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Novel antidepressant shines in phase 2 trial, but FDA has issues with its NDA
Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.
In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.
The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.
In addition,
However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”
The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.
However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
‘Well tolerated’
A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.
All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.
Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).
The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.
One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.
A version of this article first appeared on Medscape.com.
Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.
In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.
The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.
In addition,
However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”
The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.
However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
‘Well tolerated’
A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.
All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.
Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).
The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.
One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.
A version of this article first appeared on Medscape.com.
Although a novel investigational drug that combines dextromethorphan and bupropion (AXS-05, Axsome Therapeutics) met its primary and key secondary endpoints in a phase 2 trial of patients with treatment-resistant depression (TRD), the U.S. Food and Drug Administration has voiced some concerns.
In the MERIT study, AXS-05 significantly delayed time to depression relapse compared with placebo (primary endpoint) – with no relapses observed for at least 6 months. It also significantly prevented depression relapse (secondary endpoint), the company said in a news release announcing the topline results.
The drug has been granted breakthrough therapy designations by the FDA for the treatment of major depressive disorder (MDD) and agitation associated with Alzheimer’s disease.
In addition,
However, Axsome stated that the FDA has identified “deficiencies that preclude labeling discussions at this time.”
The company is “attempting to learn the nature of these deficiencies with the goal of addressing them,” Herriot Tabuteau, MD, chief executive officer of Axsome, said in a statement.
However, Dr. Tabuteau acknowledged that this development “may lead to a delay in the potential approval of AXS-05.”
‘Well tolerated’
A total of 44 adults with TRD were enrolled into the MERIT study from the long-term, open-label phase 3 trial of AXS-05.
All patients were in stable remission after treatment with AXS-05 and were randomly assigned to continued treatment with AXS-05 (45 mg dextromethorphan/105 mg bupropion twice daily) or to switch to placebo.
Compared with placebo, AXS-05 significantly delayed time to depression relapse (P = .002) and prevented depression relapse (P = .004).
The novel drug was also well tolerated, with no treatment-emergent adverse events reported in more than one participant in the AXS-05 group, the company said.
One patient treated with AXS-05 did experience gout and bacteremia, but these incidents were deemed unrelated to the medication.
A version of this article first appeared on Medscape.com.
Opioid prescribing laws having an impact
State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.
While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.
The study was published online August 9 in JAMA Internal Medicine.
Significant but limited effect
Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.
Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.
They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).
Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.
After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.
, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
Inadequate pain control?
The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.
In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.
“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.
However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.
“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.
“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.
In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.”
Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write.
However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”
In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”
The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.
While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.
The study was published online August 9 in JAMA Internal Medicine.
Significant but limited effect
Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.
Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.
They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).
Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.
After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.
, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
Inadequate pain control?
The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.
In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.
“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.
However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.
“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.
“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.
In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.”
Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write.
However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”
In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”
The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.
While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was “significantly greater than in states without such legislation,” study investigator Michael Brenner, MD, University of Michigan, Ann Arbor, said in an interview.
The study was published online August 9 in JAMA Internal Medicine.
Significant but limited effect
Because of rising concern around the opioid crisis, 23 states representing 43% of the U.S. population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.
Using Medicare data from 2013 through 2018, Dr. Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.
They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).
Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.
After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness, and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, “suggesting a significant but limited outcome” for these laws, the researchers note.
, but this was not significantly different in states with limit laws versus those without. However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.
Inadequate pain control?
The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.
In addition, it’s not possible to tell from the data whether acute pain was adequately controlled with fewer pills.
“The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study,” said Dr. Brenner.
However, “ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills,” he noted.
“A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen,” Dr. Brenner added.
“Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses,” he added.
In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, say the decrease in opioid prescribing with duration limits was “small but probably meaningful.”
Restricting initial prescriptions to seven or fewer days is “reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues,” they write.
However, Dr. Grady and Dr. Katz “worry” that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, “may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief.”
In their view, the data from this study suggest that limiting initial prescriptions to seven or fewer days is “helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain.”
The study had no specific funding. Dr. Brenner, Dr. Grady, and Dr. Katz have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Reappraisal as a way to cope with pandemic news
Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).
With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.
Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.
The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.
I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.
I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.
That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).
With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.
Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.
The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.
I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.
I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.
That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).
With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.
Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.
The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.
I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.
I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.
That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
Clinical pearls for Muslim patients with suicide risk
The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.
Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.
Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.
However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.
In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.
Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.
Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:
1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.
Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.
2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.
Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.
3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.
Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.
4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.
Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.
Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.
To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
Further reading
Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.
Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.
Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.
American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.
American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.
Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.
Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.
Institute for Muslim Mental Health: https://muslimmentalhealth.com/
Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.
Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.
Resources
Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html
Maristan: https://maristan.org/
Naseeha mental health hotline: https://naseeha.org/
Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).
Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.
Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.
The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.
Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.
Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.
However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.
In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.
Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.
Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:
1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.
Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.
2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.
Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.
3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.
Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.
4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.
Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.
Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.
To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
Further reading
Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.
Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.
Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.
American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.
American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.
Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.
Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.
Institute for Muslim Mental Health: https://muslimmentalhealth.com/
Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.
Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.
Resources
Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html
Maristan: https://maristan.org/
Naseeha mental health hotline: https://naseeha.org/
Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).
Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.
Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.
The United States of America is home to a rapidly growing population of more than 3.5 million Muslims. The American Muslim population is a microcosm of global Islamic culture and religious practice, with heterogeneity across age, sex, ethnic origin, immigration status, socioeconomic background, and religiosity. Muslims in America face stressors, including challenges with migration, language barriers, and acculturation.
Some Muslim subgroups (for example, Black Muslims) face additional, intersectional struggles, such as racial discrimination and multigenerational trauma. These challenges may lead to the onset or exacerbation of psychopathology. Nevertheless, the mental health needs of this segment of the American population remain unmet.
Among mental health problems, suicide is inadequately researched among American Muslims. Global studies from both Muslim majority and non-Muslim majority countries consistently indicate that Muslims have among the lowest rates of suicide in comparison with other religious and nonreligious groups. Overall, this body of literature alludes to suicide resiliency in Muslim populations.
However, these studies may not depict the reality for American Muslims. A new research letter, published by two of us (R.A. and B.Z.) and other colleagues at Stanford (Calif.) University’s Muslim Mental Health and Islamic Psychology Lab, highlights the possibility of risk rather than resilience among American Muslims.
In a widely sampled population-based poll, we found that across religious groups in America, Muslims were up to twice as likely to endorse a lifetime history of suicide attempt than other religious or nonreligious groups.
Because of the paucity of suicide research, further inquiry is needed to explain American Muslim evident suicide risk. Nevertheless, our research shows that discrimination and marginalization, both religious and racial, are prominent suicide risk factors in the American Muslim narrative. From 2016 to 2020, almost two-thirds of American Muslims reported facing religious discrimination every year. In 2020, Muslim children in public K-12 systems were twice as likely to face bullying, a third of whom indicated that their bully was a school staff member. While the suicide literature has yet to explore Islamophobia in depth, marginalization and discrimination are demonstrably linked to suicide.
Here are a few clinical pearls that we think will help clinicians meet the needs of these patients:
1. Emphasize the basics. Muslims may be hesitant to engage with mental health practitioners and are often unfamiliar with confidentiality standards. Some may have experience with paternalistic health care cultures where patient privacy is violated. Consequently, some Muslim patients may have concerns that medical professionals can share personal medical history with family members or allied health professionals without obtaining consent. They may worry that private matters will be spread in their community, resulting in stigmatization or discrimination.
Providers should clearly communicate the terms of confidentiality and emphasize patient autonomy over information disclosed outside of the therapeutic partnership.
2. Develop a therapeutic alliance with cultural humility. Since Muslim patients have likely witnessed discrimination, either directly or indirectly, clinicians must adopt a nonjudgmental stance when discussing cultural, religious, or moral values different from their own. Muslim patients may find defending their faith and cultural norms stigmatizing, when faced with clinicians’ assumptions.
