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Virtual school is especially difficult for children with ADHD
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.
The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.
Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.
Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
Promote good sleep patterns
Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.
So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.
Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
Create routines around the “school day”
Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.
Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.
The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
Set the stage
Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.
Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
Create reasonable expectations and positive rewards
Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.
Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).
Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.
So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
Build in breaks from the screen
Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.
Ensure there is some physical activity
Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.
They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
Know your child
Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.
Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.
Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.
If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.
Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.
If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.
Getting the most out of a psychiatric consultation
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at pdnews@mdedge.com.
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at pdnews@mdedge.com.
You’ve been struggling with what to do for a patient who has a significant mental health problem and really would love to have some help. You’re willing to fill out the requisite referral forms and wait your turn for what seems like an excruciating amount of time. But how do you ensure that you, your patient, and the family get the most out of the consultative experience so that everyone’s questions are answered and ongoing care, if needed, can continue?
To be fair, most of the burden of doing a good psychiatric or mental health consultation rests on the consultant, not the person making the request. It is their job to do a thorough evaluation and to identify any additional pieces of information that may be missing before a strong conclusion can be made. That said, however, this is the real world where everyone is busy and few have the time to track down every loose end that may exist regarding a patient’s history.
To that end, here are some recommendations for how to increase the chance that the outcome of your consultation with a child psychiatrist or other mental health professional will be maximally helpful for everyone involved. These tips are based on having been on the receiving end of psychiatric consultations for almost 2 decades and having worked closely with primary care clinicians in a number of different capacities.
The first question to ask yourself, and this may be the most important one of all, is whether or not you really need an actual psychiatrist at all at this stage versus another type of mental health professional. Physicians often are most comfortable dealing with other physicians. If a pediatrician has a question about a patient’s heart, it’s logical to consult a cardiologist. Thus if there’s a question about mental health, the knee-jerk reaction is to consult a psychiatrist. While understandable, looking first to a psychiatrist to help with a patient’s mental health struggles often is not the best move. Psychiatrists make up only one small part of all mental health professionals that also include psychologists, counselors, and clinical social workers, among others. The availability of child and adolescent psychiatrists can been exceedingly sparse while other types of mental health professionals generally are much more available. Moreover, these other types of mental health professionals also can do a great job at assessment and treatment. It is true that most can’t prescribe medication, but best practice recommendations for most of the common mental health diagnoses in youth (anxiety, depression, obsessive compulsive disorder, etc.) explicitly outline that nonpharmacologic treatments should be used first. It breaks my heart every time I do a consult for a family who has waited 6 months only to have me recommend a good therapist they could have seen right off in a week.
Get to know the mental health resources of your community beyond the small number of psychiatrists who might be there. And if you aren’t sure whether or not a referral might best go first to a mental health professional who is not a psychiatrist, just ask. That quick phone call or email might save the family a needless delay in treatment and a lot of aggravation for you.
If you are confident that it is a child & adolescent psychiatrist you want your patient to see, here are some things that will help you get the most out of that consultation and help you avoid the disappointment (for both you and the family) of an evaluation that completely misses the mark.
Select the best site (if you have an option)
Broadly speaking, psychiatrists often can be found in three main areas: academic clinics, private practice, and community mental health centers. While of course there is huge variation of clinicians at each of the sites, some generalizations regarding typical advantages and disadvantages of each setting are probably fair.
Academic settings often have psychiatrists who are local or even national experts on particular topics and can be good places to get evaluations for patients with complicated histories. At the same time, however, these settings typically rely on trainees to do much of the actual work. Many of the residents and fellows are excellent, but they turn over quickly because of graduation and finishing rotations, which can force patients to get to know a lot of different people. Academic centers also can be quite a distance from a family’s home, which often makes follow-up care a challenge (especially when we go back to more in-person visits).
Private practice psychiatrists can provide a more local option and can give families access to experienced clinicians, but many of these practices (especially the ones that take insurance) have practice models that involve seeing a lot of patients for short amounts of time and with less coordination with other types of services.
Finally, psychiatrists working at community mental health centers often work in teams that can help families get access to a lot of useful ancillary services (case management, home supports, etc.) but are part of a public mental health system that sadly is all too often overstretched and underfunded.
If you have choices for where to go for psychiatric services, keeping these things in mind can help you find the best fit for families.
Provide a medication history
While I’m not a big fan of the “what medicine do I try next?” consultation, don’t rely on families to provide this information accurately. Medications are confusing, and I can’t tell you how many times I’ve heard: “I tried the little blue pill and then the big white capsule.” Nobody feels good if the end result of a long consultative process includes a recommendation for a medication that the patient has already tried and failed. Some EMRs now have this information in a way that can be more easily packaged and shared.
State what you are looking for
If you really want the psychiatrist to take over the care of the patient, are just looking for some guidance for what to do next, or are seeking a second opinion for a patient that already works with a psychiatrist, stating so specifically can help tailor the consultation to best address the situation.
Send along past evaluations
Many patients have accumulated detailed psychological or educational evaluations over time that can include some really important information like cognitive profiles, other diagnostic impressions, and past treatment recommendations that may or may not have been implemented. Having these available to the consulting psychiatrist (of course parents need to give permission to send these along) can help the consultant avoid asking redundant questions or recommend things that already have been tried.
Rule outs of medical causes
There are a lot of psychiatric symptoms that can be caused by nonpsychiatric causes. Sometimes, there can be an assumption on the part of the psychiatrist that the pediatrician already has evaluated for these possibilities while the pediatrician assumes that the psychiatrist will work those up if needed. This is how the care of some patients fall through the cracks, and how those unflattering stories of how patients were forced to live with undiagnosed ailments (seizures, encephalopathy, Lyme disease, etc.) for years are generated. Being clear what work-up and tests already have been done to look for other causes can help everyone involved decide what should be done next and who should do it.
Yes, it is true that most of the recommendations specified here involve more work that the quick “behavioral problems: eval and treat” note that may be tempting to write when consulting with a mental health professional, but they will help avoid a lot of headaches for you down the road and, most importantly, get patients and families the timely and comprehensive care they deserve.
Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. Dr. Rettew said he had no relevant financial disclosures. Email Dr. Rettew at pdnews@mdedge.com.
Counterintuitive findings for domestic violence during COVID-19
Intimate partner violence (IPV) has not increased during the COVID-19 pandemic, at least during the early stages of the pandemic, new research suggests.
