Twenge JM et al. J Abnorm Psych. 2019;128(3):185-99.

3. Twenge JM. Have Smartphones Destroyed a Generation? The Atlantic. 2017:September.

4. Rettew DC. Bullying: An update. Child Psych Clin North Am. 2021; in press.

5. Van Der Bruggen CO et al. J Child Psychol Psychiatry. 2008;49(12):1257-69.

6. Lagerberg T et al. Selective serotonin reuptake inhibitors and suicidal behaviour: A population-based cohort study. Neuropsychopharmacology 2021 Sep 24.

7. Gobbi G et al. JAMA Psychiatry. 2019;76(4):426-34.