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Ob.gyns. report high burnout prior to pandemic
Among ob.gyns. who reported burnout in the past year, 82% say they felt burned out before the advent of the coronavirus pandemic, according the Medscape Obstetrician & Gynecologist Lifestyle, Happiness, & Burnout Report.
The past year brought unusual challenges to physicians in all specialties in different ways.
“Whether on the front lines of treating COVID-19 patients, pivoting from in-person to virtual care, or even having to shutter their practices, physicians faced an onslaught of crises, while political tensions, social unrest, and environmental concerns probably affected their lives outside of medicine,” wrote Keith L. Martin and Mary Lyn Koval, both of Medscape Business of Medicine, in the introduction to the report.
Although more physicians said their burnout began prior to the pandemic, 81% of ob.gyns. reported that they were happy outside of work prior to the pandemic. However, those reporting happiness outside of work dropped to 57% after the pandemic started.
“One does not have to do a ‘deep dive’ to understand the top reasons reported for burnout,” said Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando, in an interview. “Many conversations I have with colleagues are about the frustration of learning and managing electronic health records, insurance reimbursements, and a work-life balance. In addition, more physician practices are being purchased by hospitals or private-equity networks [that are] reducing and/or eliminating the autonomy of physicians.
“While all [respondents] exhibited a dramatic decline in ‘happiness’ prepandemic, compared with our current situation, ob.gyns. were no exception,” he added.
Burnout and suicidal thoughts
Overall, 26% of ob.gyn. survey respondents reported being burned out, 6% reported being depressed, and 18% reported being both burned out and depressed. Of those who reported burnout, 52% said burnout had “a strong or severe impact on my life,” while 20% reported a moderate impact and 28% reported little or no impact.
More than half (56%) of ob.gyns. who reported either depression or burnout said they had not sought professional help, although 17% reported receiving professional care in the past.
The main reason given for not seeking professional help was that burnout and depressive symptoms were not severe enough to merit it, according to 50% of respondents who reported burnout or depression but were not seeking help. In addition, 43% said they were too busy to seek help, 36% said they could deal with their symptoms without professional help, and 24% said they did not want to risk disclosure of their symptoms.
The most common cause of burnout was an overload of bureaucratic tasks, reported by 52% of respondents, followed by “lack of respect from administrators/employers, colleagues, or staff” (43%), and insufficient compensation or reimbursement (39%).
Notably, 19% of ob.gyns. reported suicidal thoughts, and 1% said they had attempted suicide.
“The most concerning statistic from this survey was in reference to suicidal ideation,” said Dr. Trolice. “Approximately one in five ob.gyns. have contemplated suicide, compared with 4.8% of adults age 18 and older in the U.S. reporting in 2019.”
Dr. Trolice said he was not surprised that relatively few ob.gyns. sought help for mental health issues. “Physicians are very private and usually do not seek help from colleagues, presumably from hubris. While this is unfortunate, all hospitals and health care organization should implement regular assessments of physicians’ health to ensure optimal performance from a professional and personal basis.”
Balance and self-care
The top workplace concern, by a large margin, was for work-life balance, reported by 44% of respondents, followed by compensation (19%), combining work and parenting (18%), and relationships with staff and colleagues (8%).
Approximately one-third (36%) of the ob.gyn. respondents said they made time to focus on personal well-being, compared with 35% of physicians overall. Although only 13% reported exercising every day, a total of 69% exercised at least twice a week, similar to the 70% of physicians overall who reported exercising at least twice a week.
“Work-life balance is high on the list of concerns, but physicians are split 50/50 on whether they would accept a salary reduction to improve this aspect of their lives,” Dr. Trolice said.
“Social relationships are a proven value to mental health, yet nearly 50% of ob.gyns. who reported feeling burnout use isolationism as their coping skill, citing a lack of severity to require treatment,” he noted. Nevertheless, more than 80% of responders were married and described their relationship as “good or very good.”
Address burnout at individual and organizational levels
“Sadly, the findings are not surprising,” said Iris Krisha, MD, of Emory University, Atlanta, in an interview. “Burnout rates have been steadily increasing among physicians across all specialties.” Barriers to reducing burnout exist at the organizational and individual level, therefore strategies to reduce burnout should address individual and organizational solutions, Dr. Krishna emphasized. “At the organizational level, solutions may include developing manageable workloads, creating fair productivity targets, encouraging physician engagement in work structure, supporting flexible work schedules, and allowing for protected time for education and exercise. On the individual level, physicians can work to develop stress management strategies, engage in mindfulness and self-care.”
To reduce the burden of bureaucratic tasks, “health care organizations can work toward optimizing electronic medical records and hire staff to offload clerical work, and physicians can seek training in efficiency,” said Dr. Krishna. In addition, “health care organizations can reduce the stigma that may surround burnout or mental health issues, as well as promote a culture of wellness and resilience,” to help reduce and prevent burnout.
Find positivity and purpose
Improving the workplace experience so physicians feel engaged and in control as they navigate their many responsibilities may help reduce burnout, said Dr. Trolice. On the individual level, “finding your purpose to give you more meaning at work, discovering the power of hope to embrace optimism, and building friendships at work for greater engagement with others,” can help as well.
“In the face of adversity and setbacks, people in happier workplaces tend to be better at coping with and recovering from work pressure and at reconciling conflict,” Dr. Trolice emphasized. “The practice of medicine has dramatically changed for many physicians compared with the original expectations when they applied to medical school. Nevertheless, it behooves physician to adapt to 21st century medical care as they remind themselves of their purpose.”
The report included responses from 12,339 physicians across 29 specialties who completed a 10-minute online survey between Aug. 30 and Nov. 5, 2020. Participants were required to be practicing U.S. physicians.
Among ob.gyns. who reported burnout in the past year, 82% say they felt burned out before the advent of the coronavirus pandemic, according the Medscape Obstetrician & Gynecologist Lifestyle, Happiness, & Burnout Report.
The past year brought unusual challenges to physicians in all specialties in different ways.
“Whether on the front lines of treating COVID-19 patients, pivoting from in-person to virtual care, or even having to shutter their practices, physicians faced an onslaught of crises, while political tensions, social unrest, and environmental concerns probably affected their lives outside of medicine,” wrote Keith L. Martin and Mary Lyn Koval, both of Medscape Business of Medicine, in the introduction to the report.
Although more physicians said their burnout began prior to the pandemic, 81% of ob.gyns. reported that they were happy outside of work prior to the pandemic. However, those reporting happiness outside of work dropped to 57% after the pandemic started.
“One does not have to do a ‘deep dive’ to understand the top reasons reported for burnout,” said Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando, in an interview. “Many conversations I have with colleagues are about the frustration of learning and managing electronic health records, insurance reimbursements, and a work-life balance. In addition, more physician practices are being purchased by hospitals or private-equity networks [that are] reducing and/or eliminating the autonomy of physicians.
“While all [respondents] exhibited a dramatic decline in ‘happiness’ prepandemic, compared with our current situation, ob.gyns. were no exception,” he added.
Burnout and suicidal thoughts
Overall, 26% of ob.gyn. survey respondents reported being burned out, 6% reported being depressed, and 18% reported being both burned out and depressed. Of those who reported burnout, 52% said burnout had “a strong or severe impact on my life,” while 20% reported a moderate impact and 28% reported little or no impact.
More than half (56%) of ob.gyns. who reported either depression or burnout said they had not sought professional help, although 17% reported receiving professional care in the past.
The main reason given for not seeking professional help was that burnout and depressive symptoms were not severe enough to merit it, according to 50% of respondents who reported burnout or depression but were not seeking help. In addition, 43% said they were too busy to seek help, 36% said they could deal with their symptoms without professional help, and 24% said they did not want to risk disclosure of their symptoms.
The most common cause of burnout was an overload of bureaucratic tasks, reported by 52% of respondents, followed by “lack of respect from administrators/employers, colleagues, or staff” (43%), and insufficient compensation or reimbursement (39%).
Notably, 19% of ob.gyns. reported suicidal thoughts, and 1% said they had attempted suicide.
“The most concerning statistic from this survey was in reference to suicidal ideation,” said Dr. Trolice. “Approximately one in five ob.gyns. have contemplated suicide, compared with 4.8% of adults age 18 and older in the U.S. reporting in 2019.”
Dr. Trolice said he was not surprised that relatively few ob.gyns. sought help for mental health issues. “Physicians are very private and usually do not seek help from colleagues, presumably from hubris. While this is unfortunate, all hospitals and health care organization should implement regular assessments of physicians’ health to ensure optimal performance from a professional and personal basis.”
Balance and self-care
The top workplace concern, by a large margin, was for work-life balance, reported by 44% of respondents, followed by compensation (19%), combining work and parenting (18%), and relationships with staff and colleagues (8%).
Approximately one-third (36%) of the ob.gyn. respondents said they made time to focus on personal well-being, compared with 35% of physicians overall. Although only 13% reported exercising every day, a total of 69% exercised at least twice a week, similar to the 70% of physicians overall who reported exercising at least twice a week.
“Work-life balance is high on the list of concerns, but physicians are split 50/50 on whether they would accept a salary reduction to improve this aspect of their lives,” Dr. Trolice said.
“Social relationships are a proven value to mental health, yet nearly 50% of ob.gyns. who reported feeling burnout use isolationism as their coping skill, citing a lack of severity to require treatment,” he noted. Nevertheless, more than 80% of responders were married and described their relationship as “good or very good.”
Address burnout at individual and organizational levels
“Sadly, the findings are not surprising,” said Iris Krisha, MD, of Emory University, Atlanta, in an interview. “Burnout rates have been steadily increasing among physicians across all specialties.” Barriers to reducing burnout exist at the organizational and individual level, therefore strategies to reduce burnout should address individual and organizational solutions, Dr. Krishna emphasized. “At the organizational level, solutions may include developing manageable workloads, creating fair productivity targets, encouraging physician engagement in work structure, supporting flexible work schedules, and allowing for protected time for education and exercise. On the individual level, physicians can work to develop stress management strategies, engage in mindfulness and self-care.”
To reduce the burden of bureaucratic tasks, “health care organizations can work toward optimizing electronic medical records and hire staff to offload clerical work, and physicians can seek training in efficiency,” said Dr. Krishna. In addition, “health care organizations can reduce the stigma that may surround burnout or mental health issues, as well as promote a culture of wellness and resilience,” to help reduce and prevent burnout.
Find positivity and purpose
Improving the workplace experience so physicians feel engaged and in control as they navigate their many responsibilities may help reduce burnout, said Dr. Trolice. On the individual level, “finding your purpose to give you more meaning at work, discovering the power of hope to embrace optimism, and building friendships at work for greater engagement with others,” can help as well.
“In the face of adversity and setbacks, people in happier workplaces tend to be better at coping with and recovering from work pressure and at reconciling conflict,” Dr. Trolice emphasized. “The practice of medicine has dramatically changed for many physicians compared with the original expectations when they applied to medical school. Nevertheless, it behooves physician to adapt to 21st century medical care as they remind themselves of their purpose.”
The report included responses from 12,339 physicians across 29 specialties who completed a 10-minute online survey between Aug. 30 and Nov. 5, 2020. Participants were required to be practicing U.S. physicians.
Among ob.gyns. who reported burnout in the past year, 82% say they felt burned out before the advent of the coronavirus pandemic, according the Medscape Obstetrician & Gynecologist Lifestyle, Happiness, & Burnout Report.
The past year brought unusual challenges to physicians in all specialties in different ways.
“Whether on the front lines of treating COVID-19 patients, pivoting from in-person to virtual care, or even having to shutter their practices, physicians faced an onslaught of crises, while political tensions, social unrest, and environmental concerns probably affected their lives outside of medicine,” wrote Keith L. Martin and Mary Lyn Koval, both of Medscape Business of Medicine, in the introduction to the report.
Although more physicians said their burnout began prior to the pandemic, 81% of ob.gyns. reported that they were happy outside of work prior to the pandemic. However, those reporting happiness outside of work dropped to 57% after the pandemic started.
“One does not have to do a ‘deep dive’ to understand the top reasons reported for burnout,” said Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando, in an interview. “Many conversations I have with colleagues are about the frustration of learning and managing electronic health records, insurance reimbursements, and a work-life balance. In addition, more physician practices are being purchased by hospitals or private-equity networks [that are] reducing and/or eliminating the autonomy of physicians.
“While all [respondents] exhibited a dramatic decline in ‘happiness’ prepandemic, compared with our current situation, ob.gyns. were no exception,” he added.
Burnout and suicidal thoughts
Overall, 26% of ob.gyn. survey respondents reported being burned out, 6% reported being depressed, and 18% reported being both burned out and depressed. Of those who reported burnout, 52% said burnout had “a strong or severe impact on my life,” while 20% reported a moderate impact and 28% reported little or no impact.
More than half (56%) of ob.gyns. who reported either depression or burnout said they had not sought professional help, although 17% reported receiving professional care in the past.
The main reason given for not seeking professional help was that burnout and depressive symptoms were not severe enough to merit it, according to 50% of respondents who reported burnout or depression but were not seeking help. In addition, 43% said they were too busy to seek help, 36% said they could deal with their symptoms without professional help, and 24% said they did not want to risk disclosure of their symptoms.
The most common cause of burnout was an overload of bureaucratic tasks, reported by 52% of respondents, followed by “lack of respect from administrators/employers, colleagues, or staff” (43%), and insufficient compensation or reimbursement (39%).
Notably, 19% of ob.gyns. reported suicidal thoughts, and 1% said they had attempted suicide.
“The most concerning statistic from this survey was in reference to suicidal ideation,” said Dr. Trolice. “Approximately one in five ob.gyns. have contemplated suicide, compared with 4.8% of adults age 18 and older in the U.S. reporting in 2019.”
Dr. Trolice said he was not surprised that relatively few ob.gyns. sought help for mental health issues. “Physicians are very private and usually do not seek help from colleagues, presumably from hubris. While this is unfortunate, all hospitals and health care organization should implement regular assessments of physicians’ health to ensure optimal performance from a professional and personal basis.”
Balance and self-care
The top workplace concern, by a large margin, was for work-life balance, reported by 44% of respondents, followed by compensation (19%), combining work and parenting (18%), and relationships with staff and colleagues (8%).
Approximately one-third (36%) of the ob.gyn. respondents said they made time to focus on personal well-being, compared with 35% of physicians overall. Although only 13% reported exercising every day, a total of 69% exercised at least twice a week, similar to the 70% of physicians overall who reported exercising at least twice a week.
“Work-life balance is high on the list of concerns, but physicians are split 50/50 on whether they would accept a salary reduction to improve this aspect of their lives,” Dr. Trolice said.
“Social relationships are a proven value to mental health, yet nearly 50% of ob.gyns. who reported feeling burnout use isolationism as their coping skill, citing a lack of severity to require treatment,” he noted. Nevertheless, more than 80% of responders were married and described their relationship as “good or very good.”
Address burnout at individual and organizational levels
“Sadly, the findings are not surprising,” said Iris Krisha, MD, of Emory University, Atlanta, in an interview. “Burnout rates have been steadily increasing among physicians across all specialties.” Barriers to reducing burnout exist at the organizational and individual level, therefore strategies to reduce burnout should address individual and organizational solutions, Dr. Krishna emphasized. “At the organizational level, solutions may include developing manageable workloads, creating fair productivity targets, encouraging physician engagement in work structure, supporting flexible work schedules, and allowing for protected time for education and exercise. On the individual level, physicians can work to develop stress management strategies, engage in mindfulness and self-care.”
To reduce the burden of bureaucratic tasks, “health care organizations can work toward optimizing electronic medical records and hire staff to offload clerical work, and physicians can seek training in efficiency,” said Dr. Krishna. In addition, “health care organizations can reduce the stigma that may surround burnout or mental health issues, as well as promote a culture of wellness and resilience,” to help reduce and prevent burnout.
Find positivity and purpose
Improving the workplace experience so physicians feel engaged and in control as they navigate their many responsibilities may help reduce burnout, said Dr. Trolice. On the individual level, “finding your purpose to give you more meaning at work, discovering the power of hope to embrace optimism, and building friendships at work for greater engagement with others,” can help as well.
“In the face of adversity and setbacks, people in happier workplaces tend to be better at coping with and recovering from work pressure and at reconciling conflict,” Dr. Trolice emphasized. “The practice of medicine has dramatically changed for many physicians compared with the original expectations when they applied to medical school. Nevertheless, it behooves physician to adapt to 21st century medical care as they remind themselves of their purpose.”
The report included responses from 12,339 physicians across 29 specialties who completed a 10-minute online survey between Aug. 30 and Nov. 5, 2020. Participants were required to be practicing U.S. physicians.
Consider connections between depression, chronic medical comorbidities
For many adults, depression and chronic medical conditions are inextricably linked.
In fact, the prevalence of depression is 2-10 times higher among people with chronic medical conditions, particularly in people with chronic pain, where the prevalence reaches 40%-60%, according to Jonathan E. Alpert, MD, PhD.