In April 2020, investigators surveyed over 1,750 individuals in intimate partner relationships. The survey was drawn from social media and email distribution lists. The researchers found that, of the roughly one-fifth who screened positive for IPV, half stated that the degree of victimization had remained the same since the COVID-19 outbreak; 17% reported that it had worsened; and one third reported that it had gotten better.
Those who reported worsening victimization said that sexual and physical violence, in particular, were exacerbated early in the pandemic’s course.
“I was surprised by this finding, and we certainly were not expecting it – in fact, I expected that the vast majority of victims would report that victimization got worse during stay-at-home policies, but that wasn’t the case,” lead author Katelyn Jetelina, PhD, MPH, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.
“I think the biggest take-home message is that some victims got better, but the vast majority stayed the same. These victims, men and women, were isolated with their perpetrator during COVID-19, so she added.
The study was published online Sept. 1 in Injury Prevention.
‘Shadow pandemic?’
The World Health Organization called upon health care organizations to be prepared to curb a potential IPV “shadow pandemic” during the COVID-19 pandemic.
However, no study has specifically evaluated whether self-reported victimization, particularly with regard to the severity and type of abuse, changed during the early period after COVID-19 social distancing polices were mandated.
“We scrambled right away when the pandemic hit because it was a unique opportunity to examine how behaviors change due to early stay-at-home policies; and, as a violence and injury epidemiologist, I am always curious about IPV, and this was a small subanalysis of that larger question,” Dr. Jetelina said.
The researchers recruited participants through their university and private social media accounts as well as professional distribution lists. Of those who completed the survey, 1,759 (mean age, 42 years) reported that they currently had an intimate partner. These participants were included in the study.
IPV was determined using the five-item Extended Hurt, Insulted, Threatened, and Scream (E-HITS) construct. Respondents were asked how often their partner physically hurt them, insulted them, threatened them with harm, screamed or cursed at them, or forced them to engage in sexual activities.
Each item was answered using a 5-point Likert scale. Scores ranged from 1, indicating never, to 5, indicating frequently. Participants who scored ≥7 were considered IPV positive.
Participants were also asked whether IPV severity had gotten much/somewhat better, had remained the same, or had gotten somewhat/much worse.
First peek
Of the total sample, 18% screened positive for IPV. Of these, 54% reported that the victimization had remained the same, 17% reported that it had worsened, and 30% said it had improved.
The majority of IPV victims experienced being insulted (97%) or being screamed at (86%).
Among those who reported worsening of IPV, the risk for physical violence was 4.38 times higher than the risk for nonphysical victimization. The risk for sexual victimization was 2.31 times higher than the risk for nonsexual victimization.
Among those who reported that IPV had gotten better, the improvement was 3.47 times higher with regard to physical victimization, compared with nonphysical victimization. Dr. Jetelina acknowledged that the findings cannot be generalized to the broader population.
“This was a convenience sample, but it is the first peek into what is happening behind closed doors and a first step to hearing collecting data from the victims themselves to better understand this ‘shadow pandemic’ and inform creative efforts to create better services for them while they are in isolation,” she said.
Lethality indicators
Commenting on the study, Peter Cronholm, MD, MSCE, associate professor of family medicine and community health at the Hospital of the University of Pennsylvania, Philadelphia, questioned the use of a score of 7 on the E-HITS screen to determine the presence of IPV.
“I think there are other thresholds that might be important, and even low levels of sexual violence may be different than higher levels of emotional violence,” said Dr. Cronholm, who was not involved with the study.
“Someone may have been sexually assaulted frequently but not cross the threshold, so I think it would have been helpful for the researchers to look at different types of violence,” he said.
Also commenting on the study, Jessica Palardy, LSW, program supervisor at STOP Intimate Partner Violence, Philadelphia, said, the findings “solidify a trend we sensed was happening but couldn’t confirm.”
She said her agency’s clients “have had a wide variety of experiences, in terms of increases or decreases in victimization.”
Some clients were able to use the quarantine as an excuse to stay with family or friends and so could avoid seeing their partners. “Others indicated that because their partners were distracted by figuring out a new method of work, the tension shifted away from the victim,” said Ms. Palardy, who was not involved in the research.
“For those who saw an increase in victimization, we noticed that this increase also came with an increase in lethality indicators, such as strangulation, physical violence, use of weapons and substances, etc,” she said.
She emphasized that it is critical to screen people for IPV to ensure their safety.
“The goal is to connect people with resources before they are in a more lethal situation so that they can increase their safety and know their options,” Ms. Palardy said.
The National Domestic Violence Hotline and the Crisis Text Line are two sources of support for IPV victims.
Dr. Jetelina and coauthors, Dr. Cronholm, and Ms. Palardy reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Intimate partner violence (IPV) has not increased during the COVID-19 pandemic, at least during the early stages of the pandemic, new research suggests.
In April 2020, investigators surveyed over 1,750 individuals in intimate partner relationships. The survey was drawn from social media and email distribution lists. The researchers found that, of the roughly one-fifth who screened positive for IPV, half stated that the degree of victimization had remained the same since the COVID-19 outbreak; 17% reported that it had worsened; and one third reported that it had gotten better.
Those who reported worsening victimization said that sexual and physical violence, in particular, were exacerbated early in the pandemic’s course.
“I was surprised by this finding, and we certainly were not expecting it – in fact, I expected that the vast majority of victims would report that victimization got worse during stay-at-home policies, but that wasn’t the case,” lead author Katelyn Jetelina, PhD, MPH, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.
“I think the biggest take-home message is that some victims got better, but the vast majority stayed the same. These victims, men and women, were isolated with their perpetrator during COVID-19, so she added.
The study was published online Sept. 1 in Injury Prevention.
‘Shadow pandemic?’
The World Health Organization called upon health care organizations to be prepared to curb a potential IPV “shadow pandemic” during the COVID-19 pandemic.
However, no study has specifically evaluated whether self-reported victimization, particularly with regard to the severity and type of abuse, changed during the early period after COVID-19 social distancing polices were mandated.
“We scrambled right away when the pandemic hit because it was a unique opportunity to examine how behaviors change due to early stay-at-home policies; and, as a violence and injury epidemiologist, I am always curious about IPV, and this was a small subanalysis of that larger question,” Dr. Jetelina said.
The researchers recruited participants through their university and private social media accounts as well as professional distribution lists. Of those who completed the survey, 1,759 (mean age, 42 years) reported that they currently had an intimate partner. These participants were included in the study.