Providers should be transparent about their knowledge limitations, ask humbly for a partnership of shared learning, and allow the patient to lead where appropriate. Clinicians should develop a working understanding of Islamic values and cultural norms. See below for Muslim Mental Health resources.
3. Assess suicide risk and ask follow-up questions. Some clinicians may not deem suicide assessments valuable for Muslim patients, believing that strong religious values may preclude them from suicide risk. New findings that suicide risk is prominent among American Muslims highlights the necessity for assessment.
Practitioners should conduct thorough suicide risk assessments, including: past and present ideation, plan, intent, means, relevant risk, and resilience factors. Muslims may be culturally inclined to deny ideation, especially when accompanied by family members. Providers should be on alert for incongruent cues in patient affect and behavior.
4. Accommodate inpatient religious practice. Muslims navigate daily religious choices, from prayers at prescribed times to observing Islamic dietary guidelines. During psychiatric admissions, many of these norms are suspended temporarily. Treatments that do not include the flexibility to address these concerns may mirror patients’ experiences with Islamophobia. For example, being asked to remove the hijab, even with good cause (that is, self-harm precautions), may trigger familiar discriminatory threats to safety and belonging.
Religious accommodations should be addressed in rounds so that all interacting staff maintain collective accountability for religious needs. Accommodations may require adaptive solutions, such as one-piece pull-on–style hijabs as safer alternatives to rectangular wraps. To prevent pathologizing religious observance, providers should consider meeting with Muslim chaplains and patient advocates, including family members or religious care providers, where appropriate.
Addressing the mental health needs of Muslim patients not only requires cultural humility but knowledge about unique challenges facing this diverse community.
To help further advance understanding of these issues, consider taking the American Psychiatric Association’s Muslim Mental Health CME course, which will be taught by Dr. Awaad. In addition, we have included a list of resources below.
Further reading
Moffic S et al. Islamophobia and Psychiatry: Recognition, Prevention and Treatment. New York: Springer, 2019.
Keshavarzi H et al. Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy. New York: Routledge, 2020.
Ahmed S and MM Amer. Counseling Muslims: Handbook of Mental Health Issues and Interventions. New York: Routledge/Taylor & Francis Group, 2012.
American Psychiatric Association. Stress & Trauma Toolkit for Treating Muslims in a Changing Political and Social Environment, 2019.
American Psychiatric Association. Mental Health Disparities: Muslim Americans, 2019.
Awaad R et al. JAMA Psychiatry. 2021 Jul 21. doi: 10.1001/jamapsychiatry.2021.1813.
Baca-Garcia E et al. J Affect Disord. 2011;134(1-3):327-32.
Institute for Muslim Mental Health: https://muslimmentalhealth.com/
Institute for Social Policy and Understanding. “Religious Discrimination in Multiple Forms Impacts Muslims of All Ages: American Muslim Poll, 2020.
Silverman JJ et al. Am J Psychiatry. 2015 Aug 1;172(8):798-802.
Resources
Stanford Muslim Mental Health and Islamic Psychology Lab: http://med.stanford.edu/psychiatry/research/MuslimMHLab.html
Maristan: https://maristan.org/
Naseeha mental health hotline: https://naseeha.org/
Dr. Awaad is a clinical associate professor in the department of psychiatry and behavioral sciences at Stanford University. She also serves as associate division chief of public mental health and population sciences, and diversity section chief in the psychiatry department. In addition, Dr. Awaad is executive director of Maristan, an organization focused on using authentic traditions to meet the mental health needs of the Islamic community, and is affiliated with the department of psychiatry and behavioral sciences at Stanford. Dr. Awaad is coeditor of “Islamophobia and Psychiatry: Recognition, Prevention and Treatment” (New York: Springer, 2019), and “Applying Islamic Principles to Clinical Mental Health Care: Introducing Traditional Islamically Integrated Psychotherapy” (New York: Routledge/Taylor & Francis Group, 2020).
Dr. Husain completed her medical degree from St. George’s University in True Blue, Grenada; she is currently a graduate student in the department of public health concentrating on mental health parity in the United States. She also works as a researcher at the Stanford Muslim Mental Health & Islamic Psychology Lab and as an organizer for Team Liyna, a national effort aimed at diversifying the stem cell registry responsible for more than 10,000 new registrants since 2019.
Mr. Zia, who has been affiliated with the department of psychiatry and behavioral sciences at Stanford, is a PhD candidate and Canada-Vanier scholar in the department of clinical psychology at the University of Manitoba, Winnipeg. Mr. Zia is also a psychological associate at the New Leaf Psychology Centre in Milton, Ont. He has no relevant financial relationships.
Global youth depression and anxiety doubled during pandemic
The COVID-19 pandemic doubled international rates of child and adolescent psychological disorders, according to results of a meta-analysis.
In the first year of the pandemic, an estimated one in four youth across various regions of the globe experienced clinically elevated depression symptoms, while one in five experienced clinically elevated anxiety symptoms. These pooled estimates, which increased over time, are double prepandemic estimates, according to Nicole Racine, PhD, RPsych, a clinical psychologist at the University of Calgary (Alta.) and colleagues.
Their meta-analysis of 29 studies, comprising 80,879 young people worldwide aged 18 years or less, found pooled prevalence estimates of clinically elevated youth depression and anxiety of 25.2% (95% confidence interval, 21.2%-29.7%) and 20.5% (95% CI, 17.2%-24.4%), respectively.
“The prevalence of depression and anxiety symptoms during COVID-19 [has] doubled, compared with prepandemic estimates, and moderator analyses revealed that prevalence rates were higher when collected later in the pandemic, in older adolescents, and in girls,” the researchers write online in JAMA Pediatrics.
Prepandemic estimates of clinically significant generalized anxiety and depressive symptoms in large youth cohorts were approximately 11.6% and 12.9%, respectively, the authors say.
The increases revealed in these international findings have implications for targeted mental health resource planning.
“One difficulty in the literature is that there are large discrepancies on the prevalence of child depression and anxiety during the COVID-19 pandemic, with published rates between 2% and 68%,” corresponding author Sheri Madigan, PhD, RPsych, of the University of Calgary department of psychology, said in an interview. “By conducting a synthesis of the 29 studies on over 80,000 children, we were able to determine that, on average across these studies, 25% of youth are experiencing depression and 20% are experiencing anxiety during the COVID-19 pandemic.”
The cohort
The mean age in the combined global cohort was 13 years (range 4.1-17.6 ), and the mean proportion of females was 52.7% (standard deviation) 12.3%). The findings were based on international data published from Jan. 1, 2020, to Feb. 16, 2021, in studies conducted in the Middle East (n = 1), Europe (n = 4), South America (n = 2), North America (n = 6), and East Asia (n = 16). Notably absent were data from most of Latin America and the Middle East, Africa, South East Asia, and the Pacific Islands.
As the year progressed, the prevalence of depressive symptoms rose (b = .26; 95% CI, .06-46) with the number of months elapsed. Prevalence rates also rose as both age (b = 0.08, 95% CI, 0.01-0.15), and the percentage of females in samples increased (b = .03; 95% CI, 0.01-0.05).
The authors surmise that this cumulative worsening might be because of prolonged social isolation, family financial difficulties, missed milestones, and school disruptions, which are compounded over time. A second possibility is that studies conducted in the earlier months of the pandemic were more likely to be conducted in East Asia, where the self-reported prevalence of mental health symptoms tends to be lower.
The findings highlight an urgent need for intervention and recovery efforts and also indicate the need to consider individual differences when determining targets for intervention, including age, sex, and exposure to COVID-19 stressors), they add.
Even more concerning, recent data from the Centers for Disease Control and Prevention suggest that the pandemic spurred an increase in suspected suicide attempts by teenage girls. In the United Kingdom, acute mental health presentations to emergency care tripled over 2019 at one pediatric facility during the pandemic.
The authors attribute the toll on the psychological well-being of the world’s young people to pandemic-mandated restrictions. Those entailed loss of peer interactions, social isolation, and reduced contact with support figures such as teachers, and, “In addition, schools are often a primary location for receiving psychological services, with 80% of children relying on school-based services to address their mental health needs.” For many children, these services were rendered unavailable owing to school closures, Dr. Madigan and associates write.