“About 60% of adults over 65 have two or more chronic conditions, of which depression is the single most common comorbidity,” Dr. Alpert, chair of the department of psychiatry and behavioral sciences at the Montefiore Medical Center and Albert Einstein College of Medicine, both in New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Premorbid depression is a risk factor for a number of medical conditions, such as heart disease. We also know that medical illness is a risk factor for depression. Comorbid depression predicts poorer health outcomes, including disability, hospital readmission, and mortality. It is also associated with up to severalfold higher general medical costs.”
Despite the pervasive nature of depression on other medical conditions, a limited evidence base exists to guide clinicians on treatment approaches.
“Most major depressive disorder randomized clinical trials exclude individuals with active medical illness, but we do know that medical comorbidity is associated with poorer depression outcomes,” Dr. Alpert said. For example, the STAR*D trial found that people with major depressive disorder plus medical comorbidity had lower remission rates, compared with those who had MDD alone (P < .001), while a large analysis from University of Pittsburgh researchers found that people with medical comorbidities had higher depression recurrence rates.
An assessment of the relationship between medical conditions and depression should include thinking about the association between the medical illness itself and medications with depressive symptoms.
“Are the medications contributing to depressive symptoms?” he asked. “We also want to be thinking of the impact of medical illness and medications on antidepressant pharmacokinetics and pharmacodynamics. We also want to know about the evidence for antidepressant safety, tolerability, efficacy, and anticipated drug-drug interactions among individuals with the medical illness. You also want to enhance focus on treatment adherence and coordination of care.”
Nontraditional routes of antidepressant administration exist for patients who have difficulty swallowing pills. Food and Drug Administration–approved options include transdermal selegiline; intranasal esketamine; liquid forms of fluoxetine, escitalopram, paroxetine, nortriptyline, doxepin, imipramine, and lithium; and oral disintegrating tablet forms of mirtazapine and selegiline. As for non–FDA-approved forms of antidepressant administration, small studies or case reports have appeared in the medical literature regarding intravenous ketamine, citalopram, amitriptyline, mirtazapine, maprotiline, and lithium; intramuscular ketamine and amitriptyline; and rectal forms of antidepressants such as trazodone, amitriptyline, doxepin, fluoxetine, and lamotrigine.
“It’s good to keep in mind that, when you’re not able to use by mouth antidepressants or typical tablet forms of antidepressants, there are other options available,” said Dr. Alpert, who is also chair of the American Psychiatric Association’s Council on Research.
Metabolism of medications occurs primarily in the liver, he continued, but some metabolic enzymes also line the intestinal tract. The metabolism of a substrate may be inhibited or induced by other drugs.
“If someone is on drug A and we give drug B, and drug B is inhibiting the metabolism of drug A, there will be a very rapid impact – hours to just a few days,” Dr. Alpert said. “The substrate levels rise very quickly, so within hours or days of taking drug B, drug A levels can rise steeply.” On the other hand, if someone is on drug A and you give a drug B – which induces the enzymes that usually metabolize drug A – the impact will be gradual. “That’s because induction requires increased synthesis of the metabolic enzyme responsible for metabolizing drug A,” he said. “That happens over days to weeks.”
Medications that are potential inducers of metabolism include carbamazepine, phenobarbital, phenytoin, primidone, prednisone, ritonavir, rifampin, chronic alcohol use, chronic smoking, St. John’s wort, and consumption of large quantities of cruciferous vegetables and charbroiled meats.
On the other hand, potential inhibitors of metabolism include antifungals, macrolide antibiotics, fluoroquinolones, antiretrovirals, isoniazid, antimalarials, disulfiram, SSRIs, phenothiazines, valproic acid, nefazodone, duloxetine, bupropion, beta-blockers, acute alcohol use, cimetidine, quinidine, calcium channel blockers, grapefruit juice, propafenone, and amiodarone.
“When treating people with significant medical comorbidity, start low and go slow, but persevere,” Dr. Alpert advised. “We want to always think about the risk of treating versus the risk of not treating, or not treating actively enough. Often, people with comorbid medical illness require the same or even more assertive treatment with pharmacotherapy for their depression as people without medical illness. So, we don’t want to make the mistake of undertreating depression. We also want to anticipate and address challenges with adherence.”
He also recommended being mindful of the most salient side effects for a given condition, such as lowered seizure threshold or QT prolongation in populations with brain injury or with cardiovascular disease, and to leverage dual benefits when they might exist, such as using [selective norepinephrine reuptake inhibitors] for depression and pain or hot flashes, or bupropion for depression and smoking cessation, or mirtazapine, which is effective for nausea, cachexia, or insomnia, as well as depression itself.
“We want to collaborate closely and regularly with other treaters, sharing our notes and diagnostic impressions,” Dr. Alpert said. “We want to use all the tools in the box in addition to pharmacotherapy, thinking about psychotherapy, neuromodulation, and peer navigators. We want to strive for measurement-based care using rating scales when we can, to augment our treatment. And
Dr. Alpert reports having received speaker’s honoraria, consulting fees, and research support from numerous pharmaceutical companies.
For many adults, depression and chronic medical conditions are inextricably linked.
In fact, the prevalence of depression is 2-10 times higher among people with chronic medical conditions, particularly in people with chronic pain, where the prevalence reaches 40%-60%, according to Jonathan E. Alpert, MD, PhD.
“About 60% of adults over 65 have two or more chronic conditions, of which depression is the single most common comorbidity,” Dr. Alpert, chair of the department of psychiatry and behavioral sciences at the Montefiore Medical Center and Albert Einstein College of Medicine, both in New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Premorbid depression is a risk factor for a number of medical conditions, such as heart disease. We also know that medical illness is a risk factor for depression. Comorbid depression predicts poorer health outcomes, including disability, hospital readmission, and mortality. It is also associated with up to severalfold higher general medical costs.”
Despite the pervasive nature of depression on other medical conditions, a limited evidence base exists to guide clinicians on treatment approaches.
“Most major depressive disorder randomized clinical trials exclude individuals with active medical illness, but we do know that medical comorbidity is associated with poorer depression outcomes,” Dr. Alpert said. For example, the STAR*D trial found that people with major depressive disorder plus medical comorbidity had lower remission rates, compared with those who had MDD alone (P < .001), while a large analysis from University of Pittsburgh researchers found that people with medical comorbidities had higher depression recurrence rates.
An assessment of the relationship between medical conditions and depression should include thinking about the association between the medical illness itself and medications with depressive symptoms.
“Are the medications contributing to depressive symptoms?” he asked. “We also want to be thinking of the impact of medical illness and medications on antidepressant pharmacokinetics and pharmacodynamics. We also want to know about the evidence for antidepressant safety, tolerability, efficacy, and anticipated drug-drug interactions among individuals with the medical illness. You also want to enhance focus on treatment adherence and coordination of care.”
Nontraditional routes of antidepressant administration exist for patients who have difficulty swallowing pills. Food and Drug Administration–approved options include transdermal selegiline; intranasal esketamine; liquid forms of fluoxetine, escitalopram, paroxetine, nortriptyline, doxepin, imipramine, and lithium; and oral disintegrating tablet forms of mirtazapine and selegiline. As for non–FDA-approved forms of antidepressant administration, small studies or case reports have appeared in the medical literature regarding intravenous ketamine, citalopram, amitriptyline, mirtazapine, maprotiline, and lithium; intramuscular ketamine and amitriptyline; and rectal forms of antidepressants such as trazodone, amitriptyline, doxepin, fluoxetine, and lamotrigine.
“It’s good to keep in mind that, when you’re not able to use by mouth antidepressants or typical tablet forms of antidepressants, there are other options available,” said Dr. Alpert, who is also chair of the American Psychiatric Association’s Council on Research.
Metabolism of medications occurs primarily in the liver, he continued, but some metabolic enzymes also line the intestinal tract. The metabolism of a substrate may be inhibited or induced by other drugs.
“If someone is on drug A and we give drug B, and drug B is inhibiting the metabolism of drug A, there will be a very rapid impact – hours to just a few days,” Dr. Alpert said. “The substrate levels rise very quickly, so within hours or days of taking drug B, drug A levels can rise steeply.” On the other hand, if someone is on drug A and you give a drug B – which induces the enzymes that usually metabolize drug A – the impact will be gradual. “That’s because induction requires increased synthesis of the metabolic enzyme responsible for metabolizing drug A,” he said. “That happens over days to weeks.”
Medications that are potential inducers of metabolism include carbamazepine, phenobarbital, phenytoin, primidone, prednisone, ritonavir, rifampin, chronic alcohol use, chronic smoking, St. John’s wort, and consumption of large quantities of cruciferous vegetables and charbroiled meats.
On the other hand, potential inhibitors of metabolism include antifungals, macrolide antibiotics, fluoroquinolones, antiretrovirals, isoniazid, antimalarials, disulfiram, SSRIs, phenothiazines, valproic acid, nefazodone, duloxetine, bupropion, beta-blockers, acute alcohol use, cimetidine, quinidine, calcium channel blockers, grapefruit juice, propafenone, and amiodarone.
“When treating people with significant medical comorbidity, start low and go slow, but persevere,” Dr. Alpert advised. “We want to always think about the risk of treating versus the risk of not treating, or not treating actively enough. Often, people with comorbid medical illness require the same or even more assertive treatment with pharmacotherapy for their depression as people without medical illness. So, we don’t want to make the mistake of undertreating depression. We also want to anticipate and address challenges with adherence.”
He also recommended being mindful of the most salient side effects for a given condition, such as lowered seizure threshold or QT prolongation in populations with brain injury or with cardiovascular disease, and to leverage dual benefits when they might exist, such as using [selective norepinephrine reuptake inhibitors] for depression and pain or hot flashes, or bupropion for depression and smoking cessation, or mirtazapine, which is effective for nausea, cachexia, or insomnia, as well as depression itself.
“We want to collaborate closely and regularly with other treaters, sharing our notes and diagnostic impressions,” Dr. Alpert said. “We want to use all the tools in the box in addition to pharmacotherapy, thinking about psychotherapy, neuromodulation, and peer navigators. We want to strive for measurement-based care using rating scales when we can, to augment our treatment. And
Dr. Alpert reports having received speaker’s honoraria, consulting fees, and research support from numerous pharmaceutical companies.
For many adults, depression and chronic medical conditions are inextricably linked.
In fact, the prevalence of depression is 2-10 times higher among people with chronic medical conditions, particularly in people with chronic pain, where the prevalence reaches 40%-60%, according to Jonathan E. Alpert, MD, PhD.
“About 60% of adults over 65 have two or more chronic conditions, of which depression is the single most common comorbidity,” Dr. Alpert, chair of the department of psychiatry and behavioral sciences at the Montefiore Medical Center and Albert Einstein College of Medicine, both in New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association.
“Premorbid depression is a risk factor for a number of medical conditions, such as heart disease. We also know that medical illness is a risk factor for depression. Comorbid depression predicts poorer health outcomes, including disability, hospital readmission, and mortality. It is also associated with up to severalfold higher general medical costs.”
Despite the pervasive nature of depression on other medical conditions, a limited evidence base exists to guide clinicians on treatment approaches.
“Most major depressive disorder randomized clinical trials exclude individuals with active medical illness, but we do know that medical comorbidity is associated with poorer depression outcomes,” Dr. Alpert said. For example, the STAR*D trial found that people with major depressive disorder plus medical comorbidity had lower remission rates, compared with those who had MDD alone (P < .001), while a large analysis from University of Pittsburgh researchers found that people with medical comorbidities had higher depression recurrence rates.
An assessment of the relationship between medical conditions and depression should include thinking about the association between the medical illness itself and medications with depressive symptoms.
“Are the medications contributing to depressive symptoms?” he asked. “We also want to be thinking of the impact of medical illness and medications on antidepressant pharmacokinetics and pharmacodynamics. We also want to know about the evidence for antidepressant safety, tolerability, efficacy, and anticipated drug-drug interactions among individuals with the medical illness. You also want to enhance focus on treatment adherence and coordination of care.”
Nontraditional routes of antidepressant administration exist for patients who have difficulty swallowing pills. Food and Drug Administration–approved options include transdermal selegiline; intranasal esketamine; liquid forms of fluoxetine, escitalopram, paroxetine, nortriptyline, doxepin, imipramine, and lithium; and oral disintegrating tablet forms of mirtazapine and selegiline. As for non–FDA-approved forms of antidepressant administration, small studies or case reports have appeared in the medical literature regarding intravenous ketamine, citalopram, amitriptyline, mirtazapine, maprotiline, and lithium; intramuscular ketamine and amitriptyline; and rectal forms of antidepressants such as trazodone, amitriptyline, doxepin, fluoxetine, and lamotrigine.
“It’s good to keep in mind that, when you’re not able to use by mouth antidepressants or typical tablet forms of antidepressants, there are other options available,” said Dr. Alpert, who is also chair of the American Psychiatric Association’s Council on Research.
Metabolism of medications occurs primarily in the liver, he continued, but some metabolic enzymes also line the intestinal tract. The metabolism of a substrate may be inhibited or induced by other drugs.
“If someone is on drug A and we give drug B, and drug B is inhibiting the metabolism of drug A, there will be a very rapid impact – hours to just a few days,” Dr. Alpert said. “The substrate levels rise very quickly, so within hours or days of taking drug B, drug A levels can rise steeply.” On the other hand, if someone is on drug A and you give a drug B – which induces the enzymes that usually metabolize drug A – the impact will be gradual. “That’s because induction requires increased synthesis of the metabolic enzyme responsible for metabolizing drug A,” he said. “That happens over days to weeks.”
Medications that are potential inducers of metabolism include carbamazepine, phenobarbital, phenytoin, primidone, prednisone, ritonavir, rifampin, chronic alcohol use, chronic smoking, St. John’s wort, and consumption of large quantities of cruciferous vegetables and charbroiled meats.
On the other hand, potential inhibitors of metabolism include antifungals, macrolide antibiotics, fluoroquinolones, antiretrovirals, isoniazid, antimalarials, disulfiram, SSRIs, phenothiazines, valproic acid, nefazodone, duloxetine, bupropion, beta-blockers, acute alcohol use, cimetidine, quinidine, calcium channel blockers, grapefruit juice, propafenone, and amiodarone.
“When treating people with significant medical comorbidity, start low and go slow, but persevere,” Dr. Alpert advised. “We want to always think about the risk of treating versus the risk of not treating, or not treating actively enough. Often, people with comorbid medical illness require the same or even more assertive treatment with pharmacotherapy for their depression as people without medical illness. So, we don’t want to make the mistake of undertreating depression. We also want to anticipate and address challenges with adherence.”
He also recommended being mindful of the most salient side effects for a given condition, such as lowered seizure threshold or QT prolongation in populations with brain injury or with cardiovascular disease, and to leverage dual benefits when they might exist, such as using [selective norepinephrine reuptake inhibitors] for depression and pain or hot flashes, or bupropion for depression and smoking cessation, or mirtazapine, which is effective for nausea, cachexia, or insomnia, as well as depression itself.
“We want to collaborate closely and regularly with other treaters, sharing our notes and diagnostic impressions,” Dr. Alpert said. “We want to use all the tools in the box in addition to pharmacotherapy, thinking about psychotherapy, neuromodulation, and peer navigators. We want to strive for measurement-based care using rating scales when we can, to augment our treatment. And
Dr. Alpert reports having received speaker’s honoraria, consulting fees, and research support from numerous pharmaceutical companies.
FROM NPA 2021
Screening tool may help better predict suicide attempts in adolescents
Researchers have developed a proprietary computer adaptive screening tool that may help emergency departments more accurately predict suicide attempts in adolescents, according to a recent study in JAMA Psychiatry.
The computerized adaptive screen for suicidal youth (CASSY) had an area under the curve (AUC) of 0.87 in an independent validation cohort that predicted an adolescent suicide attempt within 3 months, according to Cheryl A. King, PhD, of the department of psychiatry at the University of Michigan in Ann Arbor, and colleagues. CASSY’s adaptive design, which presents different questions based on a respondent’s answers, means “an individual’s initial item responses are used to determine a provisional estimate of their standing on the measured trait,” the researchers said.
Dr. King and colleagues evaluated the CASSY algorithm in a first study that consisted of 2,845 adolescents who were mean 15.1 years old, mostly girls (63%) enrolled from 13 different emergency departments across the United States within the Pediatric Emergency Care Applied Research Network (PECARN) between June 2015 and July 2016. To develop the CASSY algorithm, the participants received a 92-item self-report survey at baseline with three “anchor” questions from the Ask Suicide-Screening Questions (ASQ) and Columbia–Suicide Severity Rating Scale (C-SSRS). Based on the answers to the baseline survey, the researchers categorized participants as being at low, medium, or high risk for a suicide attempt, and followed participants for 3 months to record suicide attempts reported by a patient or parent.