IPV was determined using the five-item Extended Hurt, Insulted, Threatened, and Scream (E-HITS) construct. Respondents were asked how often their partner physically hurt them, insulted them, threatened them with harm, screamed or cursed at them, or forced them to engage in sexual activities.
Each item was answered using a 5-point Likert scale. Scores ranged from 1, indicating never, to 5, indicating frequently. Participants who scored ≥7 were considered IPV positive.
Participants were also asked whether IPV severity had gotten much/somewhat better, had remained the same, or had gotten somewhat/much worse.
First peek
Of the total sample, 18% screened positive for IPV. Of these, 54% reported that the victimization had remained the same, 17% reported that it had worsened, and 30% said it had improved.
The majority of IPV victims experienced being insulted (97%) or being screamed at (86%).
Among those who reported worsening of IPV, the risk for physical violence was 4.38 times higher than the risk for nonphysical victimization. The risk for sexual victimization was 2.31 times higher than the risk for nonsexual victimization.
Among those who reported that IPV had gotten better, the improvement was 3.47 times higher with regard to physical victimization, compared with nonphysical victimization. Dr. Jetelina acknowledged that the findings cannot be generalized to the broader population.
“This was a convenience sample, but it is the first peek into what is happening behind closed doors and a first step to hearing collecting data from the victims themselves to better understand this ‘shadow pandemic’ and inform creative efforts to create better services for them while they are in isolation,” she said.
Lethality indicators
Commenting on the study, Peter Cronholm, MD, MSCE, associate professor of family medicine and community health at the Hospital of the University of Pennsylvania, Philadelphia, questioned the use of a score of 7 on the E-HITS screen to determine the presence of IPV.
“I think there are other thresholds that might be important, and even low levels of sexual violence may be different than higher levels of emotional violence,” said Dr. Cronholm, who was not involved with the study.
“Someone may have been sexually assaulted frequently but not cross the threshold, so I think it would have been helpful for the researchers to look at different types of violence,” he said.
Also commenting on the study, Jessica Palardy, LSW, program supervisor at STOP Intimate Partner Violence, Philadelphia, said, the findings “solidify a trend we sensed was happening but couldn’t confirm.”
She said her agency’s clients “have had a wide variety of experiences, in terms of increases or decreases in victimization.”
Some clients were able to use the quarantine as an excuse to stay with family or friends and so could avoid seeing their partners. “Others indicated that because their partners were distracted by figuring out a new method of work, the tension shifted away from the victim,” said Ms. Palardy, who was not involved in the research.
“For those who saw an increase in victimization, we noticed that this increase also came with an increase in lethality indicators, such as strangulation, physical violence, use of weapons and substances, etc,” she said.
She emphasized that it is critical to screen people for IPV to ensure their safety.
“The goal is to connect people with resources before they are in a more lethal situation so that they can increase their safety and know their options,” Ms. Palardy said.
The National Domestic Violence Hotline and the Crisis Text Line are two sources of support for IPV victims.
Dr. Jetelina and coauthors, Dr. Cronholm, and Ms. Palardy reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Intimate partner violence (IPV) has not increased during the COVID-19 pandemic, at least during the early stages of the pandemic, new research suggests.
In April 2020, investigators surveyed over 1,750 individuals in intimate partner relationships. The survey was drawn from social media and email distribution lists. The researchers found that, of the roughly one-fifth who screened positive for IPV, half stated that the degree of victimization had remained the same since the COVID-19 outbreak; 17% reported that it had worsened; and one third reported that it had gotten better.
Those who reported worsening victimization said that sexual and physical violence, in particular, were exacerbated early in the pandemic’s course.
“I was surprised by this finding, and we certainly were not expecting it – in fact, I expected that the vast majority of victims would report that victimization got worse during stay-at-home policies, but that wasn’t the case,” lead author Katelyn Jetelina, PhD, MPH, assistant professor in the department of epidemiology, human genetics, and environmental sciences, University of Texas Health Science Center, Dallas, said in an interview.
“I think the biggest take-home message is that some victims got better, but the vast majority stayed the same. These victims, men and women, were isolated with their perpetrator during COVID-19, so she added.
The study was published online Sept. 1 in Injury Prevention.
‘Shadow pandemic?’
The World Health Organization called upon health care organizations to be prepared to curb a potential IPV “shadow pandemic” during the COVID-19 pandemic.
However, no study has specifically evaluated whether self-reported victimization, particularly with regard to the severity and type of abuse, changed during the early period after COVID-19 social distancing polices were mandated.
“We scrambled right away when the pandemic hit because it was a unique opportunity to examine how behaviors change due to early stay-at-home policies; and, as a violence and injury epidemiologist, I am always curious about IPV, and this was a small subanalysis of that larger question,” Dr. Jetelina said.
The researchers recruited participants through their university and private social media accounts as well as professional distribution lists. Of those who completed the survey, 1,759 (mean age, 42 years) reported that they currently had an intimate partner. These participants were included in the study.
IPV was determined using the five-item Extended Hurt, Insulted, Threatened, and Scream (E-HITS) construct. Respondents were asked how often their partner physically hurt them, insulted them, threatened them with harm, screamed or cursed at them, or forced them to engage in sexual activities.
Each item was answered using a 5-point Likert scale. Scores ranged from 1, indicating never, to 5, indicating frequently. Participants who scored ≥7 were considered IPV positive.
Participants were also asked whether IPV severity had gotten much/somewhat better, had remained the same, or had gotten somewhat/much worse.
First peek
Of the total sample, 18% screened positive for IPV. Of these, 54% reported that the victimization had remained the same, 17% reported that it had worsened, and 30% said it had improved.
The majority of IPV victims experienced being insulted (97%) or being screamed at (86%).
Among those who reported worsening of IPV, the risk for physical violence was 4.38 times higher than the risk for nonphysical victimization. The risk for sexual victimization was 2.31 times higher than the risk for nonsexual victimization.
Among those who reported that IPV had gotten better, the improvement was 3.47 times higher with regard to physical victimization, compared with nonphysical victimization. Dr. Jetelina acknowledged that the findings cannot be generalized to the broader population.
“This was a convenience sample, but it is the first peek into what is happening behind closed doors and a first step to hearing collecting data from the victims themselves to better understand this ‘shadow pandemic’ and inform creative efforts to create better services for them while they are in isolation,” she said.