In the context of clinical practice, doctors play a critical role. “With school closures, the physician’s office may be the only mental health checkpoint for youth,” Dr. Madigan said “So I recommend that family physicians screen for, and/or ask children and youth, about their mental health.”
On the home front, emerging research suggests that a predictable home environment can protect children’s mental well-being, with less depression and fewer behavioral problems observed in families adhering to regular routines during COVID-19. “Thus, a tangible solution to help mitigate the adverse effects of COVID-19 on youth is working with children and families to implement consistent and predictable routines around schoolwork, sleep, screen use, and physical activity,” the authors write.
They also point to the need for research on the long-term effects of the pandemic on mental health, including studies in order to “augment understanding of the implications of this crisis on the mental health trajectories of today’s children and youth.”
In an accompanying editorial, Tami D. Benton, MD, psychiatrist-in-chief at Children’s Hospital of Philadelphia, and colleagues, who were not involved in the meta-analysis, note certain limitations to the study. First, the included studies are based on self- or parent-reported symptoms. Second, the studies, more than half of which (55.2%) were done in China, may not be generalizable to all regions of the world, where 90% of children live in low- or middle-income countries.
Still, they write,“The increased mental health needs identified in the meta-analysis call for immediate action for every country. Our responses must consider the range of child mental health infrastructures available, which vary across countries, with some having well-developed and coordinated mental health services, while others have informal, limited, underfunded, or fragmented systems of care.”
Empirically supported and culturally appropriate intervention strategies for children and families according to countries and communities will be crucial, they stress.
“This meta-analysis provides the most complete evidence to date on the toll the COVID-19 pandemic has taken on child and adolescent mental health,” said Katie A. McLaughlin, PhD, a professor of psychology at Harvard University in Boston, who was not involved in the study. “The results confirm the substantial increases in symptoms of youth depression and anxiety that many clinicians and researchers have observed during the pandemic and highlight the critical need for greater investments in mental health services for children and adolescents.”
This study received no specific funding other than research support to the investigators from nonprivate entities. The authors disclosed no relevant conflicts of interest. Dr. Benton and associates and Dr. McLaughlin declared no competing interests.
The COVID-19 pandemic doubled international rates of child and adolescent psychological disorders, according to results of a meta-analysis.
In the first year of the pandemic, an estimated one in four youth across various regions of the globe experienced clinically elevated depression symptoms, while one in five experienced clinically elevated anxiety symptoms. These pooled estimates, which increased over time, are double prepandemic estimates, according to Nicole Racine, PhD, RPsych, a clinical psychologist at the University of Calgary (Alta.) and colleagues.
Their meta-analysis of 29 studies, comprising 80,879 young people worldwide aged 18 years or less, found pooled prevalence estimates of clinically elevated youth depression and anxiety of 25.2% (95% confidence interval, 21.2%-29.7%) and 20.5% (95% CI, 17.2%-24.4%), respectively.
“The prevalence of depression and anxiety symptoms during COVID-19 [has] doubled, compared with prepandemic estimates, and moderator analyses revealed that prevalence rates were higher when collected later in the pandemic, in older adolescents, and in girls,” the researchers write online in JAMA Pediatrics.
Prepandemic estimates of clinically significant generalized anxiety and depressive symptoms in large youth cohorts were approximately 11.6% and 12.9%, respectively, the authors say.
The increases revealed in these international findings have implications for targeted mental health resource planning.
“One difficulty in the literature is that there are large discrepancies on the prevalence of child depression and anxiety during the COVID-19 pandemic, with published rates between 2% and 68%,” corresponding author Sheri Madigan, PhD, RPsych, of the University of Calgary department of psychology, said in an interview. “By conducting a synthesis of the 29 studies on over 80,000 children, we were able to determine that, on average across these studies, 25% of youth are experiencing depression and 20% are experiencing anxiety during the COVID-19 pandemic.”
The cohort
The mean age in the combined global cohort was 13 years (range 4.1-17.6 ), and the mean proportion of females was 52.7% (standard deviation) 12.3%). The findings were based on international data published from Jan. 1, 2020, to Feb. 16, 2021, in studies conducted in the Middle East (n = 1), Europe (n = 4), South America (n = 2), North America (n = 6), and East Asia (n = 16). Notably absent were data from most of Latin America and the Middle East, Africa, South East Asia, and the Pacific Islands.
As the year progressed, the prevalence of depressive symptoms rose (b = .26; 95% CI, .06-46) with the number of months elapsed. Prevalence rates also rose as both age (b = 0.08, 95% CI, 0.01-0.15), and the percentage of females in samples increased (b = .03; 95% CI, 0.01-0.05).
The authors surmise that this cumulative worsening might be because of prolonged social isolation, family financial difficulties, missed milestones, and school disruptions, which are compounded over time. A second possibility is that studies conducted in the earlier months of the pandemic were more likely to be conducted in East Asia, where the self-reported prevalence of mental health symptoms tends to be lower.
The findings highlight an urgent need for intervention and recovery efforts and also indicate the need to consider individual differences when determining targets for intervention, including age, sex, and exposure to COVID-19 stressors), they add.
Even more concerning, recent data from the Centers for Disease Control and Prevention suggest that the pandemic spurred an increase in suspected suicide attempts by teenage girls. In the United Kingdom, acute mental health presentations to emergency care tripled over 2019 at one pediatric facility during the pandemic.
The authors attribute the toll on the psychological well-being of the world’s young people to pandemic-mandated restrictions. Those entailed loss of peer interactions, social isolation, and reduced contact with support figures such as teachers, and, “In addition, schools are often a primary location for receiving psychological services, with 80% of children relying on school-based services to address their mental health needs.” For many children, these services were rendered unavailable owing to school closures, Dr. Madigan and associates write.
In the context of clinical practice, doctors play a critical role. “With school closures, the physician’s office may be the only mental health checkpoint for youth,” Dr. Madigan said “So I recommend that family physicians screen for, and/or ask children and youth, about their mental health.”
On the home front, emerging research suggests that a predictable home environment can protect children’s mental well-being, with less depression and fewer behavioral problems observed in families adhering to regular routines during COVID-19. “Thus, a tangible solution to help mitigate the adverse effects of COVID-19 on youth is working with children and families to implement consistent and predictable routines around schoolwork, sleep, screen use, and physical activity,” the authors write.
They also point to the need for research on the long-term effects of the pandemic on mental health, including studies in order to “augment understanding of the implications of this crisis on the mental health trajectories of today’s children and youth.”
In an accompanying editorial, Tami D. Benton, MD, psychiatrist-in-chief at Children’s Hospital of Philadelphia, and colleagues, who were not involved in the meta-analysis, note certain limitations to the study. First, the included studies are based on self- or parent-reported symptoms. Second, the studies, more than half of which (55.2%) were done in China, may not be generalizable to all regions of the world, where 90% of children live in low- or middle-income countries.
Still, they write,“The increased mental health needs identified in the meta-analysis call for immediate action for every country. Our responses must consider the range of child mental health infrastructures available, which vary across countries, with some having well-developed and coordinated mental health services, while others have informal, limited, underfunded, or fragmented systems of care.”
Empirically supported and culturally appropriate intervention strategies for children and families according to countries and communities will be crucial, they stress.
“This meta-analysis provides the most complete evidence to date on the toll the COVID-19 pandemic has taken on child and adolescent mental health,” said Katie A. McLaughlin, PhD, a professor of psychology at Harvard University in Boston, who was not involved in the study. “The results confirm the substantial increases in symptoms of youth depression and anxiety that many clinicians and researchers have observed during the pandemic and highlight the critical need for greater investments in mental health services for children and adolescents.”
This study received no specific funding other than research support to the investigators from nonprivate entities. The authors disclosed no relevant conflicts of interest. Dr. Benton and associates and Dr. McLaughlin declared no competing interests.
The COVID-19 pandemic doubled international rates of child and adolescent psychological disorders, according to results of a meta-analysis.