Retention of participants at 3 months was 72.9%, leaving data available for 2,075 adolescents for review. The researchers found that the AUC was 0.89 (95% confidence interval, 0.85-0.91) in the first study, with a sensitivity of 82.4% and a specificity of 80%. Participants answered a mean number of 11 items during an assessment (range, 5-21 items) administered in a median time of 1 minute, 24 seconds.
In a second study consisting of a validation cohort, 4,050 adolescents from 14 PECARN emergency departments and 1 Indian Health Service hospital were followed, with a retention of 2,754 participants (69.5%) at the end of 3 months. Of the adolescents available at the end of 3 months, 62.1% were girls with a mean age of 15.0 years. The AUC for this validation group was 0.87 (95% CI, 0.85-0.89). Of these participants, 71.5% reported no previous suicide attempts, 9% reported one prior attempt, 18.2% reported multiple attempts, and 1.2% had an unknown number of suicide attempts. During the 3-month window of the second study, 6.0% of participants had at least one suicide attempt.
The researchers said that while the CASSY instrument may be advantageous for some emergency departments, “a standard screen such as the ASQ, which consists of fewer items, may be preferred in some settings, particularly those in which the cost and technical setup of a computerized adaptive screen poses too high a barrier.”
Dr. King and colleagues concluded.
Climbing adolescent suicide rate
In an interview, Igor Galynker, MD, PhD, professor in the department of psychiatry, and director of the suicide lab and the Zirinsky Center for Bipolar Disorder at the Icahn School of Medicine at Mount Sinai, New York, said the study by Dr. King and colleagues is important during a time when the suicide rate for adolescents is substantially increasing.
According to data from the CDC’s Web-based Injury Statistics Query and Reporting System, 1,750 adolescents died of suicide in 2018, and the rate of deaths by suicide has increased by 62% since the year 2000. “The issue really needs to be addressed,” said Dr. Galynker, who was not involved with the study.
Some methods of screening suicidal ideation that open with a direct question can miss suicide attempts in individuals who do not express these suicidal ideations, he explained, and the problem can be magnified in adolescent patients. “This is particularly difficult with adolescents because they’re notoriously poor historians. They cannot describe their feelings as well. It’s even more important to have methods that work for suicide prevention for adolescents and to support those predictors which do not rely on self-report,” he said.
Dr. Galynker said that CASSY is innovative because asking whether the patient is suicidal is not the “gateway question” and does not categorize people into groups determined to be at low, medium, or high risk for a suicide attempt.
“When you categorize people – adolescents in this particular case – you remove clinical judgment from [the] clinician. You deprive [the] clinician of exercising their clinical judgment in terms of somebody is or is not likely to die by suicide. That’s a serious problem,” he said, noting it may be one reason why these screening tools have difficulty identifying patients at risk of suicide.
Regarding limitations, the 3-month follow-up window for patients in the study may be too long to be clinically meaningful.
“If somebody is in treatment, 3 months is a long time. You want to know whether somebody is going to attempt suicide before the next time you see them, which is usually a month or a week,” he said.
But a strength of the CASSY instrument, Dr. Galynker said, is its ability to capture the patient’s mental state in the moment, as opposed to relying only a patient’s electronic medical record. The study also demonstrates “it should be possible to introduce detailed suicide risk assessment in the emergency rooms, and [it] should be done,” he said.
This study was funded with support from the Health Resources and Services Administration, the Maternal and Child Health Bureau, and the Emergency Medical Services for Children Network Development Demonstration Program, and a grant by the National Institute of Mental Health for the Emergency Department Screen for Teens at Risk for Suicide. Twelve authors reported personal and institutional relationships in the form of fees, grants, consultancies, royalties, copyrighted work, founding of technologies, and scientific council memberships for a variety of agencies, societies, foundations, and other organizations inside and outside of the study. Dr. Galynker reported his work unrelated to the study is supported by the National Institute of Mental Health and the American Foundation for Suicide Prevention. But he has no proprietary interests.
Researchers have developed a proprietary computer adaptive screening tool that may help emergency departments more accurately predict suicide attempts in adolescents, according to a recent study in JAMA Psychiatry.
The computerized adaptive screen for suicidal youth (CASSY) had an area under the curve (AUC) of 0.87 in an independent validation cohort that predicted an adolescent suicide attempt within 3 months, according to Cheryl A. King, PhD, of the department of psychiatry at the University of Michigan in Ann Arbor, and colleagues. CASSY’s adaptive design, which presents different questions based on a respondent’s answers, means “an individual’s initial item responses are used to determine a provisional estimate of their standing on the measured trait,” the researchers said.
Dr. King and colleagues evaluated the CASSY algorithm in a first study that consisted of 2,845 adolescents who were mean 15.1 years old, mostly girls (63%) enrolled from 13 different emergency departments across the United States within the Pediatric Emergency Care Applied Research Network (PECARN) between June 2015 and July 2016. To develop the CASSY algorithm, the participants received a 92-item self-report survey at baseline with three “anchor” questions from the Ask Suicide-Screening Questions (ASQ) and Columbia–Suicide Severity Rating Scale (C-SSRS). Based on the answers to the baseline survey, the researchers categorized participants as being at low, medium, or high risk for a suicide attempt, and followed participants for 3 months to record suicide attempts reported by a patient or parent.
Retention of participants at 3 months was 72.9%, leaving data available for 2,075 adolescents for review. The researchers found that the AUC was 0.89 (95% confidence interval, 0.85-0.91) in the first study, with a sensitivity of 82.4% and a specificity of 80%. Participants answered a mean number of 11 items during an assessment (range, 5-21 items) administered in a median time of 1 minute, 24 seconds.
In a second study consisting of a validation cohort, 4,050 adolescents from 14 PECARN emergency departments and 1 Indian Health Service hospital were followed, with a retention of 2,754 participants (69.5%) at the end of 3 months. Of the adolescents available at the end of 3 months, 62.1% were girls with a mean age of 15.0 years. The AUC for this validation group was 0.87 (95% CI, 0.85-0.89). Of these participants, 71.5% reported no previous suicide attempts, 9% reported one prior attempt, 18.2% reported multiple attempts, and 1.2% had an unknown number of suicide attempts. During the 3-month window of the second study, 6.0% of participants had at least one suicide attempt.
The researchers said that while the CASSY instrument may be advantageous for some emergency departments, “a standard screen such as the ASQ, which consists of fewer items, may be preferred in some settings, particularly those in which the cost and technical setup of a computerized adaptive screen poses too high a barrier.”
Dr. King and colleagues concluded.
Climbing adolescent suicide rate
In an interview, Igor Galynker, MD, PhD, professor in the department of psychiatry, and director of the suicide lab and the Zirinsky Center for Bipolar Disorder at the Icahn School of Medicine at Mount Sinai, New York, said the study by Dr. King and colleagues is important during a time when the suicide rate for adolescents is substantially increasing.
According to data from the CDC’s Web-based Injury Statistics Query and Reporting System, 1,750 adolescents died of suicide in 2018, and the rate of deaths by suicide has increased by 62% since the year 2000. “The issue really needs to be addressed,” said Dr. Galynker, who was not involved with the study.
Some methods of screening suicidal ideation that open with a direct question can miss suicide attempts in individuals who do not express these suicidal ideations, he explained, and the problem can be magnified in adolescent patients. “This is particularly difficult with adolescents because they’re notoriously poor historians. They cannot describe their feelings as well. It’s even more important to have methods that work for suicide prevention for adolescents and to support those predictors which do not rely on self-report,” he said.
Dr. Galynker said that CASSY is innovative because asking whether the patient is suicidal is not the “gateway question” and does not categorize people into groups determined to be at low, medium, or high risk for a suicide attempt.
“When you categorize people – adolescents in this particular case – you remove clinical judgment from [the] clinician. You deprive [the] clinician of exercising their clinical judgment in terms of somebody is or is not likely to die by suicide. That’s a serious problem,” he said, noting it may be one reason why these screening tools have difficulty identifying patients at risk of suicide.
Regarding limitations, the 3-month follow-up window for patients in the study may be too long to be clinically meaningful.
“If somebody is in treatment, 3 months is a long time. You want to know whether somebody is going to attempt suicide before the next time you see them, which is usually a month or a week,” he said.
But a strength of the CASSY instrument, Dr. Galynker said, is its ability to capture the patient’s mental state in the moment, as opposed to relying only a patient’s electronic medical record. The study also demonstrates “it should be possible to introduce detailed suicide risk assessment in the emergency rooms, and [it] should be done,” he said.
This study was funded with support from the Health Resources and Services Administration, the Maternal and Child Health Bureau, and the Emergency Medical Services for Children Network Development Demonstration Program, and a grant by the National Institute of Mental Health for the Emergency Department Screen for Teens at Risk for Suicide. Twelve authors reported personal and institutional relationships in the form of fees, grants, consultancies, royalties, copyrighted work, founding of technologies, and scientific council memberships for a variety of agencies, societies, foundations, and other organizations inside and outside of the study. Dr. Galynker reported his work unrelated to the study is supported by the National Institute of Mental Health and the American Foundation for Suicide Prevention. But he has no proprietary interests.
Researchers have developed a proprietary computer adaptive screening tool that may help emergency departments more accurately predict suicide attempts in adolescents, according to a recent study in JAMA Psychiatry.
The computerized adaptive screen for suicidal youth (CASSY) had an area under the curve (AUC) of 0.87 in an independent validation cohort that predicted an adolescent suicide attempt within 3 months, according to Cheryl A. King, PhD, of the department of psychiatry at the University of Michigan in Ann Arbor, and colleagues. CASSY’s adaptive design, which presents different questions based on a respondent’s answers, means “an individual’s initial item responses are used to determine a provisional estimate of their standing on the measured trait,” the researchers said.
Dr. King and colleagues evaluated the CASSY algorithm in a first study that consisted of 2,845 adolescents who were mean 15.1 years old, mostly girls (63%) enrolled from 13 different emergency departments across the United States within the Pediatric Emergency Care Applied Research Network (PECARN) between June 2015 and July 2016. To develop the CASSY algorithm, the participants received a 92-item self-report survey at baseline with three “anchor” questions from the Ask Suicide-Screening Questions (ASQ) and Columbia–Suicide Severity Rating Scale (C-SSRS). Based on the answers to the baseline survey, the researchers categorized participants as being at low, medium, or high risk for a suicide attempt, and followed participants for 3 months to record suicide attempts reported by a patient or parent.
Retention of participants at 3 months was 72.9%, leaving data available for 2,075 adolescents for review. The researchers found that the AUC was 0.89 (95% confidence interval, 0.85-0.91) in the first study, with a sensitivity of 82.4% and a specificity of 80%. Participants answered a mean number of 11 items during an assessment (range, 5-21 items) administered in a median time of 1 minute, 24 seconds.
In a second study consisting of a validation cohort, 4,050 adolescents from 14 PECARN emergency departments and 1 Indian Health Service hospital were followed, with a retention of 2,754 participants (69.5%) at the end of 3 months. Of the adolescents available at the end of 3 months, 62.1% were girls with a mean age of 15.0 years. The AUC for this validation group was 0.87 (95% CI, 0.85-0.89). Of these participants, 71.5% reported no previous suicide attempts, 9% reported one prior attempt, 18.2% reported multiple attempts, and 1.2% had an unknown number of suicide attempts. During the 3-month window of the second study, 6.0% of participants had at least one suicide attempt.
The researchers said that while the CASSY instrument may be advantageous for some emergency departments, “a standard screen such as the ASQ, which consists of fewer items, may be preferred in some settings, particularly those in which the cost and technical setup of a computerized adaptive screen poses too high a barrier.”
Dr. King and colleagues concluded.
Climbing adolescent suicide rate
In an interview, Igor Galynker, MD, PhD, professor in the department of psychiatry, and director of the suicide lab and the Zirinsky Center for Bipolar Disorder at the Icahn School of Medicine at Mount Sinai, New York, said the study by Dr. King and colleagues is important during a time when the suicide rate for adolescents is substantially increasing.
According to data from the CDC’s Web-based Injury Statistics Query and Reporting System, 1,750 adolescents died of suicide in 2018, and the rate of deaths by suicide has increased by 62% since the year 2000. “The issue really needs to be addressed,” said Dr. Galynker, who was not involved with the study.
Some methods of screening suicidal ideation that open with a direct question can miss suicide attempts in individuals who do not express these suicidal ideations, he explained, and the problem can be magnified in adolescent patients. “This is particularly difficult with adolescents because they’re notoriously poor historians. They cannot describe their feelings as well. It’s even more important to have methods that work for suicide prevention for adolescents and to support those predictors which do not rely on self-report,” he said.
Dr. Galynker said that CASSY is innovative because asking whether the patient is suicidal is not the “gateway question” and does not categorize people into groups determined to be at low, medium, or high risk for a suicide attempt.
“When you categorize people – adolescents in this particular case – you remove clinical judgment from [the] clinician. You deprive [the] clinician of exercising their clinical judgment in terms of somebody is or is not likely to die by suicide. That’s a serious problem,” he said, noting it may be one reason why these screening tools have difficulty identifying patients at risk of suicide.
Regarding limitations, the 3-month follow-up window for patients in the study may be too long to be clinically meaningful.
“If somebody is in treatment, 3 months is a long time. You want to know whether somebody is going to attempt suicide before the next time you see them, which is usually a month or a week,” he said.
But a strength of the CASSY instrument, Dr. Galynker said, is its ability to capture the patient’s mental state in the moment, as opposed to relying only a patient’s electronic medical record. The study also demonstrates “it should be possible to introduce detailed suicide risk assessment in the emergency rooms, and [it] should be done,” he said.
This study was funded with support from the Health Resources and Services Administration, the Maternal and Child Health Bureau, and the Emergency Medical Services for Children Network Development Demonstration Program, and a grant by the National Institute of Mental Health for the Emergency Department Screen for Teens at Risk for Suicide. Twelve authors reported personal and institutional relationships in the form of fees, grants, consultancies, royalties, copyrighted work, founding of technologies, and scientific council memberships for a variety of agencies, societies, foundations, and other organizations inside and outside of the study. Dr. Galynker reported his work unrelated to the study is supported by the National Institute of Mental Health and the American Foundation for Suicide Prevention. But he has no proprietary interests.
FROM JAMA PSYCHIATRY
Being in the now
Mindfulness as an intervention in challenging, changing, and uncertain times
The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.
As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.
The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment
It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.
Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.
Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
The how of mindfulness: Symptom management and changes in the brain
Research on mindfulness suggests that it can improve coping with anxiety,1 regulate mood,2 improve depression,3 reduce rumination,4 and mitigate trauma symptom severity.
Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,5 depression, and posttraumatic stress disorder.6 Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation7 and change the regions related to awareness and fear.8 So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
The how of mindfulness: In everyday life and treatment
How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.
And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,9 and that clinicians who practice mindfulness report higher levels of empathy toward their clients.10 Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. , perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.
It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.11 And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.
Calm, clarity, and choices
None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.
References
1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.
2. Remmers C et al. Mindfulness. 2016;7(4):829-37.
3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.
4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.
5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.
6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.
7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.
8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.
9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.
10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.
11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.
Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.
Mindfulness as an intervention in challenging, changing, and uncertain times
Mindfulness as an intervention in challenging, changing, and uncertain times
The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.
As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.
The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment
It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.
Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.
Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
The how of mindfulness: Symptom management and changes in the brain
Research on mindfulness suggests that it can improve coping with anxiety,1 regulate mood,2 improve depression,3 reduce rumination,4 and mitigate trauma symptom severity.
Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,5 depression, and posttraumatic stress disorder.6 Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation7 and change the regions related to awareness and fear.8 So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
The how of mindfulness: In everyday life and treatment
How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.
And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,9 and that clinicians who practice mindfulness report higher levels of empathy toward their clients.10 Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. , perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.
It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.11 And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.
Calm, clarity, and choices
None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.
References
1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.
2. Remmers C et al. Mindfulness. 2016;7(4):829-37.
3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.
4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.
5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.
6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.
7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.
8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.
9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.
10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.
11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.
Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.
The COVID-19 pandemic, multiple national displays of racial and social injustice, and recent political strife have left many feeling uncertain, anxious, sad, angry, grief-stricken, and struggling to cope. Coping may be especially difficult for our clients already grappling with mental health concerns, and many are looking to mental health professionals to restore a sense of well-being.
As professionals, we may be unsure about the best approach; after all, we haven’t experienced anything like this before! We’re facing many unknowns and unanswered questions, but one thing we do know is that we’re dealing with constant change. And, in fact, the only certainty is continued change and uncertainty. The truth of uncertainty can be challenging to contend with, especially when so much, including our country’s future, is in question. In times like this, there is likely no perfect treatment, but mindfulness can serve as a powerful intervention for coping with uncertainty and change, and for managing a range of difficult reactions.
The ‘what’ of mindfulness: Awareness, being in the now, and nonattachment
It’s crucial that we understand what mindfulness really is. It’s become something of a buzzword in American society, complete with misconceptions. Mindfulness has roots in many faith traditions, but as it’s practiced in the Western world, it usually has roots in Hinduism and Buddhism.