Lethality indicators
Commenting on the study, Peter Cronholm, MD, MSCE, associate professor of family medicine and community health at the Hospital of the University of Pennsylvania, Philadelphia, questioned the use of a score of 7 on the E-HITS screen to determine the presence of IPV.
“I think there are other thresholds that might be important, and even low levels of sexual violence may be different than higher levels of emotional violence,” said Dr. Cronholm, who was not involved with the study.
“Someone may have been sexually assaulted frequently but not cross the threshold, so I think it would have been helpful for the researchers to look at different types of violence,” he said.
Also commenting on the study, Jessica Palardy, LSW, program supervisor at STOP Intimate Partner Violence, Philadelphia, said, the findings “solidify a trend we sensed was happening but couldn’t confirm.”
She said her agency’s clients “have had a wide variety of experiences, in terms of increases or decreases in victimization.”
Some clients were able to use the quarantine as an excuse to stay with family or friends and so could avoid seeing their partners. “Others indicated that because their partners were distracted by figuring out a new method of work, the tension shifted away from the victim,” said Ms. Palardy, who was not involved in the research.
“For those who saw an increase in victimization, we noticed that this increase also came with an increase in lethality indicators, such as strangulation, physical violence, use of weapons and substances, etc,” she said.
She emphasized that it is critical to screen people for IPV to ensure their safety.
“The goal is to connect people with resources before they are in a more lethal situation so that they can increase their safety and know their options,” Ms. Palardy said.
The National Domestic Violence Hotline and the Crisis Text Line are two sources of support for IPV victims.
Dr. Jetelina and coauthors, Dr. Cronholm, and Ms. Palardy reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
ECT reduces all-cause mortality in Danish study
The two top developments of the year in the field of neurostimulation involve the oldest form of the therapy: electroconvulsive therapy, Alexander Sartorius, MD, said at the virtual congress of the European College of Neuropsychopharmacology.
One of these studies shot down the longstanding notion that ECT causes brain damage. The other, a Danish national registry study, demonstrated that ECT is associated with lower all-cause mortality than in patients with similarly severe depression who don’t undergo ECT.
“The take-home messages are that ECT does not lead to brain damage but rather to a profound gray matter increase. And secondly, ECT lowers all-cause mortality in patients with depression,” said Dr. Sartorius, a psychiatrist at the Central Institute of Mental Health in Mannheim, Germany.
The year has been less fruitful in terms of research involving deep brain stimulation using implantable electrodes, he continued.
“Basically, one can state that there is no breaking news in the field of deep brain stimulation. DBS remains a highly experimental form of therapy,” Dr. Sartorius said.
ECT-induced brain changes
Investigators participating in the international multicenter Global ECT-MRI Research Collaboration (GEMRIC) reported on the longitudinal effects of ECT on gray matter, white matter, and ventricular volumes in 328 patients who underwent imaging before and after ECT for a major depressive episode, as well as in 95 nondepressed controls.
The key finding was that ECT induced a widespread, nonspecific global increase in gray matter volume. Indeed, the volumetric increase was documented in 79 of 84 gray matter regions of interest. Subcortical gray matter volume increased by a mean of 1.47% in ECT-treated patients, and total cortical volume rose by 1.04%. Total white matter volume remained unchanged.
“The gray matter increase induced by ECT looks quite similar to the gray matter increase seen with physical activity,” Dr. Sartorius noted.
The size of the gray matter volume increase rose with the number of ECT sessions. However, gray matter enlargement in response to ECT showed no relationship with clinical response, indicating that this finding on brain imaging doesn’t have a promising future as a potential biomarker of treatment effectiveness (Biol Psychiatry. 2020 Mar 1;87[5]:451-61).
“The good news from this study is there is no gray matter decrease,” Dr. Sartorius said. “This study enhances the existing evidence falsifying the old idea or dogma that ECT induces brain damage. I would claim that the opposite is clearly the case.”
ECT and mortality
The same group of investigators at the University of Copenhagen who several years ago harnessed Danish national patient registries data to report that ECT was associated with an unadjusted 32% and adjusted 23% reduction in the risk of developing dementia in patients aged 70 years and older (Lancet Psychiatry. 2018 Apr;5[4]:348-56) have recently concluded that ECT was also associated with a 19% reduction in all-cause mortality, compared with that of patients hospitalized for major depression who didn’t receive ECT.
The national registries study included 5,004 patients who were treated with ECT and nearly 88,000 others who were hospitalized for major depression during 2005-2016 but didn’t receive ECT. During up to 11.3 years of follow-up, the risk of all-cause mortality was 8% lower with ECT than with no ECT in patients categorized as having mild depression, 17% lower with a history of ECT for moderate depression, 4% less with severe depression without psychotic features, and 30% less with ECT than no ECT for severe depression with psychotic features (J Psychopharmacol. 2020 Mar;34[3]:273-9).
ECT was associated with an adjusted 6.99-fold increased risk of suicide in patients with mild depression. At first look that’s unsettling, Dr. Sartorius said, but he pointed out that the size of the ECT-associated suicide risk lessened with increasing severity of depression, and in fact, there was no increased suicide risk with ECT in severely depressed patients with psychotic features. ECT was also associated with significantly higher rates of psychiatric rehospitalization, emergency department visits, and suicidal behavior in patients classified as having mild or moderate depression. Dr. Sartorius suspects these findings reflect diagnostic uncertainty surrounding the milder forms of depression, coupled with the reality that ECT is generally reserved for the most unstable, treatment-resistant patients.
Deep transcranial magnetic stimulation
A Taiwanese meta-analysis has helped clarify the role of deep transcranial magnetic stimulation (dTMS) for treatment-resistant depression. The meta-analysis included 198 patients with treatment-resistant depression who underwent dTMS and 219 who received sham treatment in a total of 15 studies, only three of which were randomized controlled trials.
Active treatment was associated with a 2.06-fold increased likelihood of remission of depressive symptoms; however, the effect was statistically significant only in the subgroup of patients on concurrent antidepressant medication. Moreover, the therapeutic benefit of dTMS was significantly greater in the nonrandomized studies, where the odds ratio for remission was 3.8-fold greater than with sham therapy. In contrast, the odds ratio for remission with dTMS dropped to 1.37 in the randomized trials (Prog Neuropsychopharmacol Biol Psychiatry. 2020 Apr 20;99:109850. doi: 10.1016/j.pnpbp.2019.109850). “dTMS has quite a bit of antidepressant potential in treatment-resistant depression, but as an augmentation strategy. More randomized trials are needed, with a particular focus on which classes of antidepressants might be most effective as concurrent therapy,” Dr. Sartorius concluded.