In the first year of the pandemic, an estimated one in four youth across various regions of the globe experienced clinically elevated depression symptoms, while one in five experienced clinically elevated anxiety symptoms. These pooled estimates, which increased over time, are double prepandemic estimates, according to Nicole Racine, PhD, RPsych, a clinical psychologist at the University of Calgary (Alta.) and colleagues.
Their meta-analysis of 29 studies, comprising 80,879 young people worldwide aged 18 years or less, found pooled prevalence estimates of clinically elevated youth depression and anxiety of 25.2% (95% confidence interval, 21.2%-29.7%) and 20.5% (95% CI, 17.2%-24.4%), respectively.
“The prevalence of depression and anxiety symptoms during COVID-19 [has] doubled, compared with prepandemic estimates, and moderator analyses revealed that prevalence rates were higher when collected later in the pandemic, in older adolescents, and in girls,” the researchers write online in JAMA Pediatrics.
Prepandemic estimates of clinically significant generalized anxiety and depressive symptoms in large youth cohorts were approximately 11.6% and 12.9%, respectively, the authors say.
The increases revealed in these international findings have implications for targeted mental health resource planning.
“One difficulty in the literature is that there are large discrepancies on the prevalence of child depression and anxiety during the COVID-19 pandemic, with published rates between 2% and 68%,” corresponding author Sheri Madigan, PhD, RPsych, of the University of Calgary department of psychology, said in an interview. “By conducting a synthesis of the 29 studies on over 80,000 children, we were able to determine that, on average across these studies, 25% of youth are experiencing depression and 20% are experiencing anxiety during the COVID-19 pandemic.”
The cohort
The mean age in the combined global cohort was 13 years (range 4.1-17.6 ), and the mean proportion of females was 52.7% (standard deviation) 12.3%). The findings were based on international data published from Jan. 1, 2020, to Feb. 16, 2021, in studies conducted in the Middle East (n = 1), Europe (n = 4), South America (n = 2), North America (n = 6), and East Asia (n = 16). Notably absent were data from most of Latin America and the Middle East, Africa, South East Asia, and the Pacific Islands.
As the year progressed, the prevalence of depressive symptoms rose (b = .26; 95% CI, .06-46) with the number of months elapsed. Prevalence rates also rose as both age (b = 0.08, 95% CI, 0.01-0.15), and the percentage of females in samples increased (b = .03; 95% CI, 0.01-0.05).
The authors surmise that this cumulative worsening might be because of prolonged social isolation, family financial difficulties, missed milestones, and school disruptions, which are compounded over time. A second possibility is that studies conducted in the earlier months of the pandemic were more likely to be conducted in East Asia, where the self-reported prevalence of mental health symptoms tends to be lower.
The findings highlight an urgent need for intervention and recovery efforts and also indicate the need to consider individual differences when determining targets for intervention, including age, sex, and exposure to COVID-19 stressors), they add.
Even more concerning, recent data from the Centers for Disease Control and Prevention suggest that the pandemic spurred an increase in suspected suicide attempts by teenage girls. In the United Kingdom, acute mental health presentations to emergency care tripled over 2019 at one pediatric facility during the pandemic.
The authors attribute the toll on the psychological well-being of the world’s young people to pandemic-mandated restrictions. Those entailed loss of peer interactions, social isolation, and reduced contact with support figures such as teachers, and, “In addition, schools are often a primary location for receiving psychological services, with 80% of children relying on school-based services to address their mental health needs.” For many children, these services were rendered unavailable owing to school closures, Dr. Madigan and associates write.
In the context of clinical practice, doctors play a critical role. “With school closures, the physician’s office may be the only mental health checkpoint for youth,” Dr. Madigan said “So I recommend that family physicians screen for, and/or ask children and youth, about their mental health.”
On the home front, emerging research suggests that a predictable home environment can protect children’s mental well-being, with less depression and fewer behavioral problems observed in families adhering to regular routines during COVID-19. “Thus, a tangible solution to help mitigate the adverse effects of COVID-19 on youth is working with children and families to implement consistent and predictable routines around schoolwork, sleep, screen use, and physical activity,” the authors write.
They also point to the need for research on the long-term effects of the pandemic on mental health, including studies in order to “augment understanding of the implications of this crisis on the mental health trajectories of today’s children and youth.”
In an accompanying editorial, Tami D. Benton, MD, psychiatrist-in-chief at Children’s Hospital of Philadelphia, and colleagues, who were not involved in the meta-analysis, note certain limitations to the study. First, the included studies are based on self- or parent-reported symptoms. Second, the studies, more than half of which (55.2%) were done in China, may not be generalizable to all regions of the world, where 90% of children live in low- or middle-income countries.
Still, they write,“The increased mental health needs identified in the meta-analysis call for immediate action for every country. Our responses must consider the range of child mental health infrastructures available, which vary across countries, with some having well-developed and coordinated mental health services, while others have informal, limited, underfunded, or fragmented systems of care.”
Empirically supported and culturally appropriate intervention strategies for children and families according to countries and communities will be crucial, they stress.
“This meta-analysis provides the most complete evidence to date on the toll the COVID-19 pandemic has taken on child and adolescent mental health,” said Katie A. McLaughlin, PhD, a professor of psychology at Harvard University in Boston, who was not involved in the study. “The results confirm the substantial increases in symptoms of youth depression and anxiety that many clinicians and researchers have observed during the pandemic and highlight the critical need for greater investments in mental health services for children and adolescents.”
This study received no specific funding other than research support to the investigators from nonprivate entities. The authors disclosed no relevant conflicts of interest. Dr. Benton and associates and Dr. McLaughlin declared no competing interests.
‘Munchausen by Internet’ crises a warning for all HCPs
A new study documents a handful of cases of women with Munchausen syndrome by Internet who targeted doulas in the United Kingdom during the COVID-19 lockdown.
The five cases were investigated by Kathryn Newns, MSc, DClinPsy, a clinical psychologist in Cambridge, England, who said the cases were brought to her attention by a doula she herself had used for the birth of her own child a decade earlier.
Dr. Newns said she believes these are not isolated cases – either geographically or in terms of the specialty involved.
“I don’t think it is likely that this is only happening in the United Kingdom. And I’m sure it’s not just happening in the doula world,” Dr. Newns told this news organization.
Coinvestigator Marc Feldman, MD, a clinical professor of psychiatry at the University of Alabama, Tuscaloosa, coined the term “Munchausen by Internet” in a 2000 article. The expression refers to use of electronic media to perpetrate hoaxes that reward posers with sympathy, control, or emotional gratification. The hoaxers do not seek financial gain.
“The ease of carrying out Munchausen behaviors makes me think that it must be much more common than it ever was,” Dr. Feldman said in an interview.
He noted that the new DSM-5 will eliminate the terms “Munchausen” and “Munchausen by Internet” and will clarify that “factitious disorder” can be partly or wholly carried out online.
The study was published in the May issue of the Annals of Clinical Psychiatry.
A warning for others
In the past, those with factitious disorder had to go to medical libraries to study up on the ailment they wanted to feign. They would then present to an emergency department or a doctor’s office and act convincingly, Dr. Feldman said.
“Now all you have to do is go to Wikipedia and you can become an expert on a medical ailment within a few minutes,” he added.
In the five cases described in the study, the hoaxers created rich stories, especially in cases 1 and 2. In those cases, the perpetrator turned out to be the same person. Subterfuge “obviously made it much harder to know she wasn’t who she purported to be,” said Dr. Newns.
Dr. Feldman noted that in Munchausen by Internet, there may be some element of truth within the stories.
For health care professionals, “it takes a considerable leap to assume that somebody who’s talking about some dreaded ailment is in fact exaggerating or outright lying,” he said.
In the five cases described in the study, persons contacted doulas, then related traumatic stories and described dramatic, immediate needs. All of the doulas were working remotely because of the COVID-19 pandemic. This likely made it easier for the perpetrators to pull off the hoaxes. The health care professionals agreed to share their experiences in the hopes of warning others.