Mindfulness roughly means “awareness”; this is an approximate translation of the Pali (an ancient Indian language) word “Sati.” Mindfulness is moment-to-moment awareness and acceptance of our present experiences, thoughts, and feelings, without judgment or attachment. Attachment relates to the continually changing nature of all thoughts, feelings, and situations. Because everything is continuously changing, we needn’t become attached; attachment can keep us from being in the now. Acceptance means facing the now, which is essential when we feel tempted to avoid or deny painful feelings or situations. Acceptance doesn’t mean that we’ve resigned to being in pain forever; it merely means that we’re willing to see things as they actually are right now. This honest assessment of the present can prepare us for next steps.
Being in touch with the now helps us reconnect with ourselves, promote clarity about our situation and choices, and increases our awareness of our thoughts and feelings, moment to moment. It can also help us realize when we’ve fallen into unhelpful or catastrophic thinking, the risk of which is high during intense stress and uncertainty like what we’re facing now. Mindfulness helps us catch ourselves so we have the opportunity to make different choices, and feel better.
The how of mindfulness: Symptom management and changes in the brain
Research on mindfulness suggests that it can improve coping with anxiety,1 regulate mood,2 improve depression,3 reduce rumination,4 and mitigate trauma symptom severity.
Because mindfulness can effectively address psychiatric concerns, mindfulness-based clinical interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy have been developed. These may reduce anxiety,5 depression, and posttraumatic stress disorder.6 Mindfulness can have a powerful impact on the brain; it’s been shown to improve the functioning of the regions associated with emotional regulation7 and change the regions related to awareness and fear.8 So, whether mindfulness is practiced in our clients’ everyday lives or used as the basis of therapeutic programs, it can promote well-being.
The how of mindfulness: In everyday life and treatment
How can we help our clients enjoy mindfulness’ benefits? I suggest that we start with ourselves. We’ll be more effective at guiding our clients in using mindfulness if we have our own experience.
And, mindfulness may help us to be more attentive to and effective in treatment. There is research demonstrating that treatment providers can benefit from mindfulness practices,9 and that clinicians who practice mindfulness report higher levels of empathy toward their clients.10 Because mindfulness is about attention and nonjudgmental and nonattached observation, it can be incorporated into many aspects of everyday life. Many options are available; we might encourage our clients to begin their day with a mindful pause, simply breathing and observing thoughts, feelings, sensations, or anything else that comes up. If they find themselves fixated on negative thinking or feelings, nonjudgmentally recognizing these experiences as temporary can help to prevent immersion and overwhelm. , perhaps during tasks such as housekeeping, working, talking with others, exercising, and even eating.
It can be beneficial to practice mindfulness before, during, and after situations that our clients know may bring on increased stress, anxiety, negative mood, and other undesirable experiences, such as watching the news or using some forms of social media. For clients who want more structure or guidance, several mobile apps are available, such as InsightTimer, Ten Percent Happier, or for Black clients, Liberate, which may be especially helpful for the impacts of racial injustice. Apps may also help clients who want to establish a formal mindfulness meditation practice, which may decrease anxiety and depression in some clinical populations.11 And, of course, with training, we can incorporate mindfulness into treatment. We may encourage clients to start our treatment or therapy sessions with a mindful pause to help them attain calm and focus, and depending on their concerns and needs, during times at which they feel particularly strong emotions. Clients may consider taking a Mindfulness-Based Stress Reduction course if something more intensive is needed, or clinicians may consider becoming trained in mindfulness-based cognitive therapy. Because recognition is increasing that mindfulness can address many clinical concerns, and because we’re contending with unprecedented challenges, mindfulness training for clinicians has become widely available.
Calm, clarity, and choices
None of us as individuals can eliminate the strife our country is living through, and none of us as clinicians can completely prevent or alleviate our clients’ pain. But by employing mindfulness, we can help clients cope with change and uncertainty, gain greater awareness of themselves and their experiences, feel calmer, attain more clarity to make better choices, and ultimately, feel better.
References
1. Bernstein A et al. J Cogn Psychother. 2011;25(2):99-113.
2. Remmers C et al. Mindfulness. 2016;7(4):829-37.
3. Rodrigues MF et al. Trends Psychiatry Psychother. Jul-Sep 2017;39(3):207-15.
4. Chambers R et al. Cogn Ther Res. 2008;32(3):303-22.
5. Montero-Marin et al. Psychol Med. 2019 Oct;49(13)2118-33.
6. Khusid MA, Vythilingam M. Mil Med. 2016 Sep;181(9):961-8.
7. Kral TRA et al. Neuroimage. 2018 Nov 1;181:301-13.
8. Desbordes G et al. Front Hum Neurosci. 2012 Nov 1. doi: 10.33891/fnhum.2012.00292.
9. Escuriex BF, Labbé EE. Mindfulness. 2011;2(4):242-53.
10. Aiken GA. Dissertation Abstracts Int Sec B: Sci Eng. 2006;67(4-B),2212.
11. Goyal M et al. JAMA Intern Med. 2014 Mar;174:357-68.
Dr. Collins is a Brooklyn-based licensed counseling psychologist, educator, and speaker. She is experienced in addressing a wide range of mental health concerns within youth, adult, and family populations. Her work has a strong social justice emphasis, and she is particularly skilled at working with clients of color. She has been a mindfulness practitioner for 10 years and is passionate about sharing the practice with others. Dr. Collins has no conflicts of interest.
COVID cuts internists’ happiness in life outside work
Before the pandemic, a large majority of internists reported that they were generally happy with life outside of work, although by specialty, they were near the bottom in happiness.
But this year’s Medscape Internist Lifestyle, Happiness & Burnout Report 2021 shows a sharp drop, with just 55% of respondents saying they are somewhat or very happy in life outside work, compared with 78% last year.
Internists were not alone among the more than 12,000 physicians who responded to the survey. The contrast from last year’s report was clear for physicians in general and reflects COVID-19’s substantial toll on clinicians.
Just 58% of physicians overall reported happy lives outside work, down from 82% last year.
Perhaps not surprising, given the particular demands on certain specialties, physicians in infectious disease were the least happy, at 45%, followed by pulmonologists (47%) and rheumatologists and intensivists, at 49%.
The highest happiness level was reported by those in diabetes and endocrinology, at 73% this year, but that proportion was also substantially lower than the 89% from last year.
Burnout has ‘strong impact on lives’
The percentage of internists who reported burnout or depression, however, has stayed fairly consistent.
More than half (52%) said that burnout had a strong or severe impact on their lives, and nearly 1 in 10 said it was severe enough that they are considering leaving medicine.
One percent of the internists who responded to the survey said they had attempted suicide, and 12% said they had thoughts of suicide but had not attempted it.
Most of those reporting burnout (82%) said it started before the COVID-19 pandemic, but 18% said it began with the pandemic.
Notably, though, physicians ranked problems related to stress from COVID-19 near the bottom among burnout drivers. The top factor, by far, again, was “too many bureaucratic tasks.”
A large majority (78%) of internists work online for up to 10 hours a week, a number that could grow as telemedicine grows.
Exercise is top coping method
Responses gave a peek into how physicians are coping with burnout. Among internists, 49% put exercise at the top. Isolating themselves from others was the next most popular choice, at 45%. Eating junk food and drinking alcohol were further down the list, at 34% and 24%, respectively.
Few internists said they drink alcohol daily, a finding consistent with past years. In fact, 29% said they don’t drink at all, and 26% said they have fewer than one alcoholic drink per week. Only 7% said they had seven or more drinks per week.
The National Institute on Alcohol Abuse and Alcoholism advises that men not have more than 14 alcoholic drinks per week and that women not have more than 7.
Work-life balance topped list of concerns
By far, internists said work-life balance was their top workplace concern. Nearly half (48%) chose that answer, more than twice the percentage who said compensation was the biggest concern (21%).
Asked whether they would take a salary cut for more work-life balance, a similar proportion (46%) said yes.
Forty-three percent of internists manage to take 3-4 weeks of vacation, and 10% take at least 5 weeks, similar to reported vacation time in last year’s survey.
The vast majority are in committed relationships, with 79% reporting that they are married, and 5% reporting that they are living with a partner. Of those who are married, 48% described the marriage as very good; 32%, good; 16%, fair; 2%, poor; and 1%, very poor; 1% preferred not to answer.
One in five internists said their spouse was a physician, and 24% said their spouse worked in the health care field but not as a physician.
Pandemic has increased burnout
Douglas S. Paauw, MD, and Eileen Barrett, MD, two members of the Internal Medicine News editorial advisory board, said they were not surprised by the survey findings.
“There is more burnout since the pandemic,” said Dr. Paauw, professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and third-year medical student clerkship director at the University of Washington. “People may be working more hours, higher stress, but also, some may be working less hours, are socially isolated, taking on a new role of helping their kids in virtual education, andn living in cramped quarters with family that they may not be accustomed to spending so much time with.”
“Also, most physicians love travel, to detress, get back in balance, and that has by and large been taken away by the pandemic,” Dr. Paauw noted. “Unfortunately, bureaucracy did not go away during the pandemic!
Dr. Barrett, an internal medicine hospitalist, said, “It is most concerning to me today that 12% have had thoughts of suicide, and yet 39% are too busy to seek care for depression or burnout, and 17% aren’t seeking due to fear it will be disclosed,”
“Credentialing, medical license applications, and malpractice insurance applications can and must be changed posthaste to support physicians and stop stigmatizing mental health diagnoses and mental health care,” she said. “Removing application questions about physician mental health will be consistent with recommendations from the Federation of State Medical Boards, medical professional societies, and the Americans with Disabilities Act, and is something actionable and achievable for every organization to do in 2021.” “From a public policy perspective, I am deeply concerned about the physician workforce and how patients will be able to receive care from exhausted, burned out physicians who may be reducing their clinical hours to restore their personal happiness – understandably so,” added Dr. Barrett, who is associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque.
She pointed out that there are mental health resources available for physicians that don’t go through their employers or insurance such as www.emotionalppe.org/.
A version of this article first appeared on Medscape.com.
Katie Lennon contributed to this report.
Before the pandemic, a large majority of internists reported that they were generally happy with life outside of work, although by specialty, they were near the bottom in happiness.
But this year’s Medscape Internist Lifestyle, Happiness & Burnout Report 2021 shows a sharp drop, with just 55% of respondents saying they are somewhat or very happy in life outside work, compared with 78% last year.
Internists were not alone among the more than 12,000 physicians who responded to the survey. The contrast from last year’s report was clear for physicians in general and reflects COVID-19’s substantial toll on clinicians.
Just 58% of physicians overall reported happy lives outside work, down from 82% last year.
Perhaps not surprising, given the particular demands on certain specialties, physicians in infectious disease were the least happy, at 45%, followed by pulmonologists (47%) and rheumatologists and intensivists, at 49%.
The highest happiness level was reported by those in diabetes and endocrinology, at 73% this year, but that proportion was also substantially lower than the 89% from last year.
Burnout has ‘strong impact on lives’
The percentage of internists who reported burnout or depression, however, has stayed fairly consistent.
More than half (52%) said that burnout had a strong or severe impact on their lives, and nearly 1 in 10 said it was severe enough that they are considering leaving medicine.
One percent of the internists who responded to the survey said they had attempted suicide, and 12% said they had thoughts of suicide but had not attempted it.
Most of those reporting burnout (82%) said it started before the COVID-19 pandemic, but 18% said it began with the pandemic.
Notably, though, physicians ranked problems related to stress from COVID-19 near the bottom among burnout drivers. The top factor, by far, again, was “too many bureaucratic tasks.”
A large majority (78%) of internists work online for up to 10 hours a week, a number that could grow as telemedicine grows.
Exercise is top coping method
Responses gave a peek into how physicians are coping with burnout. Among internists, 49% put exercise at the top. Isolating themselves from others was the next most popular choice, at 45%. Eating junk food and drinking alcohol were further down the list, at 34% and 24%, respectively.
Few internists said they drink alcohol daily, a finding consistent with past years. In fact, 29% said they don’t drink at all, and 26% said they have fewer than one alcoholic drink per week. Only 7% said they had seven or more drinks per week.
The National Institute on Alcohol Abuse and Alcoholism advises that men not have more than 14 alcoholic drinks per week and that women not have more than 7.
Work-life balance topped list of concerns
By far, internists said work-life balance was their top workplace concern. Nearly half (48%) chose that answer, more than twice the percentage who said compensation was the biggest concern (21%).
Asked whether they would take a salary cut for more work-life balance, a similar proportion (46%) said yes.
Forty-three percent of internists manage to take 3-4 weeks of vacation, and 10% take at least 5 weeks, similar to reported vacation time in last year’s survey.
The vast majority are in committed relationships, with 79% reporting that they are married, and 5% reporting that they are living with a partner. Of those who are married, 48% described the marriage as very good; 32%, good; 16%, fair; 2%, poor; and 1%, very poor; 1% preferred not to answer.
One in five internists said their spouse was a physician, and 24% said their spouse worked in the health care field but not as a physician.
Pandemic has increased burnout
Douglas S. Paauw, MD, and Eileen Barrett, MD, two members of the Internal Medicine News editorial advisory board, said they were not surprised by the survey findings.
“There is more burnout since the pandemic,” said Dr. Paauw, professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and third-year medical student clerkship director at the University of Washington. “People may be working more hours, higher stress, but also, some may be working less hours, are socially isolated, taking on a new role of helping their kids in virtual education, andn living in cramped quarters with family that they may not be accustomed to spending so much time with.”
“Also, most physicians love travel, to detress, get back in balance, and that has by and large been taken away by the pandemic,” Dr. Paauw noted. “Unfortunately, bureaucracy did not go away during the pandemic!
Dr. Barrett, an internal medicine hospitalist, said, “It is most concerning to me today that 12% have had thoughts of suicide, and yet 39% are too busy to seek care for depression or burnout, and 17% aren’t seeking due to fear it will be disclosed,”
“Credentialing, medical license applications, and malpractice insurance applications can and must be changed posthaste to support physicians and stop stigmatizing mental health diagnoses and mental health care,” she said. “Removing application questions about physician mental health will be consistent with recommendations from the Federation of State Medical Boards, medical professional societies, and the Americans with Disabilities Act, and is something actionable and achievable for every organization to do in 2021.” “From a public policy perspective, I am deeply concerned about the physician workforce and how patients will be able to receive care from exhausted, burned out physicians who may be reducing their clinical hours to restore their personal happiness – understandably so,” added Dr. Barrett, who is associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque.
She pointed out that there are mental health resources available for physicians that don’t go through their employers or insurance such as www.emotionalppe.org/.
A version of this article first appeared on Medscape.com.
Katie Lennon contributed to this report.
Before the pandemic, a large majority of internists reported that they were generally happy with life outside of work, although by specialty, they were near the bottom in happiness.
But this year’s Medscape Internist Lifestyle, Happiness & Burnout Report 2021 shows a sharp drop, with just 55% of respondents saying they are somewhat or very happy in life outside work, compared with 78% last year.
Internists were not alone among the more than 12,000 physicians who responded to the survey. The contrast from last year’s report was clear for physicians in general and reflects COVID-19’s substantial toll on clinicians.
Just 58% of physicians overall reported happy lives outside work, down from 82% last year.
Perhaps not surprising, given the particular demands on certain specialties, physicians in infectious disease were the least happy, at 45%, followed by pulmonologists (47%) and rheumatologists and intensivists, at 49%.
The highest happiness level was reported by those in diabetes and endocrinology, at 73% this year, but that proportion was also substantially lower than the 89% from last year.
Burnout has ‘strong impact on lives’
The percentage of internists who reported burnout or depression, however, has stayed fairly consistent.
More than half (52%) said that burnout had a strong or severe impact on their lives, and nearly 1 in 10 said it was severe enough that they are considering leaving medicine.
One percent of the internists who responded to the survey said they had attempted suicide, and 12% said they had thoughts of suicide but had not attempted it.
Most of those reporting burnout (82%) said it started before the COVID-19 pandemic, but 18% said it began with the pandemic.
Notably, though, physicians ranked problems related to stress from COVID-19 near the bottom among burnout drivers. The top factor, by far, again, was “too many bureaucratic tasks.”
A large majority (78%) of internists work online for up to 10 hours a week, a number that could grow as telemedicine grows.
Exercise is top coping method
Responses gave a peek into how physicians are coping with burnout. Among internists, 49% put exercise at the top. Isolating themselves from others was the next most popular choice, at 45%. Eating junk food and drinking alcohol were further down the list, at 34% and 24%, respectively.
Few internists said they drink alcohol daily, a finding consistent with past years. In fact, 29% said they don’t drink at all, and 26% said they have fewer than one alcoholic drink per week. Only 7% said they had seven or more drinks per week.