He reported having no financial conflicts regarding his presentation.
SOURCE: Sartorius A. ECNP 2020, Session TP.03.
The two top developments of the year in the field of neurostimulation involve the oldest form of the therapy: electroconvulsive therapy, Alexander Sartorius, MD, said at the virtual congress of the European College of Neuropsychopharmacology.
One of these studies shot down the longstanding notion that ECT causes brain damage. The other, a Danish national registry study, demonstrated that ECT is associated with lower all-cause mortality than in patients with similarly severe depression who don’t undergo ECT.
“The take-home messages are that ECT does not lead to brain damage but rather to a profound gray matter increase. And secondly, ECT lowers all-cause mortality in patients with depression,” said Dr. Sartorius, a psychiatrist at the Central Institute of Mental Health in Mannheim, Germany.
The year has been less fruitful in terms of research involving deep brain stimulation using implantable electrodes, he continued.
“Basically, one can state that there is no breaking news in the field of deep brain stimulation. DBS remains a highly experimental form of therapy,” Dr. Sartorius said.
ECT-induced brain changes
Investigators participating in the international multicenter Global ECT-MRI Research Collaboration (GEMRIC) reported on the longitudinal effects of ECT on gray matter, white matter, and ventricular volumes in 328 patients who underwent imaging before and after ECT for a major depressive episode, as well as in 95 nondepressed controls.
The key finding was that ECT induced a widespread, nonspecific global increase in gray matter volume. Indeed, the volumetric increase was documented in 79 of 84 gray matter regions of interest. Subcortical gray matter volume increased by a mean of 1.47% in ECT-treated patients, and total cortical volume rose by 1.04%. Total white matter volume remained unchanged.
“The gray matter increase induced by ECT looks quite similar to the gray matter increase seen with physical activity,” Dr. Sartorius noted.
The size of the gray matter volume increase rose with the number of ECT sessions. However, gray matter enlargement in response to ECT showed no relationship with clinical response, indicating that this finding on brain imaging doesn’t have a promising future as a potential biomarker of treatment effectiveness (Biol Psychiatry. 2020 Mar 1;87[5]:451-61).
“The good news from this study is there is no gray matter decrease,” Dr. Sartorius said. “This study enhances the existing evidence falsifying the old idea or dogma that ECT induces brain damage. I would claim that the opposite is clearly the case.”
ECT and mortality
The same group of investigators at the University of Copenhagen who several years ago harnessed Danish national patient registries data to report that ECT was associated with an unadjusted 32% and adjusted 23% reduction in the risk of developing dementia in patients aged 70 years and older (Lancet Psychiatry. 2018 Apr;5[4]:348-56) have recently concluded that ECT was also associated with a 19% reduction in all-cause mortality, compared with that of patients hospitalized for major depression who didn’t receive ECT.
The national registries study included 5,004 patients who were treated with ECT and nearly 88,000 others who were hospitalized for major depression during 2005-2016 but didn’t receive ECT. During up to 11.3 years of follow-up, the risk of all-cause mortality was 8% lower with ECT than with no ECT in patients categorized as having mild depression, 17% lower with a history of ECT for moderate depression, 4% less with severe depression without psychotic features, and 30% less with ECT than no ECT for severe depression with psychotic features (J Psychopharmacol. 2020 Mar;34[3]:273-9).
ECT was associated with an adjusted 6.99-fold increased risk of suicide in patients with mild depression. At first look that’s unsettling, Dr. Sartorius said, but he pointed out that the size of the ECT-associated suicide risk lessened with increasing severity of depression, and in fact, there was no increased suicide risk with ECT in severely depressed patients with psychotic features. ECT was also associated with significantly higher rates of psychiatric rehospitalization, emergency department visits, and suicidal behavior in patients classified as having mild or moderate depression. Dr. Sartorius suspects these findings reflect diagnostic uncertainty surrounding the milder forms of depression, coupled with the reality that ECT is generally reserved for the most unstable, treatment-resistant patients.
Deep transcranial magnetic stimulation
A Taiwanese meta-analysis has helped clarify the role of deep transcranial magnetic stimulation (dTMS) for treatment-resistant depression. The meta-analysis included 198 patients with treatment-resistant depression who underwent dTMS and 219 who received sham treatment in a total of 15 studies, only three of which were randomized controlled trials.
Active treatment was associated with a 2.06-fold increased likelihood of remission of depressive symptoms; however, the effect was statistically significant only in the subgroup of patients on concurrent antidepressant medication. Moreover, the therapeutic benefit of dTMS was significantly greater in the nonrandomized studies, where the odds ratio for remission was 3.8-fold greater than with sham therapy. In contrast, the odds ratio for remission with dTMS dropped to 1.37 in the randomized trials (Prog Neuropsychopharmacol Biol Psychiatry. 2020 Apr 20;99:109850. doi: 10.1016/j.pnpbp.2019.109850). “dTMS has quite a bit of antidepressant potential in treatment-resistant depression, but as an augmentation strategy. More randomized trials are needed, with a particular focus on which classes of antidepressants might be most effective as concurrent therapy,” Dr. Sartorius concluded.
He reported having no financial conflicts regarding his presentation.
SOURCE: Sartorius A. ECNP 2020, Session TP.03.
The two top developments of the year in the field of neurostimulation involve the oldest form of the therapy: electroconvulsive therapy, Alexander Sartorius, MD, said at the virtual congress of the European College of Neuropsychopharmacology.
One of these studies shot down the longstanding notion that ECT causes brain damage. The other, a Danish national registry study, demonstrated that ECT is associated with lower all-cause mortality than in patients with similarly severe depression who don’t undergo ECT.
“The take-home messages are that ECT does not lead to brain damage but rather to a profound gray matter increase. And secondly, ECT lowers all-cause mortality in patients with depression,” said Dr. Sartorius, a psychiatrist at the Central Institute of Mental Health in Mannheim, Germany.
The year has been less fruitful in terms of research involving deep brain stimulation using implantable electrodes, he continued.
“Basically, one can state that there is no breaking news in the field of deep brain stimulation. DBS remains a highly experimental form of therapy,” Dr. Sartorius said.