Elaborate scenarios
The first two cases were ultimately determined to involve one person who had created elaborate scenarios.
In case 1, the hoaxer, who called herself “Jessica,” texted the doula “Charlotte” when she was allegedly 39 weeks’ pregnant. She said she was unable to go to the hospital because of the COVID-19 risks to her husband, who had cystic fibrosis and had recently undergone a heart and lung transplant.
The husband “Jordan” took over communications, using the same WhatsApp number as Jessica, as Jessica went into labor.
Ostensibly, a midwife team had come to Jessica’s and Jordan’s house. When the doula was on the phone with Jordan, she heard Jessica crying, grunting, and screaming, and then, at 2:00 a.m., she heard the sound of a baby crying. A photo of the baby was texted to Charlotte.
Soon, there were many problems. Jessica allegedly had a postpartum hemorrhage, and mother and baby were taken to separate hospitals. The baby was then diagnosed with congenital heart disease.
Over the next week, “midwives” started texting back and forth with Charlotte. The doula began to have doubts and asked a midwife to share a visual communication.
After receiving no response, Charlotte used a video call, got Jessica on screen, and told her she thought there was no baby. Jessica said the baby was real and showed a “growth chart” as proof of the 5-day-old baby’s existence. The birth and baby noises were later determined to be recordings.
Child deaths
After sharing information among themselves on a private Facebook group, the doulas determined that the person in case 2, “Dakota,” was the same woman who was involved in case 1.
In case 2, a doula had spent 2 years supporting Dakota through the deaths of a parent and her baby, who had a congenital defect. A baby-loss charity had also worked with Dakota but could not confirm the baby’s existence.
Dakota had gone so far as to make a video for the doula that showed a hospital room. In a voice-over, Dakota thanks everyone for the support she received as the baby died.
In case 3, “Hannah” texted a doula seeking emotional but not birth support. The doula, Nikki Barrow, has recounted the case on her own blog.
Hannah became desperate when she went into labor. Ms. Barrow remained close via texts, phone, and video calls, even as the baby supposedly died after 3 days. The doula lit a candle for the baby and cried with Hannah.
Ms. Barrow was eventually able to break away from Hannah, saying she was not a bereavement specialist. However, days later, Hannah tracked her down and claimed she had an infection in her heart and did not have much time to live. At that point, Ms. Barrow stopped all contact.
She determined from other doulas that Hannah had been hoaxing doulas for 4 or 5 years. Some had offered to get her help, but she refused and ended all contact.
Multiple COVID crises?
In case 4, a woman sought support on a doula-centered Facebook page and said her partner “Jack” would be in touch. Jack sent the doula hundreds of emails, texts, and WhatsApp messages and then said he was hospitalized with COVID. The woman, “Hayley,” was also soon diagnosed with COVID.
Hayley refused video contact and did not share photos. Drama continued to unfold. She reported that her baby was breach, that she had a second uterus with a second pregnancy simultaneously, and that the baby had COVID.
Hayley also claimed that her partner had come to the hospital, had raped her, and had brandished a gun. When the doula called the police, they did not find Hayley at the hospital or elsewhere.
In case 5, a “grandmother” contacted “Lisa” to find a doula for her daughter-in-law, “Anna.” Hours later, Anna was giving birth, and the baby had to be taken to the hospital because of cardiac and breathing problems. The doula heard nothing more after a few weeks.
However, at least three other doulas said they had supported the same “family.”
Online training program
In all cases, the doulas were not paid for their time. Reports to the police prompted no action because no money had changed hands. Some doulas said they felt bereaved, angry, or “silly” that they had been hoodwinked. All noted how difficult it was to disengage from clients who seemed to be in peril.
Ms. Barrow decided to create an online training program in which doulas are advised on how to stay safe while working online.
DoulaMatch, which matches birth support specialists with women in the United States and Canada, offers tips to help protect doulas from hoaxes.
Kim James, BDT(DONA), ICCE, LCCE, CLE, the owner and operator of DoulaMatch, said the organization is aware of “scammers who waste everyone’s time and have found doulas to be the latest easy targets.”
However, she noted, “I’ve only very occasionally and anecdotally heard about people fabricating a pregnancy for emotional gratification.”
In his 2000 article, Dr. Feldman offers clues to help detect hoaxers. He advises clinicians to be wary of the following:
- Cases in which the length, frequency, and duration of posts are incongruous with the severity of the illness the person is claiming to have; for example, someone who claims to be in submitting detailed posts.
- Near-fatal exacerbations of illness alternating with miraculous recoveries.
- Personal claims that are fantastic, are contradicted by later posts, or are disproved.
- Continual dramatic events occurring in the person’s life, especially when others in a group become the focus of attention.
- Others ostensibly posting on behalf of the individual who have identical patterns of writing, such as making grammatical errors, misspellings, and using stylistic idiosyncrasies.
A version of this article first appeared on Medscape.com.
A new study documents a handful of cases of women with Munchausen syndrome by Internet who targeted doulas in the United Kingdom during the COVID-19 lockdown.
The five cases were investigated by Kathryn Newns, MSc, DClinPsy, a clinical psychologist in Cambridge, England, who said the cases were brought to her attention by a doula she herself had used for the birth of her own child a decade earlier.
Dr. Newns said she believes these are not isolated cases – either geographically or in terms of the specialty involved.
“I don’t think it is likely that this is only happening in the United Kingdom. And I’m sure it’s not just happening in the doula world,” Dr. Newns told this news organization.
Coinvestigator Marc Feldman, MD, a clinical professor of psychiatry at the University of Alabama, Tuscaloosa, coined the term “Munchausen by Internet” in a 2000 article. The expression refers to use of electronic media to perpetrate hoaxes that reward posers with sympathy, control, or emotional gratification. The hoaxers do not seek financial gain.
“The ease of carrying out Munchausen behaviors makes me think that it must be much more common than it ever was,” Dr. Feldman said in an interview.
He noted that the new DSM-5 will eliminate the terms “Munchausen” and “Munchausen by Internet” and will clarify that “factitious disorder” can be partly or wholly carried out online.
The study was published in the May issue of the Annals of Clinical Psychiatry.
A warning for others
In the past, those with factitious disorder had to go to medical libraries to study up on the ailment they wanted to feign. They would then present to an emergency department or a doctor’s office and act convincingly, Dr. Feldman said.
“Now all you have to do is go to Wikipedia and you can become an expert on a medical ailment within a few minutes,” he added.
In the five cases described in the study, the hoaxers created rich stories, especially in cases 1 and 2. In those cases, the perpetrator turned out to be the same person. Subterfuge “obviously made it much harder to know she wasn’t who she purported to be,” said Dr. Newns.
Dr. Feldman noted that in Munchausen by Internet, there may be some element of truth within the stories.
For health care professionals, “it takes a considerable leap to assume that somebody who’s talking about some dreaded ailment is in fact exaggerating or outright lying,” he said.
In the five cases described in the study, persons contacted doulas, then related traumatic stories and described dramatic, immediate needs. All of the doulas were working remotely because of the COVID-19 pandemic. This likely made it easier for the perpetrators to pull off the hoaxes. The health care professionals agreed to share their experiences in the hopes of warning others.
Elaborate scenarios
The first two cases were ultimately determined to involve one person who had created elaborate scenarios.
In case 1, the hoaxer, who called herself “Jessica,” texted the doula “Charlotte” when she was allegedly 39 weeks’ pregnant. She said she was unable to go to the hospital because of the COVID-19 risks to her husband, who had cystic fibrosis and had recently undergone a heart and lung transplant.
The husband “Jordan” took over communications, using the same WhatsApp number as Jessica, as Jessica went into labor.
Ostensibly, a midwife team had come to Jessica’s and Jordan’s house. When the doula was on the phone with Jordan, she heard Jessica crying, grunting, and screaming, and then, at 2:00 a.m., she heard the sound of a baby crying. A photo of the baby was texted to Charlotte.
Soon, there were many problems. Jessica allegedly had a postpartum hemorrhage, and mother and baby were taken to separate hospitals. The baby was then diagnosed with congenital heart disease.