The National Institute on Alcohol Abuse and Alcoholism advises that men not have more than 14 alcoholic drinks per week and that women not have more than 7.
Work-life balance topped list of concerns
By far, internists said work-life balance was their top workplace concern. Nearly half (48%) chose that answer, more than twice the percentage who said compensation was the biggest concern (21%).
Asked whether they would take a salary cut for more work-life balance, a similar proportion (46%) said yes.
Forty-three percent of internists manage to take 3-4 weeks of vacation, and 10% take at least 5 weeks, similar to reported vacation time in last year’s survey.
The vast majority are in committed relationships, with 79% reporting that they are married, and 5% reporting that they are living with a partner. Of those who are married, 48% described the marriage as very good; 32%, good; 16%, fair; 2%, poor; and 1%, very poor; 1% preferred not to answer.
One in five internists said their spouse was a physician, and 24% said their spouse worked in the health care field but not as a physician.
Pandemic has increased burnout
Douglas S. Paauw, MD, and Eileen Barrett, MD, two members of the Internal Medicine News editorial advisory board, said they were not surprised by the survey findings.
“There is more burnout since the pandemic,” said Dr. Paauw, professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and third-year medical student clerkship director at the University of Washington. “People may be working more hours, higher stress, but also, some may be working less hours, are socially isolated, taking on a new role of helping their kids in virtual education, andn living in cramped quarters with family that they may not be accustomed to spending so much time with.”
“Also, most physicians love travel, to detress, get back in balance, and that has by and large been taken away by the pandemic,” Dr. Paauw noted. “Unfortunately, bureaucracy did not go away during the pandemic!
Dr. Barrett, an internal medicine hospitalist, said, “It is most concerning to me today that 12% have had thoughts of suicide, and yet 39% are too busy to seek care for depression or burnout, and 17% aren’t seeking due to fear it will be disclosed,”
“Credentialing, medical license applications, and malpractice insurance applications can and must be changed posthaste to support physicians and stop stigmatizing mental health diagnoses and mental health care,” she said. “Removing application questions about physician mental health will be consistent with recommendations from the Federation of State Medical Boards, medical professional societies, and the Americans with Disabilities Act, and is something actionable and achievable for every organization to do in 2021.” “From a public policy perspective, I am deeply concerned about the physician workforce and how patients will be able to receive care from exhausted, burned out physicians who may be reducing their clinical hours to restore their personal happiness – understandably so,” added Dr. Barrett, who is associate professor in the division of hospital medicine, department of internal medicine, at the University of New Mexico, Albuquerque.
She pointed out that there are mental health resources available for physicians that don’t go through their employers or insurance such as www.emotionalppe.org/.
A version of this article first appeared on Medscape.com.
Katie Lennon contributed to this report.
Tips offered for treating co-occurring ADHD and SUDs
When Frances R. Levin, MD, began her clinical psychiatry career in the mid-1990s, she spent a lot of time educating colleagues about the validity of an ADHD diagnosis in adults.
“That’s no longer an issue,” Dr. Levin, the Kennedy-Leavy Professor of Psychiatry at Columbia University, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “But at the time, we often thought, ‘ADHD is something that’s specific to people who are stimulant users.’ In fact, what we found over the years was that these rates are elevated in a range of substance use populations.”
According to National Comorbidity Survey, a nontreatment sample of more than 3,000 adults, individuals who have SUD have two to three times the risk of having ADHD, while individuals who have ADHD have about three times the rate of having an SUD, compared with those who don’t (Am J Psychiatry. 2006;163[4]:716-23). “When you move to treatment samples, the rates also remain quite high,” said Dr. Levin, who is also chief of the division of substance use disorders at the medical center.
“In the general population, the rates of ADHD are 2%-4%. When we look at people who are coming in specifically for treatment of their SUD, the rates are substantially higher, ranging from 10% to 24%.”
According to a 2014 review of medical literature, potential reasons for the association between ADHD and SUD vary and include underlying biologic deficits, such as parental SUDs and genetics; conduct disorder symptoms, such as defiance, rule breaking, and delinquency; poor performance in school, such as low grades, grade retention, or drop-out; and social difficulties, such as rejection from conventional groups or few quality friendships (Annu Rev Clin Psychol. 2014;10:607-39). Other potential pathways include neurocognitive deficits, stress-negative affect models, impulsive anger, and other underlying traits.
One key reason to treat ADHD in patients with SUDs is that they tend to develop the SUD earlier when the ADHD is present, Dr. Levin said. They’re also less likely to be retained in treatment and have a reduced likelihood of going into remission if dependence develops. “Even when they do achieve remission, it seems to take longer for people to reach remission,” she said. “They have more treatment exposure yet do less well in treatment. This can make it more challenging to treat this population.”
One common assumption from clinicians regarding patients with ADHD and a concomitant SUD is that standard treatments for ADHD do not work in active substance users. Another is that, even if treatments work for ADHD, they do not affect the substance use disorder. “Understandably, there is also concern that active substance abusers will misuse and divert their medications,” she said. “Finally, there are often additional psychiatric comorbidities that may make it harder to effectively treat individuals with ADHD and SUD.”
Since 2002, 15 double-blind outpatient studies using stimulants/atomoxetine to treat substance abusers with ADHD have appeared in the medical literature, Dr. Levin said. Only three have included adolescents. “That’s surprising, because up to 40% of kids who come in for treatment, often for cannabis use disorder, will have ADHD, yet there is very little guidance from empirical studies as to how to best treat them,” she said. “There have been several studies looking at atomoxetine to treat substance abusers with ADHD, but results have been mixed. In the cannabis use populations, atomoxetine has not been shown to be effective in treating the substance use disorder, and results are mixed regarding superiority in reducing ADHD symptoms. There is one study showing that ADHD is more likely to be improved in adults with alcohol use disorders with mixed results regarding the alcohol use.”
Overall, most of the outpatient and inpatient studies conducted in this population have demonstrated some signal in terms of reducing ADHD, she said, while a minority of the outpatient studies suggest some benefit in terms of substance use. “What’s interesting is that when you see a response in terms of the ADHD, you often see an improvement in the substance use as well,” Dr. Levin said. “This potentially suggests that patients may be self-medicating their ADHD symptoms or that if the ADHD responds to treatment, then the patient may benefit from the psychosocial interventions that targets the SUD.”
A separate meta-analysis involving more than 1,000 patients found mixed results from pharmacologic interventions and concluded that, while they modestly improved ADHD symptoms, no beneficial effect was seen on drug abstinence or on treatment discontinuation (J Psychopharmacol. 2015 Jan;29[1]:15-23). “I would argue that you don’t need to be as nihilistic about this as the meta-analysis might suggest, because the devil’s in the details,” said Dr. Levin, whose own research was included in the work.
“First of all, many of the studies had high drop-out rates. The outcome measures were variable, and some of the studies used formulations with poor bioavailability. Also, trials that evaluated atomoxetine or stimulants were combined, which may be problematic given the different mechanisms of action. Further, the meta-analysis did not include two recent placebo-controlled trials in adults with stimulant-use disorders that both found that higher dosing of a long-acting stimulant resulted in greater improvements in ADHD symptoms and stimulant use” (Addict. 2014;109[3]:440-9 and JAMA Psychiatry. 2015;72[6]:593-602).
Dr. Levin went on to note that there are few empirical data to guide treatment for those who have multiple psychiatric disorders, let alone treatment for ADHD and SUDs without additional psychiatric disorders. The challenge is what to treat first and/or how to treat the concomitant conditions safely.
“Generally, if possible, treat what is most clinically impairing first,” she said. “Overall, both stimulants and atomoxetine may work for ADHD even in the presence of additional depression, anxiety disorders, and substance use disorders.”
She cautioned against treating a patient with ADHD medication if there is a preexisting psychosis or bipolar illness. “If you start a stimulant or atomoxetine and psychosis or mania occurs, you clearly want to stop the medication and reassess,” she said. Researchers found that the risk of precipitating mania with a stimulant is uncommon if you alleviate symptoms first with a mood stabilizer. “This is a situation where you probably want to treat the bipolar illness first, but it does not preclude the treatment of ADHD once the mood stabilization has occurred,” she said.
In patients with ADHD and anxiety, she often treats the ADHD first, “because oftentimes the anxiety is driven by the procrastination and the inability to get things done,” she explained. “It’s important to determine whether the anxiety is an independent disorder rather than symptoms of ADHD. Inner restlessness can be described as anxiety.”
When there are concerns that preclude the use of a controlled medication, there are medications, in addition to atomoxetine, that might be considered. While bupropion is not Food and Drug Administration approved for ADHD, it might be useful in comorbid mood disorders for nicotine dependence. Other off-label medications that may help include guanfacine, modafinil, and tricyclic antidepressants.
“To date, robust dosing of long-acting amphetamine or methylphenidate formulations have been shown to be effective for patients with stimulant-use disorder, but as mentioned earlier, the data only come from two studies,” she said.
In order to determine whether stimulant treatment is yielding a benefit in a patient with co-occurring ADHD and SUD, she recommends carrying out a structured assessment of ADHD symptoms. Monitoring for functional improvement is also key.
“If there is no improvement in social, occupational, or academic settings and the patient is still actively using drugs, then there is no reason to keep prescribing,” she said. Close monitoring for cardiovascular or other psychiatric symptoms are key as well. Further, for those individuals with both ADHD and a substance-use disorder, it is critical that both are targeted for treatment.
Dr. Levin reported that she has received research, training, or salary support from the National Institute on Drug Abuse, New York state, and the Substance Abuse and Mental Health Services Administration. She has also received or currently receives industry support from Indivior and U.S. World Meds and for medication and from Major League Baseball. In addition, Dr. Levin has been an unpaid scientific advisory board member for Alkermes, Indivior, and Novartis.
When Frances R. Levin, MD, began her clinical psychiatry career in the mid-1990s, she spent a lot of time educating colleagues about the validity of an ADHD diagnosis in adults.
“That’s no longer an issue,” Dr. Levin, the Kennedy-Leavy Professor of Psychiatry at Columbia University, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “But at the time, we often thought, ‘ADHD is something that’s specific to people who are stimulant users.’ In fact, what we found over the years was that these rates are elevated in a range of substance use populations.”
According to National Comorbidity Survey, a nontreatment sample of more than 3,000 adults, individuals who have SUD have two to three times the risk of having ADHD, while individuals who have ADHD have about three times the rate of having an SUD, compared with those who don’t (Am J Psychiatry. 2006;163[4]:716-23). “When you move to treatment samples, the rates also remain quite high,” said Dr. Levin, who is also chief of the division of substance use disorders at the medical center.
“In the general population, the rates of ADHD are 2%-4%. When we look at people who are coming in specifically for treatment of their SUD, the rates are substantially higher, ranging from 10% to 24%.”
According to a 2014 review of medical literature, potential reasons for the association between ADHD and SUD vary and include underlying biologic deficits, such as parental SUDs and genetics; conduct disorder symptoms, such as defiance, rule breaking, and delinquency; poor performance in school, such as low grades, grade retention, or drop-out; and social difficulties, such as rejection from conventional groups or few quality friendships (Annu Rev Clin Psychol. 2014;10:607-39). Other potential pathways include neurocognitive deficits, stress-negative affect models, impulsive anger, and other underlying traits.
One key reason to treat ADHD in patients with SUDs is that they tend to develop the SUD earlier when the ADHD is present, Dr. Levin said. They’re also less likely to be retained in treatment and have a reduced likelihood of going into remission if dependence develops. “Even when they do achieve remission, it seems to take longer for people to reach remission,” she said. “They have more treatment exposure yet do less well in treatment. This can make it more challenging to treat this population.”
One common assumption from clinicians regarding patients with ADHD and a concomitant SUD is that standard treatments for ADHD do not work in active substance users. Another is that, even if treatments work for ADHD, they do not affect the substance use disorder. “Understandably, there is also concern that active substance abusers will misuse and divert their medications,” she said. “Finally, there are often additional psychiatric comorbidities that may make it harder to effectively treat individuals with ADHD and SUD.”
Since 2002, 15 double-blind outpatient studies using stimulants/atomoxetine to treat substance abusers with ADHD have appeared in the medical literature, Dr. Levin said. Only three have included adolescents. “That’s surprising, because up to 40% of kids who come in for treatment, often for cannabis use disorder, will have ADHD, yet there is very little guidance from empirical studies as to how to best treat them,” she said. “There have been several studies looking at atomoxetine to treat substance abusers with ADHD, but results have been mixed. In the cannabis use populations, atomoxetine has not been shown to be effective in treating the substance use disorder, and results are mixed regarding superiority in reducing ADHD symptoms. There is one study showing that ADHD is more likely to be improved in adults with alcohol use disorders with mixed results regarding the alcohol use.”
Overall, most of the outpatient and inpatient studies conducted in this population have demonstrated some signal in terms of reducing ADHD, she said, while a minority of the outpatient studies suggest some benefit in terms of substance use. “What’s interesting is that when you see a response in terms of the ADHD, you often see an improvement in the substance use as well,” Dr. Levin said. “This potentially suggests that patients may be self-medicating their ADHD symptoms or that if the ADHD responds to treatment, then the patient may benefit from the psychosocial interventions that targets the SUD.”
A separate meta-analysis involving more than 1,000 patients found mixed results from pharmacologic interventions and concluded that, while they modestly improved ADHD symptoms, no beneficial effect was seen on drug abstinence or on treatment discontinuation (J Psychopharmacol. 2015 Jan;29[1]:15-23). “I would argue that you don’t need to be as nihilistic about this as the meta-analysis might suggest, because the devil’s in the details,” said Dr. Levin, whose own research was included in the work.
“First of all, many of the studies had high drop-out rates. The outcome measures were variable, and some of the studies used formulations with poor bioavailability. Also, trials that evaluated atomoxetine or stimulants were combined, which may be problematic given the different mechanisms of action. Further, the meta-analysis did not include two recent placebo-controlled trials in adults with stimulant-use disorders that both found that higher dosing of a long-acting stimulant resulted in greater improvements in ADHD symptoms and stimulant use” (Addict. 2014;109[3]:440-9 and JAMA Psychiatry. 2015;72[6]:593-602).
Dr. Levin went on to note that there are few empirical data to guide treatment for those who have multiple psychiatric disorders, let alone treatment for ADHD and SUDs without additional psychiatric disorders. The challenge is what to treat first and/or how to treat the concomitant conditions safely.
“Generally, if possible, treat what is most clinically impairing first,” she said. “Overall, both stimulants and atomoxetine may work for ADHD even in the presence of additional depression, anxiety disorders, and substance use disorders.”
She cautioned against treating a patient with ADHD medication if there is a preexisting psychosis or bipolar illness. “If you start a stimulant or atomoxetine and psychosis or mania occurs, you clearly want to stop the medication and reassess,” she said. Researchers found that the risk of precipitating mania with a stimulant is uncommon if you alleviate symptoms first with a mood stabilizer. “This is a situation where you probably want to treat the bipolar illness first, but it does not preclude the treatment of ADHD once the mood stabilization has occurred,” she said.
In patients with ADHD and anxiety, she often treats the ADHD first, “because oftentimes the anxiety is driven by the procrastination and the inability to get things done,” she explained. “It’s important to determine whether the anxiety is an independent disorder rather than symptoms of ADHD. Inner restlessness can be described as anxiety.”
When there are concerns that preclude the use of a controlled medication, there are medications, in addition to atomoxetine, that might be considered. While bupropion is not Food and Drug Administration approved for ADHD, it might be useful in comorbid mood disorders for nicotine dependence. Other off-label medications that may help include guanfacine, modafinil, and tricyclic antidepressants.
“To date, robust dosing of long-acting amphetamine or methylphenidate formulations have been shown to be effective for patients with stimulant-use disorder, but as mentioned earlier, the data only come from two studies,” she said.
In order to determine whether stimulant treatment is yielding a benefit in a patient with co-occurring ADHD and SUD, she recommends carrying out a structured assessment of ADHD symptoms. Monitoring for functional improvement is also key.
“If there is no improvement in social, occupational, or academic settings and the patient is still actively using drugs, then there is no reason to keep prescribing,” she said. Close monitoring for cardiovascular or other psychiatric symptoms are key as well. Further, for those individuals with both ADHD and a substance-use disorder, it is critical that both are targeted for treatment.
Dr. Levin reported that she has received research, training, or salary support from the National Institute on Drug Abuse, New York state, and the Substance Abuse and Mental Health Services Administration. She has also received or currently receives industry support from Indivior and U.S. World Meds and for medication and from Major League Baseball. In addition, Dr. Levin has been an unpaid scientific advisory board member for Alkermes, Indivior, and Novartis.
When Frances R. Levin, MD, began her clinical psychiatry career in the mid-1990s, she spent a lot of time educating colleagues about the validity of an ADHD diagnosis in adults.