ECT-induced brain changes
Investigators participating in the international multicenter Global ECT-MRI Research Collaboration (GEMRIC) reported on the longitudinal effects of ECT on gray matter, white matter, and ventricular volumes in 328 patients who underwent imaging before and after ECT for a major depressive episode, as well as in 95 nondepressed controls.
The key finding was that ECT induced a widespread, nonspecific global increase in gray matter volume. Indeed, the volumetric increase was documented in 79 of 84 gray matter regions of interest. Subcortical gray matter volume increased by a mean of 1.47% in ECT-treated patients, and total cortical volume rose by 1.04%. Total white matter volume remained unchanged.
“The gray matter increase induced by ECT looks quite similar to the gray matter increase seen with physical activity,” Dr. Sartorius noted.
The size of the gray matter volume increase rose with the number of ECT sessions. However, gray matter enlargement in response to ECT showed no relationship with clinical response, indicating that this finding on brain imaging doesn’t have a promising future as a potential biomarker of treatment effectiveness (Biol Psychiatry. 2020 Mar 1;87[5]:451-61).
“The good news from this study is there is no gray matter decrease,” Dr. Sartorius said. “This study enhances the existing evidence falsifying the old idea or dogma that ECT induces brain damage. I would claim that the opposite is clearly the case.”
ECT and mortality
The same group of investigators at the University of Copenhagen who several years ago harnessed Danish national patient registries data to report that ECT was associated with an unadjusted 32% and adjusted 23% reduction in the risk of developing dementia in patients aged 70 years and older (Lancet Psychiatry. 2018 Apr;5[4]:348-56) have recently concluded that ECT was also associated with a 19% reduction in all-cause mortality, compared with that of patients hospitalized for major depression who didn’t receive ECT.
The national registries study included 5,004 patients who were treated with ECT and nearly 88,000 others who were hospitalized for major depression during 2005-2016 but didn’t receive ECT. During up to 11.3 years of follow-up, the risk of all-cause mortality was 8% lower with ECT than with no ECT in patients categorized as having mild depression, 17% lower with a history of ECT for moderate depression, 4% less with severe depression without psychotic features, and 30% less with ECT than no ECT for severe depression with psychotic features (J Psychopharmacol. 2020 Mar;34[3]:273-9).
ECT was associated with an adjusted 6.99-fold increased risk of suicide in patients with mild depression. At first look that’s unsettling, Dr. Sartorius said, but he pointed out that the size of the ECT-associated suicide risk lessened with increasing severity of depression, and in fact, there was no increased suicide risk with ECT in severely depressed patients with psychotic features. ECT was also associated with significantly higher rates of psychiatric rehospitalization, emergency department visits, and suicidal behavior in patients classified as having mild or moderate depression. Dr. Sartorius suspects these findings reflect diagnostic uncertainty surrounding the milder forms of depression, coupled with the reality that ECT is generally reserved for the most unstable, treatment-resistant patients.
Deep transcranial magnetic stimulation
A Taiwanese meta-analysis has helped clarify the role of deep transcranial magnetic stimulation (dTMS) for treatment-resistant depression. The meta-analysis included 198 patients with treatment-resistant depression who underwent dTMS and 219 who received sham treatment in a total of 15 studies, only three of which were randomized controlled trials.
Active treatment was associated with a 2.06-fold increased likelihood of remission of depressive symptoms; however, the effect was statistically significant only in the subgroup of patients on concurrent antidepressant medication. Moreover, the therapeutic benefit of dTMS was significantly greater in the nonrandomized studies, where the odds ratio for remission was 3.8-fold greater than with sham therapy. In contrast, the odds ratio for remission with dTMS dropped to 1.37 in the randomized trials (Prog Neuropsychopharmacol Biol Psychiatry. 2020 Apr 20;99:109850. doi: 10.1016/j.pnpbp.2019.109850). “dTMS has quite a bit of antidepressant potential in treatment-resistant depression, but as an augmentation strategy. More randomized trials are needed, with a particular focus on which classes of antidepressants might be most effective as concurrent therapy,” Dr. Sartorius concluded.
He reported having no financial conflicts regarding his presentation.
SOURCE: Sartorius A. ECNP 2020, Session TP.03.
FROM ECNP 2020
Watch for nonsuicidal self-injury in girls with ADHD, comorbidities
Recent studies constitute a clarion call for clinicians to routinely screen adolescents with ADHD for nonsuicidal self-injury (NSSI) and its risk factors, Judit Balazs, MD, PhD, said at the virtual congress of the European College of Neuropsychopharmacology.
She was lead author of one of these studies, which drew a remarkable and disturbing conclusion: “We found – and it’s a very alarming result – that more than 70% of those people who had ADHD and [nonsuicidal self-injury] were girls. The girls with ADHD seem to be a high-risk population,” observed Dr. Balazs, professor and chair of the department of developmental psychology at Eotvos Lorand University, Budapest.
NSSI first became a specific diagnosis in the DSM-5. It is defined as deliberate, nonculturally sanctioned, nonsuicidal self-injury on at least five occasions within the past year and carried out with the aim of improving one’s emotional state as a result. The prevalence of NSSI among the general population of adolescents is high, with various investigators reporting rates of 15%-45%. Among adolescents with mental disorders, the reported prevalence climbs to 40%-80%. even though it’s now clear that many cases of pediatric-onset ADHD continue on well into adulthood, albeit often undiagnosed.
Whether NSSI and suicidal behavior are actually the same entity is currently a topic of intense research, according to Dr. Balazs, who is both a child and adolescent psychiatrist, as well as an adult psychiatrist.
She presented highlights of her cross-sectional study of 202 adolescent inpatients, 51% of them female, at the Vadaskert Child and Adolescent Psychiatry Hospital, a tertiary care center in Budapest. Using the structured diagnostic Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and the self-rated Deliberate Self-Harm Inventory, Dr. Balazs and her coinvestigators determined that 52 of the adolescents, including 23 boys and 29 girls, met full diagnostic criteria for ADHD and another 77 demonstrated more than five subthreshold ADHD symptoms.
Strikingly, 35 of the 52 teens diagnosed with ADHD, or 67%, had current NSSI. Only 10 of these patients were boys. The other 25, or 71% of the total, were girls.