Over the next week, “midwives” started texting back and forth with Charlotte. The doula began to have doubts and asked a midwife to share a visual communication.
After receiving no response, Charlotte used a video call, got Jessica on screen, and told her she thought there was no baby. Jessica said the baby was real and showed a “growth chart” as proof of the 5-day-old baby’s existence. The birth and baby noises were later determined to be recordings.
Child deaths
After sharing information among themselves on a private Facebook group, the doulas determined that the person in case 2, “Dakota,” was the same woman who was involved in case 1.
In case 2, a doula had spent 2 years supporting Dakota through the deaths of a parent and her baby, who had a congenital defect. A baby-loss charity had also worked with Dakota but could not confirm the baby’s existence.
Dakota had gone so far as to make a video for the doula that showed a hospital room. In a voice-over, Dakota thanks everyone for the support she received as the baby died.
In case 3, “Hannah” texted a doula seeking emotional but not birth support. The doula, Nikki Barrow, has recounted the case on her own blog.
Hannah became desperate when she went into labor. Ms. Barrow remained close via texts, phone, and video calls, even as the baby supposedly died after 3 days. The doula lit a candle for the baby and cried with Hannah.
Ms. Barrow was eventually able to break away from Hannah, saying she was not a bereavement specialist. However, days later, Hannah tracked her down and claimed she had an infection in her heart and did not have much time to live. At that point, Ms. Barrow stopped all contact.
She determined from other doulas that Hannah had been hoaxing doulas for 4 or 5 years. Some had offered to get her help, but she refused and ended all contact.
Multiple COVID crises?
In case 4, a woman sought support on a doula-centered Facebook page and said her partner “Jack” would be in touch. Jack sent the doula hundreds of emails, texts, and WhatsApp messages and then said he was hospitalized with COVID. The woman, “Hayley,” was also soon diagnosed with COVID.
Hayley refused video contact and did not share photos. Drama continued to unfold. She reported that her baby was breach, that she had a second uterus with a second pregnancy simultaneously, and that the baby had COVID.
Hayley also claimed that her partner had come to the hospital, had raped her, and had brandished a gun. When the doula called the police, they did not find Hayley at the hospital or elsewhere.
In case 5, a “grandmother” contacted “Lisa” to find a doula for her daughter-in-law, “Anna.” Hours later, Anna was giving birth, and the baby had to be taken to the hospital because of cardiac and breathing problems. The doula heard nothing more after a few weeks.
However, at least three other doulas said they had supported the same “family.”
Online training program
In all cases, the doulas were not paid for their time. Reports to the police prompted no action because no money had changed hands. Some doulas said they felt bereaved, angry, or “silly” that they had been hoodwinked. All noted how difficult it was to disengage from clients who seemed to be in peril.
Ms. Barrow decided to create an online training program in which doulas are advised on how to stay safe while working online.
DoulaMatch, which matches birth support specialists with women in the United States and Canada, offers tips to help protect doulas from hoaxes.
Kim James, BDT(DONA), ICCE, LCCE, CLE, the owner and operator of DoulaMatch, said the organization is aware of “scammers who waste everyone’s time and have found doulas to be the latest easy targets.”
However, she noted, “I’ve only very occasionally and anecdotally heard about people fabricating a pregnancy for emotional gratification.”
In his 2000 article, Dr. Feldman offers clues to help detect hoaxers. He advises clinicians to be wary of the following:
- Cases in which the length, frequency, and duration of posts are incongruous with the severity of the illness the person is claiming to have; for example, someone who claims to be in submitting detailed posts.
- Near-fatal exacerbations of illness alternating with miraculous recoveries.
- Personal claims that are fantastic, are contradicted by later posts, or are disproved.
- Continual dramatic events occurring in the person’s life, especially when others in a group become the focus of attention.
- Others ostensibly posting on behalf of the individual who have identical patterns of writing, such as making grammatical errors, misspellings, and using stylistic idiosyncrasies.
A version of this article first appeared on Medscape.com.
A new study documents a handful of cases of women with Munchausen syndrome by Internet who targeted doulas in the United Kingdom during the COVID-19 lockdown.
The five cases were investigated by Kathryn Newns, MSc, DClinPsy, a clinical psychologist in Cambridge, England, who said the cases were brought to her attention by a doula she herself had used for the birth of her own child a decade earlier.
Dr. Newns said she believes these are not isolated cases – either geographically or in terms of the specialty involved.
“I don’t think it is likely that this is only happening in the United Kingdom. And I’m sure it’s not just happening in the doula world,” Dr. Newns told this news organization.
Coinvestigator Marc Feldman, MD, a clinical professor of psychiatry at the University of Alabama, Tuscaloosa, coined the term “Munchausen by Internet” in a 2000 article. The expression refers to use of electronic media to perpetrate hoaxes that reward posers with sympathy, control, or emotional gratification. The hoaxers do not seek financial gain.
“The ease of carrying out Munchausen behaviors makes me think that it must be much more common than it ever was,” Dr. Feldman said in an interview.
He noted that the new DSM-5 will eliminate the terms “Munchausen” and “Munchausen by Internet” and will clarify that “factitious disorder” can be partly or wholly carried out online.
The study was published in the May issue of the Annals of Clinical Psychiatry.
A warning for others
In the past, those with factitious disorder had to go to medical libraries to study up on the ailment they wanted to feign. They would then present to an emergency department or a doctor’s office and act convincingly, Dr. Feldman said.
“Now all you have to do is go to Wikipedia and you can become an expert on a medical ailment within a few minutes,” he added.
In the five cases described in the study, the hoaxers created rich stories, especially in cases 1 and 2. In those cases, the perpetrator turned out to be the same person. Subterfuge “obviously made it much harder to know she wasn’t who she purported to be,” said Dr. Newns.
Dr. Feldman noted that in Munchausen by Internet, there may be some element of truth within the stories.
For health care professionals, “it takes a considerable leap to assume that somebody who’s talking about some dreaded ailment is in fact exaggerating or outright lying,” he said.
In the five cases described in the study, persons contacted doulas, then related traumatic stories and described dramatic, immediate needs. All of the doulas were working remotely because of the COVID-19 pandemic. This likely made it easier for the perpetrators to pull off the hoaxes. The health care professionals agreed to share their experiences in the hopes of warning others.
Elaborate scenarios
The first two cases were ultimately determined to involve one person who had created elaborate scenarios.
In case 1, the hoaxer, who called herself “Jessica,” texted the doula “Charlotte” when she was allegedly 39 weeks’ pregnant. She said she was unable to go to the hospital because of the COVID-19 risks to her husband, who had cystic fibrosis and had recently undergone a heart and lung transplant.
The husband “Jordan” took over communications, using the same WhatsApp number as Jessica, as Jessica went into labor.
Ostensibly, a midwife team had come to Jessica’s and Jordan’s house. When the doula was on the phone with Jordan, she heard Jessica crying, grunting, and screaming, and then, at 2:00 a.m., she heard the sound of a baby crying. A photo of the baby was texted to Charlotte.
Soon, there were many problems. Jessica allegedly had a postpartum hemorrhage, and mother and baby were taken to separate hospitals. The baby was then diagnosed with congenital heart disease.
Over the next week, “midwives” started texting back and forth with Charlotte. The doula began to have doubts and asked a midwife to share a visual communication.
After receiving no response, Charlotte used a video call, got Jessica on screen, and told her she thought there was no baby. Jessica said the baby was real and showed a “growth chart” as proof of the 5-day-old baby’s existence. The birth and baby noises were later determined to be recordings.
Child deaths
After sharing information among themselves on a private Facebook group, the doulas determined that the person in case 2, “Dakota,” was the same woman who was involved in case 1.
In case 2, a doula had spent 2 years supporting Dakota through the deaths of a parent and her baby, who had a congenital defect. A baby-loss charity had also worked with Dakota but could not confirm the baby’s existence.
Dakota had gone so far as to make a video for the doula that showed a hospital room. In a voice-over, Dakota thanks everyone for the support she received as the baby died.