“That’s no longer an issue,” Dr. Levin, the Kennedy-Leavy Professor of Psychiatry at Columbia University, New York, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “But at the time, we often thought, ‘ADHD is something that’s specific to people who are stimulant users.’ In fact, what we found over the years was that these rates are elevated in a range of substance use populations.”
According to National Comorbidity Survey, a nontreatment sample of more than 3,000 adults, individuals who have SUD have two to three times the risk of having ADHD, while individuals who have ADHD have about three times the rate of having an SUD, compared with those who don’t (Am J Psychiatry. 2006;163[4]:716-23). “When you move to treatment samples, the rates also remain quite high,” said Dr. Levin, who is also chief of the division of substance use disorders at the medical center.
“In the general population, the rates of ADHD are 2%-4%. When we look at people who are coming in specifically for treatment of their SUD, the rates are substantially higher, ranging from 10% to 24%.”
According to a 2014 review of medical literature, potential reasons for the association between ADHD and SUD vary and include underlying biologic deficits, such as parental SUDs and genetics; conduct disorder symptoms, such as defiance, rule breaking, and delinquency; poor performance in school, such as low grades, grade retention, or drop-out; and social difficulties, such as rejection from conventional groups or few quality friendships (Annu Rev Clin Psychol. 2014;10:607-39). Other potential pathways include neurocognitive deficits, stress-negative affect models, impulsive anger, and other underlying traits.
One key reason to treat ADHD in patients with SUDs is that they tend to develop the SUD earlier when the ADHD is present, Dr. Levin said. They’re also less likely to be retained in treatment and have a reduced likelihood of going into remission if dependence develops. “Even when they do achieve remission, it seems to take longer for people to reach remission,” she said. “They have more treatment exposure yet do less well in treatment. This can make it more challenging to treat this population.”
One common assumption from clinicians regarding patients with ADHD and a concomitant SUD is that standard treatments for ADHD do not work in active substance users. Another is that, even if treatments work for ADHD, they do not affect the substance use disorder. “Understandably, there is also concern that active substance abusers will misuse and divert their medications,” she said. “Finally, there are often additional psychiatric comorbidities that may make it harder to effectively treat individuals with ADHD and SUD.”
Since 2002, 15 double-blind outpatient studies using stimulants/atomoxetine to treat substance abusers with ADHD have appeared in the medical literature, Dr. Levin said. Only three have included adolescents. “That’s surprising, because up to 40% of kids who come in for treatment, often for cannabis use disorder, will have ADHD, yet there is very little guidance from empirical studies as to how to best treat them,” she said. “There have been several studies looking at atomoxetine to treat substance abusers with ADHD, but results have been mixed. In the cannabis use populations, atomoxetine has not been shown to be effective in treating the substance use disorder, and results are mixed regarding superiority in reducing ADHD symptoms. There is one study showing that ADHD is more likely to be improved in adults with alcohol use disorders with mixed results regarding the alcohol use.”
Overall, most of the outpatient and inpatient studies conducted in this population have demonstrated some signal in terms of reducing ADHD, she said, while a minority of the outpatient studies suggest some benefit in terms of substance use. “What’s interesting is that when you see a response in terms of the ADHD, you often see an improvement in the substance use as well,” Dr. Levin said. “This potentially suggests that patients may be self-medicating their ADHD symptoms or that if the ADHD responds to treatment, then the patient may benefit from the psychosocial interventions that targets the SUD.”
A separate meta-analysis involving more than 1,000 patients found mixed results from pharmacologic interventions and concluded that, while they modestly improved ADHD symptoms, no beneficial effect was seen on drug abstinence or on treatment discontinuation (J Psychopharmacol. 2015 Jan;29[1]:15-23). “I would argue that you don’t need to be as nihilistic about this as the meta-analysis might suggest, because the devil’s in the details,” said Dr. Levin, whose own research was included in the work.
“First of all, many of the studies had high drop-out rates. The outcome measures were variable, and some of the studies used formulations with poor bioavailability. Also, trials that evaluated atomoxetine or stimulants were combined, which may be problematic given the different mechanisms of action. Further, the meta-analysis did not include two recent placebo-controlled trials in adults with stimulant-use disorders that both found that higher dosing of a long-acting stimulant resulted in greater improvements in ADHD symptoms and stimulant use” (Addict. 2014;109[3]:440-9 and JAMA Psychiatry. 2015;72[6]:593-602).
Dr. Levin went on to note that there are few empirical data to guide treatment for those who have multiple psychiatric disorders, let alone treatment for ADHD and SUDs without additional psychiatric disorders. The challenge is what to treat first and/or how to treat the concomitant conditions safely.
“Generally, if possible, treat what is most clinically impairing first,” she said. “Overall, both stimulants and atomoxetine may work for ADHD even in the presence of additional depression, anxiety disorders, and substance use disorders.”
She cautioned against treating a patient with ADHD medication if there is a preexisting psychosis or bipolar illness. “If you start a stimulant or atomoxetine and psychosis or mania occurs, you clearly want to stop the medication and reassess,” she said. Researchers found that the risk of precipitating mania with a stimulant is uncommon if you alleviate symptoms first with a mood stabilizer. “This is a situation where you probably want to treat the bipolar illness first, but it does not preclude the treatment of ADHD once the mood stabilization has occurred,” she said.
In patients with ADHD and anxiety, she often treats the ADHD first, “because oftentimes the anxiety is driven by the procrastination and the inability to get things done,” she explained. “It’s important to determine whether the anxiety is an independent disorder rather than symptoms of ADHD. Inner restlessness can be described as anxiety.”
When there are concerns that preclude the use of a controlled medication, there are medications, in addition to atomoxetine, that might be considered. While bupropion is not Food and Drug Administration approved for ADHD, it might be useful in comorbid mood disorders for nicotine dependence. Other off-label medications that may help include guanfacine, modafinil, and tricyclic antidepressants.
“To date, robust dosing of long-acting amphetamine or methylphenidate formulations have been shown to be effective for patients with stimulant-use disorder, but as mentioned earlier, the data only come from two studies,” she said.
In order to determine whether stimulant treatment is yielding a benefit in a patient with co-occurring ADHD and SUD, she recommends carrying out a structured assessment of ADHD symptoms. Monitoring for functional improvement is also key.
“If there is no improvement in social, occupational, or academic settings and the patient is still actively using drugs, then there is no reason to keep prescribing,” she said. Close monitoring for cardiovascular or other psychiatric symptoms are key as well. Further, for those individuals with both ADHD and a substance-use disorder, it is critical that both are targeted for treatment.
Dr. Levin reported that she has received research, training, or salary support from the National Institute on Drug Abuse, New York state, and the Substance Abuse and Mental Health Services Administration. She has also received or currently receives industry support from Indivior and U.S. World Meds and for medication and from Major League Baseball. In addition, Dr. Levin has been an unpaid scientific advisory board member for Alkermes, Indivior, and Novartis.
FROM NPA 2021
One in 10 family docs with burnout consider quitting medicine
and 1 in 10 said it was serious enough to make them consider leaving medicine.
Yet, responses to the Medscape Family Medicine Physician Lifestyle, Happiness & Burnout Report 2021 also indicate that family physicians are in the middle of the pack again this year in rankings by specialty of physician happiness outside work. Overall, more than 12,000 physicians from more than 29 specialties responded to this year’s survey, conducted between Aug. 30 and Nov. 5, 2020.
Happiness levels sink for physicians
In light of the COVID-19 pandemic, happiness levels took a sharp drop among physicians across the board. Last year, for instance, the happiness level was highest for physicians practicing in diabetes and endocrinology, at 89%. They remain the happiest this year, but the proportion saying they were happy dropped to 73%. Infectious disease physicians were the least happy outside work both last year and this year, with the proportion reporting they were happy dropping from 69% to 45%.
For family physicians, happiness levels outside work plunged from 79% last year to 57% this year.
Burnout and depression levels, however, remained steady. The portion saying they were either burned out or burned out and depressed was up only 1 percentage point, rising to 47%.
Fifteen percent of family physicians have had thoughts of suicide, and 1% said they had attempted it, according to the survey responses.
The most common strategy for coping with burnout, reported by 48% of family physicians, is talking with family members and close friends, followed closely by exercise, reported by 46%.
Sixty-eight percent of family physicians say they exercise at least twice a week, and 12% exercise every day.
However, not all coping strategies were as positive: Forty-five percent said they cope by isolating themselves from others; 40% turned to junk food; and 23%-24% said they drank alcohol or were binge-eating to cope. Respondents could choose more than one answer.
Among family physicians, 75% expressed anxiety about their futures, given the pandemic, which is similar to the proportion among physicians overall (77%) who had the same worries.
Work-life balance biggest worry
The survey also asked what workplace issues concern family physicians the most. The biggest concern, by far, was work-life balance, chosen by 51%. Next highest was compensation, at 19%, followed by combining parenthood and work (9%) and relationships with colleagues/staff (6%).
More than half (52%) of family doctors said they would take a cut in pay to have better work-life balance.
A little more than a third (36%) of family physicians – about the same percentage as physicians overall – said they always or most of the time spend enough time on their own health and wellness. One in five said they rarely or never do.
The amount of work required beyond the bedside continues to frustrate family physicians.
Again this year, the top cause of burnout, chosen by 70% of family physicians, was “too many bureaucratic tasks.” That was followed by “spending too many hours at work” (37%) and “increasing computerization of practice” (32%).
A large majority (82%) of family doctors report that they work online up to 10 hours a week, a number that could increase with the rise of telemedicine; 64% are personally online up to 10 hours a week. But even with combined personal and professional Internet time, family doctors don’t come close to the average time spent online among all Internet users, which Hootsuite and We Are Social report is an average of 7 hours per day.
Most in committed, satisfying relationships
Most family medicine physicians are juggling committed relationships with work life. In this survey, 78% said they were married, and another 5% said they were living with a partner.
A little more than half of married family doctors described their marriages as very good (51%). The rest were good (32%); fair (13%); poor (2%); and very poor (2%). Some (15%) had spouses who were also physicians, and 25% said their spouses worked in the health care field but were not physicians.
Almost all family physicians were able to take some vacation time during this reporting period – 43% took 3-4 weeks; 35% took 1-2 weeks; 10% took less than 1 week; 9% took 5-6 weeks; and 4% took more than 6 weeks.
If they drove to vacation destinations, they were likely to be in their favorite make of vehicle, which for family physicians were Toyotas (22%), Hondas (14%) and Fords (11%), according to the survey responses. Physicians overall favored Toyotas, Hondas, and BMWs.
A version of this article first appeared on Medscape.com.
and 1 in 10 said it was serious enough to make them consider leaving medicine.
Yet, responses to the Medscape Family Medicine Physician Lifestyle, Happiness & Burnout Report 2021 also indicate that family physicians are in the middle of the pack again this year in rankings by specialty of physician happiness outside work. Overall, more than 12,000 physicians from more than 29 specialties responded to this year’s survey, conducted between Aug. 30 and Nov. 5, 2020.
Happiness levels sink for physicians
In light of the COVID-19 pandemic, happiness levels took a sharp drop among physicians across the board. Last year, for instance, the happiness level was highest for physicians practicing in diabetes and endocrinology, at 89%. They remain the happiest this year, but the proportion saying they were happy dropped to 73%. Infectious disease physicians were the least happy outside work both last year and this year, with the proportion reporting they were happy dropping from 69% to 45%.
For family physicians, happiness levels outside work plunged from 79% last year to 57% this year.
Burnout and depression levels, however, remained steady. The portion saying they were either burned out or burned out and depressed was up only 1 percentage point, rising to 47%.
Fifteen percent of family physicians have had thoughts of suicide, and 1% said they had attempted it, according to the survey responses.
The most common strategy for coping with burnout, reported by 48% of family physicians, is talking with family members and close friends, followed closely by exercise, reported by 46%.
Sixty-eight percent of family physicians say they exercise at least twice a week, and 12% exercise every day.
However, not all coping strategies were as positive: Forty-five percent said they cope by isolating themselves from others; 40% turned to junk food; and 23%-24% said they drank alcohol or were binge-eating to cope. Respondents could choose more than one answer.
Among family physicians, 75% expressed anxiety about their futures, given the pandemic, which is similar to the proportion among physicians overall (77%) who had the same worries.
Work-life balance biggest worry
The survey also asked what workplace issues concern family physicians the most. The biggest concern, by far, was work-life balance, chosen by 51%. Next highest was compensation, at 19%, followed by combining parenthood and work (9%) and relationships with colleagues/staff (6%).
More than half (52%) of family doctors said they would take a cut in pay to have better work-life balance.
A little more than a third (36%) of family physicians – about the same percentage as physicians overall – said they always or most of the time spend enough time on their own health and wellness. One in five said they rarely or never do.
The amount of work required beyond the bedside continues to frustrate family physicians.
Again this year, the top cause of burnout, chosen by 70% of family physicians, was “too many bureaucratic tasks.” That was followed by “spending too many hours at work” (37%) and “increasing computerization of practice” (32%).
A large majority (82%) of family doctors report that they work online up to 10 hours a week, a number that could increase with the rise of telemedicine; 64% are personally online up to 10 hours a week. But even with combined personal and professional Internet time, family doctors don’t come close to the average time spent online among all Internet users, which Hootsuite and We Are Social report is an average of 7 hours per day.
Most in committed, satisfying relationships
Most family medicine physicians are juggling committed relationships with work life. In this survey, 78% said they were married, and another 5% said they were living with a partner.
A little more than half of married family doctors described their marriages as very good (51%). The rest were good (32%); fair (13%); poor (2%); and very poor (2%). Some (15%) had spouses who were also physicians, and 25% said their spouses worked in the health care field but were not physicians.
Almost all family physicians were able to take some vacation time during this reporting period – 43% took 3-4 weeks; 35% took 1-2 weeks; 10% took less than 1 week; 9% took 5-6 weeks; and 4% took more than 6 weeks.
If they drove to vacation destinations, they were likely to be in their favorite make of vehicle, which for family physicians were Toyotas (22%), Hondas (14%) and Fords (11%), according to the survey responses. Physicians overall favored Toyotas, Hondas, and BMWs.
A version of this article first appeared on Medscape.com.
and 1 in 10 said it was serious enough to make them consider leaving medicine.
Yet, responses to the Medscape Family Medicine Physician Lifestyle, Happiness & Burnout Report 2021 also indicate that family physicians are in the middle of the pack again this year in rankings by specialty of physician happiness outside work. Overall, more than 12,000 physicians from more than 29 specialties responded to this year’s survey, conducted between Aug. 30 and Nov. 5, 2020.
Happiness levels sink for physicians
In light of the COVID-19 pandemic, happiness levels took a sharp drop among physicians across the board. Last year, for instance, the happiness level was highest for physicians practicing in diabetes and endocrinology, at 89%. They remain the happiest this year, but the proportion saying they were happy dropped to 73%. Infectious disease physicians were the least happy outside work both last year and this year, with the proportion reporting they were happy dropping from 69% to 45%.
For family physicians, happiness levels outside work plunged from 79% last year to 57% this year.
Burnout and depression levels, however, remained steady. The portion saying they were either burned out or burned out and depressed was up only 1 percentage point, rising to 47%.
Fifteen percent of family physicians have had thoughts of suicide, and 1% said they had attempted it, according to the survey responses.
The most common strategy for coping with burnout, reported by 48% of family physicians, is talking with family members and close friends, followed closely by exercise, reported by 46%.
Sixty-eight percent of family physicians say they exercise at least twice a week, and 12% exercise every day.
However, not all coping strategies were as positive: Forty-five percent said they cope by isolating themselves from others; 40% turned to junk food; and 23%-24% said they drank alcohol or were binge-eating to cope. Respondents could choose more than one answer.
Among family physicians, 75% expressed anxiety about their futures, given the pandemic, which is similar to the proportion among physicians overall (77%) who had the same worries.
Work-life balance biggest worry
The survey also asked what workplace issues concern family physicians the most. The biggest concern, by far, was work-life balance, chosen by 51%. Next highest was compensation, at 19%, followed by combining parenthood and work (9%) and relationships with colleagues/staff (6%).
More than half (52%) of family doctors said they would take a cut in pay to have better work-life balance.
A little more than a third (36%) of family physicians – about the same percentage as physicians overall – said they always or most of the time spend enough time on their own health and wellness. One in five said they rarely or never do.
The amount of work required beyond the bedside continues to frustrate family physicians.
Again this year, the top cause of burnout, chosen by 70% of family physicians, was “too many bureaucratic tasks.” That was followed by “spending too many hours at work” (37%) and “increasing computerization of practice” (32%).
A large majority (82%) of family doctors report that they work online up to 10 hours a week, a number that could increase with the rise of telemedicine; 64% are personally online up to 10 hours a week. But even with combined personal and professional Internet time, family doctors don’t come close to the average time spent online among all Internet users, which Hootsuite and We Are Social report is an average of 7 hours per day.
Most in committed, satisfying relationships
Most family medicine physicians are juggling committed relationships with work life. In this survey, 78% said they were married, and another 5% said they were living with a partner.