Psychiatric comorbidities proved to be the rule rather than the exception in the adolescent inpatients with ADHD plus NSSI. Among these inpatients, 94% had a history of suicidal behavior. In addition, 66% carried the diagnosis of oppositional defiant disorder, 63% generalized anxiety disorder, 60% had a psychotic disorder, and 51% had experienced a manic episode. Among them, 49% were diagnosed with social anxiety disorder, 46% with obsessive-compulsive disorder, 31% with panic disorder, 23% with conduct disorder, and an equal percentage with agoraphobia. Furthermore, 43% had a major depressive disorder and 34%, dysthymia. Alcohol abuse or dependence was present in 20%, and an equal percentage had psychoactive substance use disorder.
Dr. Balazs said she and her coinvestigators were surprised by the high prevalence of symptoms of comorbid psychotic disorder in conjunction with NSSI and ADHD. One possible explanation, she opined, is that as inpatients the study participants were at the more severe end of the disease spectrum, and some patients may have been admitted not solely because of the severity of their comorbidities. Another possibility is that, in some cases, what was labeled psychotic disorder may actually have been prodromal unipolar depression.
A key finding in Dr. Balazs’s study was that, according to a regression analysis, the relationship between ADHD and NSSI was mediated entirely by the symptoms of the ADHD comorbidities. Specifically, the significant risk factors for NSSI in patients with ADHD were affective disorders, suicidality, and psychotic disorders in both sexes, with the addition of comorbid alcohol abuse or dependence in girls only. There was no evidence of a direct causal relationship between ADHD, per se, and NSSI.
‘Findings warrant further investigation’
The study, which looks at the association between NSSI and adolescents is interesting, yet preliminary, said David Fassler, MD, in an interview.
“The authors conclude that girls with ADHD are at particularly high risk of NSSI,” said Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington. Dr. Fassler was not involved with the study.
“It is limited by sample size, acuity, and the incidence of comorbidities,” said Dr. Fassler, who had no conflicts of interest. “Nonetheless, the findings are intriguing and warrant further investigation with larger samples in diverse clinical settings.”
The study was supported by the Hungarian Scientific Research Fund. In addition, Dr. Balazs received funding from the Hungarian Academy of Sciences. The full details of the study have been published (BMC Psychiatry. 2018 Feb 6;18[1]:34).
SOURCE: Balazs J et al. ECNP 2020, Abstract EDU.02.
Recent studies constitute a clarion call for clinicians to routinely screen adolescents with ADHD for nonsuicidal self-injury (NSSI) and its risk factors, Judit Balazs, MD, PhD, said at the virtual congress of the European College of Neuropsychopharmacology.
She was lead author of one of these studies, which drew a remarkable and disturbing conclusion: “We found – and it’s a very alarming result – that more than 70% of those people who had ADHD and [nonsuicidal self-injury] were girls. The girls with ADHD seem to be a high-risk population,” observed Dr. Balazs, professor and chair of the department of developmental psychology at Eotvos Lorand University, Budapest.
NSSI first became a specific diagnosis in the DSM-5. It is defined as deliberate, nonculturally sanctioned, nonsuicidal self-injury on at least five occasions within the past year and carried out with the aim of improving one’s emotional state as a result. The prevalence of NSSI among the general population of adolescents is high, with various investigators reporting rates of 15%-45%. Among adolescents with mental disorders, the reported prevalence climbs to 40%-80%. even though it’s now clear that many cases of pediatric-onset ADHD continue on well into adulthood, albeit often undiagnosed.
Whether NSSI and suicidal behavior are actually the same entity is currently a topic of intense research, according to Dr. Balazs, who is both a child and adolescent psychiatrist, as well as an adult psychiatrist.
She presented highlights of her cross-sectional study of 202 adolescent inpatients, 51% of them female, at the Vadaskert Child and Adolescent Psychiatry Hospital, a tertiary care center in Budapest. Using the structured diagnostic Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and the self-rated Deliberate Self-Harm Inventory, Dr. Balazs and her coinvestigators determined that 52 of the adolescents, including 23 boys and 29 girls, met full diagnostic criteria for ADHD and another 77 demonstrated more than five subthreshold ADHD symptoms.
Strikingly, 35 of the 52 teens diagnosed with ADHD, or 67%, had current NSSI. Only 10 of these patients were boys. The other 25, or 71% of the total, were girls.
Psychiatric comorbidities proved to be the rule rather than the exception in the adolescent inpatients with ADHD plus NSSI. Among these inpatients, 94% had a history of suicidal behavior. In addition, 66% carried the diagnosis of oppositional defiant disorder, 63% generalized anxiety disorder, 60% had a psychotic disorder, and 51% had experienced a manic episode. Among them, 49% were diagnosed with social anxiety disorder, 46% with obsessive-compulsive disorder, 31% with panic disorder, 23% with conduct disorder, and an equal percentage with agoraphobia. Furthermore, 43% had a major depressive disorder and 34%, dysthymia. Alcohol abuse or dependence was present in 20%, and an equal percentage had psychoactive substance use disorder.
Dr. Balazs said she and her coinvestigators were surprised by the high prevalence of symptoms of comorbid psychotic disorder in conjunction with NSSI and ADHD. One possible explanation, she opined, is that as inpatients the study participants were at the more severe end of the disease spectrum, and some patients may have been admitted not solely because of the severity of their comorbidities. Another possibility is that, in some cases, what was labeled psychotic disorder may actually have been prodromal unipolar depression.
A key finding in Dr. Balazs’s study was that, according to a regression analysis, the relationship between ADHD and NSSI was mediated entirely by the symptoms of the ADHD comorbidities. Specifically, the significant risk factors for NSSI in patients with ADHD were affective disorders, suicidality, and psychotic disorders in both sexes, with the addition of comorbid alcohol abuse or dependence in girls only. There was no evidence of a direct causal relationship between ADHD, per se, and NSSI.
‘Findings warrant further investigation’
The study, which looks at the association between NSSI and adolescents is interesting, yet preliminary, said David Fassler, MD, in an interview.
“The authors conclude that girls with ADHD are at particularly high risk of NSSI,” said Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington. Dr. Fassler was not involved with the study.
“It is limited by sample size, acuity, and the incidence of comorbidities,” said Dr. Fassler, who had no conflicts of interest. “Nonetheless, the findings are intriguing and warrant further investigation with larger samples in diverse clinical settings.”