In case 3, “Hannah” texted a doula seeking emotional but not birth support. The doula, Nikki Barrow, has recounted the case on her own blog.
Hannah became desperate when she went into labor. Ms. Barrow remained close via texts, phone, and video calls, even as the baby supposedly died after 3 days. The doula lit a candle for the baby and cried with Hannah.
Ms. Barrow was eventually able to break away from Hannah, saying she was not a bereavement specialist. However, days later, Hannah tracked her down and claimed she had an infection in her heart and did not have much time to live. At that point, Ms. Barrow stopped all contact.
She determined from other doulas that Hannah had been hoaxing doulas for 4 or 5 years. Some had offered to get her help, but she refused and ended all contact.
Multiple COVID crises?
In case 4, a woman sought support on a doula-centered Facebook page and said her partner “Jack” would be in touch. Jack sent the doula hundreds of emails, texts, and WhatsApp messages and then said he was hospitalized with COVID. The woman, “Hayley,” was also soon diagnosed with COVID.
Hayley refused video contact and did not share photos. Drama continued to unfold. She reported that her baby was breach, that she had a second uterus with a second pregnancy simultaneously, and that the baby had COVID.
Hayley also claimed that her partner had come to the hospital, had raped her, and had brandished a gun. When the doula called the police, they did not find Hayley at the hospital or elsewhere.
In case 5, a “grandmother” contacted “Lisa” to find a doula for her daughter-in-law, “Anna.” Hours later, Anna was giving birth, and the baby had to be taken to the hospital because of cardiac and breathing problems. The doula heard nothing more after a few weeks.
However, at least three other doulas said they had supported the same “family.”
Online training program
In all cases, the doulas were not paid for their time. Reports to the police prompted no action because no money had changed hands. Some doulas said they felt bereaved, angry, or “silly” that they had been hoodwinked. All noted how difficult it was to disengage from clients who seemed to be in peril.
Ms. Barrow decided to create an online training program in which doulas are advised on how to stay safe while working online.
DoulaMatch, which matches birth support specialists with women in the United States and Canada, offers tips to help protect doulas from hoaxes.
Kim James, BDT(DONA), ICCE, LCCE, CLE, the owner and operator of DoulaMatch, said the organization is aware of “scammers who waste everyone’s time and have found doulas to be the latest easy targets.”
However, she noted, “I’ve only very occasionally and anecdotally heard about people fabricating a pregnancy for emotional gratification.”
In his 2000 article, Dr. Feldman offers clues to help detect hoaxers. He advises clinicians to be wary of the following:
- Cases in which the length, frequency, and duration of posts are incongruous with the severity of the illness the person is claiming to have; for example, someone who claims to be in submitting detailed posts.
- Near-fatal exacerbations of illness alternating with miraculous recoveries.
- Personal claims that are fantastic, are contradicted by later posts, or are disproved.
- Continual dramatic events occurring in the person’s life, especially when others in a group become the focus of attention.
- Others ostensibly posting on behalf of the individual who have identical patterns of writing, such as making grammatical errors, misspellings, and using stylistic idiosyncrasies.
A version of this article first appeared on Medscape.com.
Reckoning with America’s alarming rise in anti-Asian hate
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
The Surfside tragedy: A call for healing the healers
The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.
With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.
It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.
The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.
According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.
So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.
Working on the front lines
Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.
Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.
This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.
They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.
Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.
Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.
“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”
Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.
Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”
Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.
The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.
“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
Understanding the role of psychoneuroimmunology
In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.
She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.
Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”
Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.
She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.
The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.
Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.
Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.
“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”
Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:
1. Share your own loss experience with a caring and nonjudgmental person.
2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.
3. Be willing to ask for help.
4. Be aware of risks and countertransference in our work.
5. Attend workshops.
6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.
7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.
8. Schedule play.
9. Develop a healthy self-care regimen to remain present doing this work.
10. Consider the benefits of exercise.
11. Enjoy the beauty and wonder of nature.
12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.
13. Spend time with loving family and friends.
14. Adopt a pet.
15. Eat healthy foods; get plenty of rest.
16. Walk in the rain.
17. Listen to music.
18. Enjoy a relaxing bubble bath.
19. Sing, dance, and enjoy the blessings of this life.
20. Love yourself; you truly can be your own best friend.
To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.
While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.
The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.
With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.
It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.
The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.
According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.
So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.
Working on the front lines
Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.
Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.
This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.
They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.
Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.
Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.
“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”
Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.
Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”
Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.
The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.
“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
Understanding the role of psychoneuroimmunology
In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.
She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.
Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”
Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.
She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.
The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.
Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.
Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.
“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”
Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:
1. Share your own loss experience with a caring and nonjudgmental person.
2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.
3. Be willing to ask for help.
4. Be aware of risks and countertransference in our work.
5. Attend workshops.
6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.
7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.
8. Schedule play.
9. Develop a healthy self-care regimen to remain present doing this work.
10. Consider the benefits of exercise.
11. Enjoy the beauty and wonder of nature.
12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.
13. Spend time with loving family and friends.
14. Adopt a pet.
15. Eat healthy foods; get plenty of rest.
16. Walk in the rain.
17. Listen to music.
18. Enjoy a relaxing bubble bath.
19. Sing, dance, and enjoy the blessings of this life.
20. Love yourself; you truly can be your own best friend.
To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.
While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.
The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.
With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.
It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.
The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.
According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.
So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.
Working on the front lines
Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.
Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.
This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.
They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.
Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.
Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.
“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”
Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.
Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”
Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.
The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.
“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
Understanding the role of psychoneuroimmunology
In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.
She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.
Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”
Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.
She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.
The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.
Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.
Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.
“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”
Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:
1. Share your own loss experience with a caring and nonjudgmental person.
2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.
3. Be willing to ask for help.
4. Be aware of risks and countertransference in our work.
5. Attend workshops.
6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.
7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.
8. Schedule play.
9. Develop a healthy self-care regimen to remain present doing this work.
10. Consider the benefits of exercise.
11. Enjoy the beauty and wonder of nature.
12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.
13. Spend time with loving family and friends.
14. Adopt a pet.
15. Eat healthy foods; get plenty of rest.
16. Walk in the rain.
17. Listen to music.
18. Enjoy a relaxing bubble bath.
19. Sing, dance, and enjoy the blessings of this life.
20. Love yourself; you truly can be your own best friend.
To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.
While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.
Mental illness admissions: 18-44 is the age of prevalence
More mental and/or substance use disorders are ranked among the top-five diagnoses for hospitalized men and women aged 18-44 years than for any other age group, according to a recent report from the Agency for Healthcare Research and Quality.
aged 18-44, while depressive disorders were the third-most common (195.0 stays per 100,000) and alcohol-related disorders were fifth at 153.2 per 100,000, Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in an AHRQ statistical brief.
Prevalence was somewhat lower in women aged 18-44 years, with two mental illnesses appearing among the top five nonmaternal diagnoses: Depressive disorders were second at 222.5 stays per 100,000 and bipolar and related disorders were fourth at 142.0 per 100,000. The leading primary diagnosis in women in 2018 was septicemia, which was the most common cause overall in the age group at a rate of 279.3 per 100,000, the investigators reported.
There were no mental and/or substance use disorders in the top five primary diagnoses for any of the other adult age groups – 45-64, 65-74, and ≥75 – included in the report. Septicemia was the leading diagnosis for men in all three groups and for women in two of three (45-64 and ≥75), with osteoarthritis first among women aged 65-74 years, they said.
There was one mental illness among the top-five diagnoses for children under age 18 years, as depressive disorders were the most common reason for stays in girls (176.6 per 100,000 population) and the fifth most common for boys (74.0 per 100,000), said Dr. McDermott of IBM Watson Health and Mr. Roemer of AHRQ.
Septicemia was the leading nonmaternal, nonneonatal diagnosis for all inpatient stays and all ages in 2018 with a rate of 679.5 per 100,000, followed by heart failure (347.9), osteoarthritis (345.5), pneumonia not related to tuberculosis (226.8), and diabetes mellitus (207.8), based on data from the National Inpatient Sample.