A little more than half of married family doctors described their marriages as very good (51%). The rest were good (32%); fair (13%); poor (2%); and very poor (2%). Some (15%) had spouses who were also physicians, and 25% said their spouses worked in the health care field but were not physicians.
Almost all family physicians were able to take some vacation time during this reporting period – 43% took 3-4 weeks; 35% took 1-2 weeks; 10% took less than 1 week; 9% took 5-6 weeks; and 4% took more than 6 weeks.
If they drove to vacation destinations, they were likely to be in their favorite make of vehicle, which for family physicians were Toyotas (22%), Hondas (14%) and Fords (11%), according to the survey responses. Physicians overall favored Toyotas, Hondas, and BMWs.
A version of this article first appeared on Medscape.com.
Akathisia: “Ants in the Pants”
Potentially poor outcome if untreated
Case
The patient is a 65-year-old female with increasing anxiety and agitation. She completed cycle 2 of chemotherapy for breast cancer several hours ago. Her premedication was Reglan (metoclopramide); her only other medication is tamoxifen. Other than breast cancer, she suffers only from osteoarthritis.
She is found pacing about the ward – almost uncontrollably. She feels she must move, only to have to stop and, shortly afterwards, feels the urge to move again. This has never happened to her before. She must move despite being fatigued. She also complains of an odd overall feeling; something akin to “ant in the pants.” She is nervous and exhausted. What is her diagnosis and what clues to it are in her presentation?
Background
The word “akathisia” is derived from the Greek language and means “unable to sit.” It is thought to occur as a consequence of dopaminergic blockade in the midbrain region. The decrease in dopaminergic activity leads to a subsequent decrease in inhibitory motor control which, in turn, manifests as involuntary movements.
In this malady, the patient is seen as perpetually in motion. The patient feels the need to move until they must stop. But once static, they have the urge to move again. They pace, they rock and they ‘fidget’ – they just cannot sit still. This feeling has been likened to having “ants in the pants.” Patients become anxious, agitated, and suffer from insomnia. They cannot rest.
If left unresolved akathisia can torment patients to sheer exhaustion. For some it serves as a harbinger of suicide. This toxicity is more commonly seen in the psychiatric pharmacy with the most common offender being haloperidol. The causative agents of the least notoriety are the non-antipsychotics.
Diagnosis and treatment
Akathisia is an extrapyramidal symptom found largely but NOT exclusively with psychiatric medications. There are drugs in the non-psychiatric field that can also cause it, including antiemetics (e.g., metoclopramide), antihypertensives (e.g., diltiazem), and narcotics (e.g., cocaine). Metoclopramide is given under circumstances ranging from diabetic gastroparesis to premedicating chemotherapy. It is a peripheral and centrally acting dopamine antagonist. There are no lab tests or radiographic workups to diagnose akathisia. Its manifestations are erratic and disturbing, and the prognosis is doleful if unresolved.
The primary intervention for the treatment of akathisia is its recognition and the discontinuation of the offending drug. Beyond this, for symptomatic care, there is a compendium of case reports and small studies supporting many drugs, but only a few have received consistent recommendation. Beta-adrenergic antagonists, such as propranolol, are considered the gold standard, the first choice for the treatment of akathisia. Their toxicities include orthostatic hypotension and bradycardia. Additionally, they are contraindicated in the setting of asthma.
Anticholinergics, such as benztropine (cogentin) and trihexylphenidyl (artane) are considered in the literature as 2nd line treatments, behind beta-blockers. However, the data advocating their use is limited. They have multiple side-effects including sedation, memory impairment, visual impairment, and urinary retention. They are also contraindicated in patients with closed-angle glaucoma.
An equivalent alternative to beta-blockers could also be the 5HT2a receptor antagonists such as mirtazapine (remeron) and cyproheptadine (periactin). This class of medications is thought to act by an inhibitory control of dopaminergic neurons. Sedation and weight gain are the primary toxicities, and they are contraindicated in patients who are breastfeeding.
Benzodiazepines, such as clonazepam (klonopin), have shown some efficacy in improving symptoms but the data is very limited. The risk of tolerance and dependence, coupled with the problems of sedation impacting the elderly, prompts their placement in reserve. Vitamin B6 (pyridoxine), when given in a high dose format, causes significant improvement in akathisia. However, it can cause headache and nausea. Chronic administration of high doses has also been found to cause a severe and irreversible sensory neuropathy as well as lead to seizures. Many other agents have been studied, but the data are too small to warrant recommendation.
Conclusion
Akathisia remains an extreme reaction to drugs not always in the psychotropic class. The hospitalist will likely deal with the acute onset, a dramatic form, and a potentially poor outcome if untreated. The patient’s only true defense is the physician’s clinical acumen and their ability to recognize it.
Dr. Killeen is a physician in Tampa, Fla. He practices internal medicine, hematology, and oncology, and has worked in hospice and hospital medicine.
Recommended reading
Van Gool AR, Doorduijn JK, Sevnaeve C. Severe akathisia as a side effect of metoclopramide. Pharm World Sci. 2010; 32(6):704-706.
Loonen AJM, Stahl SM. The mechanism of drug-induced akathisia. CNS Spectr. 2010;15(11):491-494.
Forcen FE, Matsoukas K, Alici Y. Antipsychotic-induced akathisia in delirium: A systemic review. Palliat Support Care. 2016;14(1):77-84.
Sethuram K, Gedzior J. Akathisia: Case presentation and review of newer treatment agents. Psychiatric Annals. 2014;44(8):391-396.
Pringsheim T, et al. The assessment and treatment of antipsychotic-induced akathisia. Can J Psychiatry. 2018;63(11): 719-729.
Tachere RO, Mandana M. Beyond anxiety and agitation: A clinical approach to akathisia. Royal Australian Coll Gen Practitioners. 2017;46(5): 296-298.
Key points
- Although associated more with psychiatric medications, akathisia can occur with non-psychotropics as well.
- To recognize the illness, the clinician must notice the repetitive involuntary movements and pacing as well as the “ants in the pants” fidgeting involved.
- Primary treatment consists of medication discontinuation with pharmaceutical intervention as a backup.
- Recognition is the key to successful treatment.
Classic signs of akathisia
- Fidgeting – “ants in the pants”
- Swinging the legs while seated
- Rocking from foot to foot
- Walking while in a static position
- Inability to sit or stand still – pacing
- Onset appears with the initiation or dose adjustment of an offending drug
Quiz
1. Which of the following findings occur in Akathisia?
A. Fidgeting
B. Pacing
C. Swinging the legs while seated
D. All the above
Answer: D
Akathisia is manifest as involuntary hyperactivity of the extremities, particularly the lower extremities. People feel the urge to move, to continue endlessly in motion, stopping only when fatigue sets in. The fidgeting has been described by patients as feeling like “ants in the pants.”
2. Which of the following interventions are used to treat akathisia?
A. Drug discontinuation
B. Propranolol
C. Mirtazapine
D. All the above
Answer: D
All the interventions mentioned are used to treat akathisia. The foremost is to stop the offending drug. Failing this, propranolol is the “gold standard” while 5HT2a antagonists, such as mirtazapine, are favored when beta-blockers either fail or are contraindicated.
3. The use of pyridoxine (Vitamin B6) in the treatment of akathisia is associated with what toxicities?
A. Headache
B. Nausea
C. Seizures
D. All the above
Answer: D
The use of Vitamin B6 in the treatment of akathisia has several drawbacks. Its administration is associated with headache and nausea, and high dose usage increases the risk of seizure.
4. If unresolved, akathisia can lead to which of the following?
A. Insomnia
B. Suicide
C. Physical exhaustion
D. All the above
Answer: D
Akathisia, left unrecognized and untreated, can eventually lead to physical exhaustion, and is compounded by difficulties in trying to rest, hence insomnia. The physical and mental torment of this malady can lead to suicide.
Potentially poor outcome if untreated
Potentially poor outcome if untreated
Case
The patient is a 65-year-old female with increasing anxiety and agitation. She completed cycle 2 of chemotherapy for breast cancer several hours ago. Her premedication was Reglan (metoclopramide); her only other medication is tamoxifen. Other than breast cancer, she suffers only from osteoarthritis.
She is found pacing about the ward – almost uncontrollably. She feels she must move, only to have to stop and, shortly afterwards, feels the urge to move again. This has never happened to her before. She must move despite being fatigued. She also complains of an odd overall feeling; something akin to “ant in the pants.” She is nervous and exhausted. What is her diagnosis and what clues to it are in her presentation?
Background
The word “akathisia” is derived from the Greek language and means “unable to sit.” It is thought to occur as a consequence of dopaminergic blockade in the midbrain region. The decrease in dopaminergic activity leads to a subsequent decrease in inhibitory motor control which, in turn, manifests as involuntary movements.
In this malady, the patient is seen as perpetually in motion. The patient feels the need to move until they must stop. But once static, they have the urge to move again. They pace, they rock and they ‘fidget’ – they just cannot sit still. This feeling has been likened to having “ants in the pants.” Patients become anxious, agitated, and suffer from insomnia. They cannot rest.
If left unresolved akathisia can torment patients to sheer exhaustion. For some it serves as a harbinger of suicide. This toxicity is more commonly seen in the psychiatric pharmacy with the most common offender being haloperidol. The causative agents of the least notoriety are the non-antipsychotics.
Diagnosis and treatment
Akathisia is an extrapyramidal symptom found largely but NOT exclusively with psychiatric medications. There are drugs in the non-psychiatric field that can also cause it, including antiemetics (e.g., metoclopramide), antihypertensives (e.g., diltiazem), and narcotics (e.g., cocaine). Metoclopramide is given under circumstances ranging from diabetic gastroparesis to premedicating chemotherapy. It is a peripheral and centrally acting dopamine antagonist. There are no lab tests or radiographic workups to diagnose akathisia. Its manifestations are erratic and disturbing, and the prognosis is doleful if unresolved.
The primary intervention for the treatment of akathisia is its recognition and the discontinuation of the offending drug. Beyond this, for symptomatic care, there is a compendium of case reports and small studies supporting many drugs, but only a few have received consistent recommendation. Beta-adrenergic antagonists, such as propranolol, are considered the gold standard, the first choice for the treatment of akathisia. Their toxicities include orthostatic hypotension and bradycardia. Additionally, they are contraindicated in the setting of asthma.
Anticholinergics, such as benztropine (cogentin) and trihexylphenidyl (artane) are considered in the literature as 2nd line treatments, behind beta-blockers. However, the data advocating their use is limited. They have multiple side-effects including sedation, memory impairment, visual impairment, and urinary retention. They are also contraindicated in patients with closed-angle glaucoma.
An equivalent alternative to beta-blockers could also be the 5HT2a receptor antagonists such as mirtazapine (remeron) and cyproheptadine (periactin). This class of medications is thought to act by an inhibitory control of dopaminergic neurons. Sedation and weight gain are the primary toxicities, and they are contraindicated in patients who are breastfeeding.
Benzodiazepines, such as clonazepam (klonopin), have shown some efficacy in improving symptoms but the data is very limited. The risk of tolerance and dependence, coupled with the problems of sedation impacting the elderly, prompts their placement in reserve. Vitamin B6 (pyridoxine), when given in a high dose format, causes significant improvement in akathisia. However, it can cause headache and nausea. Chronic administration of high doses has also been found to cause a severe and irreversible sensory neuropathy as well as lead to seizures. Many other agents have been studied, but the data are too small to warrant recommendation.
Conclusion
Akathisia remains an extreme reaction to drugs not always in the psychotropic class. The hospitalist will likely deal with the acute onset, a dramatic form, and a potentially poor outcome if untreated. The patient’s only true defense is the physician’s clinical acumen and their ability to recognize it.
Dr. Killeen is a physician in Tampa, Fla. He practices internal medicine, hematology, and oncology, and has worked in hospice and hospital medicine.
Recommended reading
Van Gool AR, Doorduijn JK, Sevnaeve C. Severe akathisia as a side effect of metoclopramide. Pharm World Sci. 2010; 32(6):704-706.
Loonen AJM, Stahl SM. The mechanism of drug-induced akathisia. CNS Spectr. 2010;15(11):491-494.
Forcen FE, Matsoukas K, Alici Y. Antipsychotic-induced akathisia in delirium: A systemic review. Palliat Support Care. 2016;14(1):77-84.
Sethuram K, Gedzior J. Akathisia: Case presentation and review of newer treatment agents. Psychiatric Annals. 2014;44(8):391-396.
Pringsheim T, et al. The assessment and treatment of antipsychotic-induced akathisia. Can J Psychiatry. 2018;63(11): 719-729.
Tachere RO, Mandana M. Beyond anxiety and agitation: A clinical approach to akathisia. Royal Australian Coll Gen Practitioners. 2017;46(5): 296-298.
Key points
- Although associated more with psychiatric medications, akathisia can occur with non-psychotropics as well.
- To recognize the illness, the clinician must notice the repetitive involuntary movements and pacing as well as the “ants in the pants” fidgeting involved.
- Primary treatment consists of medication discontinuation with pharmaceutical intervention as a backup.
- Recognition is the key to successful treatment.
Classic signs of akathisia
- Fidgeting – “ants in the pants”
- Swinging the legs while seated
- Rocking from foot to foot
- Walking while in a static position
- Inability to sit or stand still – pacing
- Onset appears with the initiation or dose adjustment of an offending drug
Quiz
1. Which of the following findings occur in Akathisia?
A. Fidgeting
B. Pacing
C. Swinging the legs while seated
D. All the above
Answer: D
Akathisia is manifest as involuntary hyperactivity of the extremities, particularly the lower extremities. People feel the urge to move, to continue endlessly in motion, stopping only when fatigue sets in. The fidgeting has been described by patients as feeling like “ants in the pants.”
2. Which of the following interventions are used to treat akathisia?
A. Drug discontinuation
B. Propranolol
C. Mirtazapine
D. All the above
Answer: D
All the interventions mentioned are used to treat akathisia. The foremost is to stop the offending drug. Failing this, propranolol is the “gold standard” while 5HT2a antagonists, such as mirtazapine, are favored when beta-blockers either fail or are contraindicated.
3. The use of pyridoxine (Vitamin B6) in the treatment of akathisia is associated with what toxicities?
A. Headache
B. Nausea
C. Seizures
D. All the above
Answer: D
The use of Vitamin B6 in the treatment of akathisia has several drawbacks. Its administration is associated with headache and nausea, and high dose usage increases the risk of seizure.
4. If unresolved, akathisia can lead to which of the following?
A. Insomnia
B. Suicide
C. Physical exhaustion
D. All the above
Answer: D
Akathisia, left unrecognized and untreated, can eventually lead to physical exhaustion, and is compounded by difficulties in trying to rest, hence insomnia. The physical and mental torment of this malady can lead to suicide.
Case
The patient is a 65-year-old female with increasing anxiety and agitation. She completed cycle 2 of chemotherapy for breast cancer several hours ago. Her premedication was Reglan (metoclopramide); her only other medication is tamoxifen. Other than breast cancer, she suffers only from osteoarthritis.
She is found pacing about the ward – almost uncontrollably. She feels she must move, only to have to stop and, shortly afterwards, feels the urge to move again. This has never happened to her before. She must move despite being fatigued. She also complains of an odd overall feeling; something akin to “ant in the pants.” She is nervous and exhausted. What is her diagnosis and what clues to it are in her presentation?
Background
The word “akathisia” is derived from the Greek language and means “unable to sit.” It is thought to occur as a consequence of dopaminergic blockade in the midbrain region. The decrease in dopaminergic activity leads to a subsequent decrease in inhibitory motor control which, in turn, manifests as involuntary movements.
In this malady, the patient is seen as perpetually in motion. The patient feels the need to move until they must stop. But once static, they have the urge to move again. They pace, they rock and they ‘fidget’ – they just cannot sit still. This feeling has been likened to having “ants in the pants.” Patients become anxious, agitated, and suffer from insomnia. They cannot rest.
If left unresolved akathisia can torment patients to sheer exhaustion. For some it serves as a harbinger of suicide. This toxicity is more commonly seen in the psychiatric pharmacy with the most common offender being haloperidol. The causative agents of the least notoriety are the non-antipsychotics.
Diagnosis and treatment
Akathisia is an extrapyramidal symptom found largely but NOT exclusively with psychiatric medications. There are drugs in the non-psychiatric field that can also cause it, including antiemetics (e.g., metoclopramide), antihypertensives (e.g., diltiazem), and narcotics (e.g., cocaine). Metoclopramide is given under circumstances ranging from diabetic gastroparesis to premedicating chemotherapy. It is a peripheral and centrally acting dopamine antagonist. There are no lab tests or radiographic workups to diagnose akathisia. Its manifestations are erratic and disturbing, and the prognosis is doleful if unresolved.
The primary intervention for the treatment of akathisia is its recognition and the discontinuation of the offending drug. Beyond this, for symptomatic care, there is a compendium of case reports and small studies supporting many drugs, but only a few have received consistent recommendation. Beta-adrenergic antagonists, such as propranolol, are considered the gold standard, the first choice for the treatment of akathisia. Their toxicities include orthostatic hypotension and bradycardia. Additionally, they are contraindicated in the setting of asthma.
Anticholinergics, such as benztropine (cogentin) and trihexylphenidyl (artane) are considered in the literature as 2nd line treatments, behind beta-blockers. However, the data advocating their use is limited. They have multiple side-effects including sedation, memory impairment, visual impairment, and urinary retention. They are also contraindicated in patients with closed-angle glaucoma.
An equivalent alternative to beta-blockers could also be the 5HT2a receptor antagonists such as mirtazapine (remeron) and cyproheptadine (periactin). This class of medications is thought to act by an inhibitory control of dopaminergic neurons. Sedation and weight gain are the primary toxicities, and they are contraindicated in patients who are breastfeeding.
Benzodiazepines, such as clonazepam (klonopin), have shown some efficacy in improving symptoms but the data is very limited. The risk of tolerance and dependence, coupled with the problems of sedation impacting the elderly, prompts their placement in reserve. Vitamin B6 (pyridoxine), when given in a high dose format, causes significant improvement in akathisia. However, it can cause headache and nausea. Chronic administration of high doses has also been found to cause a severe and irreversible sensory neuropathy as well as lead to seizures. Many other agents have been studied, but the data are too small to warrant recommendation.
Conclusion
Akathisia remains an extreme reaction to drugs not always in the psychotropic class. The hospitalist will likely deal with the acute onset, a dramatic form, and a potentially poor outcome if untreated. The patient’s only true defense is the physician’s clinical acumen and their ability to recognize it.
Dr. Killeen is a physician in Tampa, Fla. He practices internal medicine, hematology, and oncology, and has worked in hospice and hospital medicine.
Recommended reading
Van Gool AR, Doorduijn JK, Sevnaeve C. Severe akathisia as a side effect of metoclopramide. Pharm World Sci. 2010; 32(6):704-706.
Loonen AJM, Stahl SM. The mechanism of drug-induced akathisia. CNS Spectr. 2010;15(11):491-494.
Forcen FE, Matsoukas K, Alici Y. Antipsychotic-induced akathisia in delirium: A systemic review. Palliat Support Care. 2016;14(1):77-84.
Sethuram K, Gedzior J. Akathisia: Case presentation and review of newer treatment agents. Psychiatric Annals. 2014;44(8):391-396.
Pringsheim T, et al. The assessment and treatment of antipsychotic-induced akathisia. Can J Psychiatry. 2018;63(11): 719-729.
Tachere RO, Mandana M. Beyond anxiety and agitation: A clinical approach to akathisia. Royal Australian Coll Gen Practitioners. 2017;46(5): 296-298.
Key points
- Although associated more with psychiatric medications, akathisia can occur with non-psychotropics as well.
- To recognize the illness, the clinician must notice the repetitive involuntary movements and pacing as well as the “ants in the pants” fidgeting involved.
- Primary treatment consists of medication discontinuation with pharmaceutical intervention as a backup.
- Recognition is the key to successful treatment.
Classic signs of akathisia
- Fidgeting – “ants in the pants”
- Swinging the legs while seated
- Rocking from foot to foot
- Walking while in a static position
- Inability to sit or stand still – pacing
- Onset appears with the initiation or dose adjustment of an offending drug
Quiz
1. Which of the following findings occur in Akathisia?
A. Fidgeting
B. Pacing
C. Swinging the legs while seated
D. All the above
Answer: D
Akathisia is manifest as involuntary hyperactivity of the extremities, particularly the lower extremities. People feel the urge to move, to continue endlessly in motion, stopping only when fatigue sets in. The fidgeting has been described by patients as feeling like “ants in the pants.”
2. Which of the following interventions are used to treat akathisia?
A. Drug discontinuation
B. Propranolol
C. Mirtazapine
D. All the above
Answer: D
All the interventions mentioned are used to treat akathisia. The foremost is to stop the offending drug. Failing this, propranolol is the “gold standard” while 5HT2a antagonists, such as mirtazapine, are favored when beta-blockers either fail or are contraindicated.
3. The use of pyridoxine (Vitamin B6) in the treatment of akathisia is associated with what toxicities?
A. Headache
B. Nausea
C. Seizures
D. All the above
Answer: D
The use of Vitamin B6 in the treatment of akathisia has several drawbacks. Its administration is associated with headache and nausea, and high dose usage increases the risk of seizure.
4. If unresolved, akathisia can lead to which of the following?
A. Insomnia
B. Suicide
C. Physical exhaustion
D. All the above
Answer: D
Akathisia, left unrecognized and untreated, can eventually lead to physical exhaustion, and is compounded by difficulties in trying to rest, hence insomnia. The physical and mental torment of this malady can lead to suicide.
Emerging research shows link between suicidality, ‘high-potency’ cannabis products
Number of suicides positive for marijuana on rise soared among Colorado youth
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
Number of suicides positive for marijuana on rise soared among Colorado youth
Number of suicides positive for marijuana on rise soared among Colorado youth
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
In the days since recreational sales of marijuana became legal in Colorado in January 2014, concerning trends have emerged among the state’s young cannabis users.
According to a report from the Rocky Mountain High Intensity Drug Trafficking Area, between 2014 and 2017, the number of suicides positive for marijuana increased 250% among those aged 10-19 years (from 4 to 14) and 22% among those aged 20 and older (from 118 to 144). “Other states are seeing something similar, and there is an emerging research showing a relationship between suicidality and the use of marijuana, especially high-potency products that are available in legalized markets,” Paula D. Riggs, MD, reported during an annual psychopharmacology update held by the Nevada Psychiatric Association.
During that same 3-year time span, the proportion of Colorado youth aged 12 years and older who used marijuana in the past month jumped by 45%, which is more than 85% above the national average. “Similarly, among college-age students, we’ve seen an 18% increase in past-month marijuana use, which is 60% above the national average,” said Dr. Riggs, professor and vice chair of psychiatry at the University of Colorado at Denver, Aurora.
Among adolescents, state health officials have observed a 5% increase in the proportion of those who used marijuana in the past month, which is more than 54% above the national average. “But a concerning trend is that we’re seeing an increase in the use of concentrates such as dabs and waxes,” she said. “That’s worrisome in terms of exposure to high-potency products.”
In other findings, 48% of young marijuana users reported going to work high (40% at least once per week), and there has been a 170% increase in youth ED urgent care visits for marijuana-related illnesses such as cannabinoid hyperemesis syndrome or first-episode psychosis. State health officials have also observed a 148% increase in marijuana-related hospitalizations.
According to Dr. Riggs, who also directs the University of Colorado’s division of addiction science, prevention, and treatment, the average marijuana joint in the 1960s contained about 3% tetrahydrocannabinol (THC), a level that crept up to the 4%-6% range in 2002. In today’s postlegalization era, the average joint now contains 13%-23% THC. “What’s concerning is that the concentrates – the dabs, waxes, shatter, and butane hash oils – contain upward of 70%-95% THC,” Dr. Riggs said. “Those are highly potent products that represent about 25% of the market share now. That’s a very big concern because the higher the potency the cannabis product used, the greater the abuse liability and addictive potential.”
The use of high-potency products also doubles the risk of developing generalized anxiety disorder, triples the risk of tobacco dependence, doubles the risk of other illicit substance disorders, and it at least quadruples the risk of developing first-episode psychosis in young people. “So, when you’re taking a cannabis use history, it’s important to ask patients about the potency of the products being used,” she said.
In the 2019 Monitoring the Future survey, 12% of U.S. 8th graders self-reported marijuana use in the past year and 7% in the past month, compared with 29% and 18% of 10th graders, respectively. Self-reported use by 12th graders was even more elevated (36% in the past year and 29% in the past month). “The concern is, this survey doesn’t really capture what’s happening with marijuana concentrates,” Dr. Riggs said.
A survey of Colorado youth conducted by the state’s Department of Public Health and Environment found that the percentage of students who reported using concentrated forms of marijuana has risen steadily in recent years and now stands at roughly 34%. “The use of edibles has also crept up,” said Dr. Riggs, who noted that marijuana dispensaries in Colorado outnumber Starbucks locations and McDonald’s restaurants. “You might not think that’s particularly concerning, except that the use of edibles is even more associated with onset of psychosis than other forms. This is probably because when you eat a marijuana product, you can’t control the exposure or the dose that you’re ingesting. We need to be concerned about these trends.”
European studies report that 30%-50% of new cases of first-onset psychosis are attributed to high-potency cannabis. “There is a dose-response relationship between cannabis and psychosis,” Dr. Riggs said. “That is, the frequency and duration of cannabis use, or the use of high-potency products, and the age of onset, are strongly associated with the risk of first-episode psychosis.
Researchers have known for some time that alterations in the endocannabinoid system are associated with psychosis independent of cannabis exposure. “Dysregulation of that endocannabinoid system occurs in patients at all stages of the psychosis continuum,” she continued. “It also means that the endocannabinoid system is a potential therapeutic target for psychosis.”
According to Dr. Riggs, THC exposure acutely increases dopamine in the ventral striatum and it can produce transient psychotomimetic effects in clinical and nonclinical populations. Genetic differences in the dopaminergic system can also interact with cannabis use to increase the risk of psychosis.
“For example, the COMT (catechol-O-methyltransferase) breaks down catecholamines such as dopamine in the prefrontal cortex,” she explained. “If you have a COMT gene polymorphism, that increases your risk of developing psychosis due to increased levels of dopamine signaling.”
She emphasized the importance of clinicians to understand that the age of cannabis use onset, the duration, frequency, and THC potency is related to the psychosis risk and worse prognosis. The earlier the initiation of marijuana use, the greater potential for first-episode psychosis. “Those who continue using cannabis after a first-episode psychosis have greater severity of psychotic illness and more treatment resistance, and they’re less likely to engage or be compliant with treatment recommendations,” Dr. Riggs said. “So, Because if they resume cannabis use, this can turn into a more chronic psychotic disorder.”
She added that, while insufficient evidence exists to determine whether cannabis plays a causal role in the development of schizophrenia or not, mounting evidence suggests that cannabis use may precipitate earlier onset of schizophrenia in those with other risk factors for the disorder. “There is considerable evidence that cannabis use increases the risk of psychosis in a dose-related manner, especially with an onset before age 16,” Dr. Riggs said. “However, this does not mean that cannabis is safe for young adults. Cannabis-induced psychotic symptoms often develop during young adulthood and may become chronic.”
Dr. Riggs disclosed that she had received grant funding from the National Institute on Drug Abuse. She is also executive director for Encompass, which provides integrated treatment for adolescents and young adults.
FROM NPA 2021
Victorious endurance: To pass the breaking point and not break
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.
I’ve been thinking a lot about endurance recently.
COVID-19 is surging in the United States. Health care workers exhausted from the first and second waves are quickly reaching the verge of collapse. I’m seeing more and more heartbreaking articles about the bone-deep fatigue, fear, and frustration health care workers are facing, and I weep. As horrible as it is to be fighting this terrifying, little-understood, invisible virus, health care workers are also fighting an equally distressing war against misinformation, recklessness, apathy, and outright denial.
As if that wasn’t enough, we are also dealing with racial and social unrest not seen in decades. The most significant cultural divisions and political animosity perhaps since the Civil War. A contested election. The fraying of our democratic institutions and our standing in the global community. The weakest economy since the Great Depression. Record unemployment. Many individuals and families facing or already experiencing eviction and food insecurity. Record-setting fires, hurricanes, and other natural disasters that are only projected to intensify due to climate change.
That’s a lot to endure. And we don’t have much choice other than to live through it. Some of us will break under the strain; others will disengage by giving up clinical work or even leaving health care altogether. Some of us will pack it in and retire, walk away from relationships with family members or longtime friends, or even emigrate to another country (New Zealand, anyone?). Some of us will passively hunker down, letting the challenges of this time overwhelm us and just hoping we can hang on long enough to emerge, albeit beaten and scarred, on the other side.
But some of us will experience victorious endurance – the kind that doesn’t just accept suffering but finds a way to triumph over it. I came across the concept of victorious endurance in the Bible, but its origin is earlier, from classical Greece. It comes from the ancient Greek word hupomone, which literally means “abiding under” – as in disciplining oneself to bear up under a trial when one would more naturally rebel, or just give up. The ancient Greeks were big on virtues like self-control, long-suffering, and perseverance in the face of seemingly insurmountable difficulties; Odysseus was a poster child for hupomone. I believe the concept of victorious endurance can be applicable for people across many belief systems, philosophies, and ways of life.
The late William Barclay, former professor of divinity and biblical criticism at the University of Glasgow, Scotland, said of hupomone:
It is untranslatable. It does not describe the frame of mind which can sit down with folded hands and bowed head and let a torrent of troubles sweep over it in passive resignation. It describes the ability to bear things in such a triumphant way that it transfigures them. Chrysostom has a great panegyric on this hupomone. He calls it “the root of all goods, the mother of piety, the fruit that never withers, a fortress that is never taken, a harbour that knows no storms” and “the queen of virtues, the foundation of right actions, peace in war, calm in tempest, security in plots.” It is the courageous and triumphant ability to pass the breaking-point and not to break and always to greet the unseen with a cheer. It is the alchemy which transmutes tribulation into strength and glory.
Barclay further noted that “Cicero defines patientia, its Latin equivalent, as: ‘The voluntary and daily suffering of hard and difficult things, for the sake of honour and usefulness.”
In the midst of the most challenging public health emergency of our lifetimes, I am seeing hospitalists – and nurses, respiratory therapists, and countless other health care workers – doing exactly this, every day. I’m so incredibly proud of you all, and thankful beyond words.
I doubt that victorious endurance comes naturally to any of us; it’s something we work at, pursue and nurture. What’s the secret to cultivating victorious endurance in the midst of unimaginable stress? I’m pretty sure there’s no specific formula. I don’t mean to sound like a Pollyanna or to make light of the tumult and turmoil of these times, but here are a few things that, based on my own experiences, may help cultivate this valuable virtue.
Be part of a support network. In the midst of great stress, and especially during this time of social distancing, it’s especially tempting to just hunker down, close in on ourselves, and shut others out – sometimes even our closest friends and loved ones. Maintaining relationships is just too exhausting. But you need people who can come alongside you and offer words of encouragement when you are at your lowest. And there’s nothing that will bring out the best in you like being there to encourage and support someone else. We all need to both receive and to give emotional support at a time like this.
Take the long view. When we’re in the middle of a serious crisis, it seems like the problems we’re facing will last forever. There’s no light at the end of the tunnel, no port in the storm. But even this pandemic won’t last forever. If we can keep in mind the fact that things will eventually get better and that the current situation isn’t permanent, it can help us maintain our perspective and have more patience with the current dysfunction.
Focus on who you want to be in this moment. This is the hardest time most of us have ever lived through, both professionally and personally. But let me throw you a challenge. When you look back on this time from the perspective of five years from now, or maybe ten, how will you want to remember yourself? Who will you want to have been during this time? Looking back, what will make you proud of how you handled this challenge? Be that person.
Look for things to be thankful for. In the midst of the chaos that is our lives and our work right now, I believe we can still occasionally see moments of grace if we keep our eyes open for them. If we aren’t looking for them, we may miss them entirely. And those small moments of love, touches of compassion, displays of selflessness, and even flashes of victorious endurance in yourself or others are gifts to be treasured and held on to – to give thanks for.
Embrace a cause greater than yourself. May I suggest that one thing that might help our efforts to cultivate the virtue of victorious endurance during difficult times might be to embrace a cause that is bigger than yourself; that is, one that lures you to focus beyond your immediate circumstances? What are you passionate about, outside of your life’s normal routine?
If you don’t have a passion, consider what you might become passionate about, with a little effort. For some of us, like me, this will be our faith in God. For others it may be advocating for an end to racism or for broader social justice issues. Maybe it’s working to overcome our cultural and political divisions or to strengthen the institutions of our democracy. Perhaps it’s getting involved with efforts to mitigate climate change. Maybe it’s reaching out to the homeless or hungry in your own community or mentoring a child who is being left behind by the demands of remote learning.
Or perhaps what you embrace is even closer to home: maybe it’s working to eliminate health disparities in your institution or health system, or figuring out how to use technology and resources differently to improve how care is being delivered during or after this pandemic. Maybe it’s as simple as re-committing yourself to personally care for every patient you see today with the very best you have to offer, and with patience, compassion, and grace.
Find something that sets your heart on fire. Something that makes you want to take this difficult time and “transmute tribulation into strength and glory.” Something that, when you look back on these days, will make you thankful that you didn’t just hunker down and subsist through them. Instead, you accomplished great things; you learned; you contributed; and you grew stronger and better.
That’s victorious endurance.
Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey. This essay was published initially on The Hospital Leader, the official blog of SHM.