Depressive disorders were most common mental health diagnosis in those admitted to hospitals and the 12th most common diagnosis overall; schizophrenia, in 16th place overall, was the only other mental illness among the top 20, the investigators said.
“This information can help establish national health priorities, initiatives, and action plans,” Dr. McDermott and Mr. Roemer wrote, and “at the hospital level, administrators can use diagnosis-related information to inform planning and resource allocation, such as optimizing subspecialty services or units for the care of high-priority conditions.”
More mental and/or substance use disorders are ranked among the top-five diagnoses for hospitalized men and women aged 18-44 years than for any other age group, according to a recent report from the Agency for Healthcare Research and Quality.
aged 18-44, while depressive disorders were the third-most common (195.0 stays per 100,000) and alcohol-related disorders were fifth at 153.2 per 100,000, Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in an AHRQ statistical brief.
Prevalence was somewhat lower in women aged 18-44 years, with two mental illnesses appearing among the top five nonmaternal diagnoses: Depressive disorders were second at 222.5 stays per 100,000 and bipolar and related disorders were fourth at 142.0 per 100,000. The leading primary diagnosis in women in 2018 was septicemia, which was the most common cause overall in the age group at a rate of 279.3 per 100,000, the investigators reported.
There were no mental and/or substance use disorders in the top five primary diagnoses for any of the other adult age groups – 45-64, 65-74, and ≥75 – included in the report. Septicemia was the leading diagnosis for men in all three groups and for women in two of three (45-64 and ≥75), with osteoarthritis first among women aged 65-74 years, they said.
There was one mental illness among the top-five diagnoses for children under age 18 years, as depressive disorders were the most common reason for stays in girls (176.6 per 100,000 population) and the fifth most common for boys (74.0 per 100,000), said Dr. McDermott of IBM Watson Health and Mr. Roemer of AHRQ.
Septicemia was the leading nonmaternal, nonneonatal diagnosis for all inpatient stays and all ages in 2018 with a rate of 679.5 per 100,000, followed by heart failure (347.9), osteoarthritis (345.5), pneumonia not related to tuberculosis (226.8), and diabetes mellitus (207.8), based on data from the National Inpatient Sample.
Depressive disorders were most common mental health diagnosis in those admitted to hospitals and the 12th most common diagnosis overall; schizophrenia, in 16th place overall, was the only other mental illness among the top 20, the investigators said.
“This information can help establish national health priorities, initiatives, and action plans,” Dr. McDermott and Mr. Roemer wrote, and “at the hospital level, administrators can use diagnosis-related information to inform planning and resource allocation, such as optimizing subspecialty services or units for the care of high-priority conditions.”
More mental and/or substance use disorders are ranked among the top-five diagnoses for hospitalized men and women aged 18-44 years than for any other age group, according to a recent report from the Agency for Healthcare Research and Quality.
aged 18-44, while depressive disorders were the third-most common (195.0 stays per 100,000) and alcohol-related disorders were fifth at 153.2 per 100,000, Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in an AHRQ statistical brief.
Prevalence was somewhat lower in women aged 18-44 years, with two mental illnesses appearing among the top five nonmaternal diagnoses: Depressive disorders were second at 222.5 stays per 100,000 and bipolar and related disorders were fourth at 142.0 per 100,000. The leading primary diagnosis in women in 2018 was septicemia, which was the most common cause overall in the age group at a rate of 279.3 per 100,000, the investigators reported.
There were no mental and/or substance use disorders in the top five primary diagnoses for any of the other adult age groups – 45-64, 65-74, and ≥75 – included in the report. Septicemia was the leading diagnosis for men in all three groups and for women in two of three (45-64 and ≥75), with osteoarthritis first among women aged 65-74 years, they said.
There was one mental illness among the top-five diagnoses for children under age 18 years, as depressive disorders were the most common reason for stays in girls (176.6 per 100,000 population) and the fifth most common for boys (74.0 per 100,000), said Dr. McDermott of IBM Watson Health and Mr. Roemer of AHRQ.
Septicemia was the leading nonmaternal, nonneonatal diagnosis for all inpatient stays and all ages in 2018 with a rate of 679.5 per 100,000, followed by heart failure (347.9), osteoarthritis (345.5), pneumonia not related to tuberculosis (226.8), and diabetes mellitus (207.8), based on data from the National Inpatient Sample.
Depressive disorders were most common mental health diagnosis in those admitted to hospitals and the 12th most common diagnosis overall; schizophrenia, in 16th place overall, was the only other mental illness among the top 20, the investigators said.
“This information can help establish national health priorities, initiatives, and action plans,” Dr. McDermott and Mr. Roemer wrote, and “at the hospital level, administrators can use diagnosis-related information to inform planning and resource allocation, such as optimizing subspecialty services or units for the care of high-priority conditions.”
Bronchitis the leader at putting children in the hospital
About 7% (99,000) of the 1.47 million nonmaternal, nonneonatal hospital stays in children aged 0-17 years involved a primary diagnosis of acute bronchitis in 2018, representing the leading cause of admissions in boys (154.7 stays per 100,000 population) and the second-leading diagnosis in girls (113.1 stays per 100,000), Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in a statistical brief.
Depressive disorders were the most common primary diagnosis in girls, with a rate of 176.7 stays per 100,000, and the second-leading diagnosis overall, although the rate was less than half that (74.0 per 100,000) in boys. Two other respiratory conditions, asthma and pneumonia, were among the top five for both girls and boys, as was epilepsy, they reported.
The combined rate for all diagnoses was slightly higher for boys, 2,051 per 100,000, compared with 1,922 for girls, they said based on data from the National Inpatient Sample.
“Identifying the most frequent primary conditions for which patients are admitted to the hospital is important to the implementation and improvement of health care delivery, quality initiatives, and health policy,” said Dr. McDermott of IBM Watson Health and Mr. Roemer of the AHRQ.
About 7% (99,000) of the 1.47 million nonmaternal, nonneonatal hospital stays in children aged 0-17 years involved a primary diagnosis of acute bronchitis in 2018, representing the leading cause of admissions in boys (154.7 stays per 100,000 population) and the second-leading diagnosis in girls (113.1 stays per 100,000), Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in a statistical brief.
Depressive disorders were the most common primary diagnosis in girls, with a rate of 176.7 stays per 100,000, and the second-leading diagnosis overall, although the rate was less than half that (74.0 per 100,000) in boys. Two other respiratory conditions, asthma and pneumonia, were among the top five for both girls and boys, as was epilepsy, they reported.
The combined rate for all diagnoses was slightly higher for boys, 2,051 per 100,000, compared with 1,922 for girls, they said based on data from the National Inpatient Sample.
“Identifying the most frequent primary conditions for which patients are admitted to the hospital is important to the implementation and improvement of health care delivery, quality initiatives, and health policy,” said Dr. McDermott of IBM Watson Health and Mr. Roemer of the AHRQ.
About 7% (99,000) of the 1.47 million nonmaternal, nonneonatal hospital stays in children aged 0-17 years involved a primary diagnosis of acute bronchitis in 2018, representing the leading cause of admissions in boys (154.7 stays per 100,000 population) and the second-leading diagnosis in girls (113.1 stays per 100,000), Kimberly W. McDermott, PhD, and Marc Roemer, MS, said in a statistical brief.
Depressive disorders were the most common primary diagnosis in girls, with a rate of 176.7 stays per 100,000, and the second-leading diagnosis overall, although the rate was less than half that (74.0 per 100,000) in boys. Two other respiratory conditions, asthma and pneumonia, were among the top five for both girls and boys, as was epilepsy, they reported.
The combined rate for all diagnoses was slightly higher for boys, 2,051 per 100,000, compared with 1,922 for girls, they said based on data from the National Inpatient Sample.
“Identifying the most frequent primary conditions for which patients are admitted to the hospital is important to the implementation and improvement of health care delivery, quality initiatives, and health policy,” said Dr. McDermott of IBM Watson Health and Mr. Roemer of the AHRQ.