The study was supported by the Hungarian Scientific Research Fund. In addition, Dr. Balazs received funding from the Hungarian Academy of Sciences. The full details of the study have been published (BMC Psychiatry. 2018 Feb 6;18[1]:34).
SOURCE: Balazs J et al. ECNP 2020, Abstract EDU.02.
Recent studies constitute a clarion call for clinicians to routinely screen adolescents with ADHD for nonsuicidal self-injury (NSSI) and its risk factors, Judit Balazs, MD, PhD, said at the virtual congress of the European College of Neuropsychopharmacology.
She was lead author of one of these studies, which drew a remarkable and disturbing conclusion: “We found – and it’s a very alarming result – that more than 70% of those people who had ADHD and [nonsuicidal self-injury] were girls. The girls with ADHD seem to be a high-risk population,” observed Dr. Balazs, professor and chair of the department of developmental psychology at Eotvos Lorand University, Budapest.
NSSI first became a specific diagnosis in the DSM-5. It is defined as deliberate, nonculturally sanctioned, nonsuicidal self-injury on at least five occasions within the past year and carried out with the aim of improving one’s emotional state as a result. The prevalence of NSSI among the general population of adolescents is high, with various investigators reporting rates of 15%-45%. Among adolescents with mental disorders, the reported prevalence climbs to 40%-80%. even though it’s now clear that many cases of pediatric-onset ADHD continue on well into adulthood, albeit often undiagnosed.
Whether NSSI and suicidal behavior are actually the same entity is currently a topic of intense research, according to Dr. Balazs, who is both a child and adolescent psychiatrist, as well as an adult psychiatrist.
She presented highlights of her cross-sectional study of 202 adolescent inpatients, 51% of them female, at the Vadaskert Child and Adolescent Psychiatry Hospital, a tertiary care center in Budapest. Using the structured diagnostic Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and the self-rated Deliberate Self-Harm Inventory, Dr. Balazs and her coinvestigators determined that 52 of the adolescents, including 23 boys and 29 girls, met full diagnostic criteria for ADHD and another 77 demonstrated more than five subthreshold ADHD symptoms.
Strikingly, 35 of the 52 teens diagnosed with ADHD, or 67%, had current NSSI. Only 10 of these patients were boys. The other 25, or 71% of the total, were girls.
Psychiatric comorbidities proved to be the rule rather than the exception in the adolescent inpatients with ADHD plus NSSI. Among these inpatients, 94% had a history of suicidal behavior. In addition, 66% carried the diagnosis of oppositional defiant disorder, 63% generalized anxiety disorder, 60% had a psychotic disorder, and 51% had experienced a manic episode. Among them, 49% were diagnosed with social anxiety disorder, 46% with obsessive-compulsive disorder, 31% with panic disorder, 23% with conduct disorder, and an equal percentage with agoraphobia. Furthermore, 43% had a major depressive disorder and 34%, dysthymia. Alcohol abuse or dependence was present in 20%, and an equal percentage had psychoactive substance use disorder.
Dr. Balazs said she and her coinvestigators were surprised by the high prevalence of symptoms of comorbid psychotic disorder in conjunction with NSSI and ADHD. One possible explanation, she opined, is that as inpatients the study participants were at the more severe end of the disease spectrum, and some patients may have been admitted not solely because of the severity of their comorbidities. Another possibility is that, in some cases, what was labeled psychotic disorder may actually have been prodromal unipolar depression.
A key finding in Dr. Balazs’s study was that, according to a regression analysis, the relationship between ADHD and NSSI was mediated entirely by the symptoms of the ADHD comorbidities. Specifically, the significant risk factors for NSSI in patients with ADHD were affective disorders, suicidality, and psychotic disorders in both sexes, with the addition of comorbid alcohol abuse or dependence in girls only. There was no evidence of a direct causal relationship between ADHD, per se, and NSSI.
‘Findings warrant further investigation’
The study, which looks at the association between NSSI and adolescents is interesting, yet preliminary, said David Fassler, MD, in an interview.
“The authors conclude that girls with ADHD are at particularly high risk of NSSI,” said Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington. Dr. Fassler was not involved with the study.
“It is limited by sample size, acuity, and the incidence of comorbidities,” said Dr. Fassler, who had no conflicts of interest. “Nonetheless, the findings are intriguing and warrant further investigation with larger samples in diverse clinical settings.”
The study was supported by the Hungarian Scientific Research Fund. In addition, Dr. Balazs received funding from the Hungarian Academy of Sciences. The full details of the study have been published (BMC Psychiatry. 2018 Feb 6;18[1]:34).
SOURCE: Balazs J et al. ECNP 2020, Abstract EDU.02.
FROM ECNP 2020
Can experiencing bigotry and racism lead to PTSD?
I have been studying, writing about, and treating posttraumatic stress disorder for many years. Over this time, I have seen PTSD expand to more and more areas of life, including my own view of a “subthreshold” version, which occurs in vulnerable people who experience a job loss, divorce, financial setbacks, or any number of painful life events.
As I noted in my recent book, “Find Freedom Fast,” for some people, PTSD can be triggered in the wake of events that are not life-threatening yet catastrophic for them and not tied to manmade or natural disasters, torture, assault, or war zone experiences.
The expansion of PTSD has led to the disorder being recognized in ICU patients during and after recovery (Crit Care Med. 2015 May;43[5]:1121-9), as well as in people diagnosed with cancer (Lancet Psychiatry. 2017 Apr;4[4]:330-8) and other illnesses that may cause emotional trauma – where one feels that one’s life is threatened. In some instances, the person’s life might indeed be in danger, not unlike what can happen in disasters, wars, torture, and even in some encounters with law enforcement.
This leads me to yet another circumstance that in some, may be tied to PTSD – and that is racial, religious, ethnic, and gender-related bigotry. In these cases, individuals feel threatened just for who they are in a society. Being on the receiving end of a circumstance that threatens a person’s very existence would seem to me to place a person as a potential survivor of PTSD, as well as any number of disorders, including anxiety, depression, or even paranoia.
Yes, discrimination and prejudice have been with us for a long time, and what concerns me is the psychological effect it has on children as well as adults. Friends of Irish descent remind me of hearing stories from parents and grandparents about employment signs reading, “Irish need not apply.” Certainly, those of Italian ancestry will easily recall the prejudice focused against them. And members of the Jewish community also can easily remember the bigotry and exclusion they have been subject to in certain neighborhoods and organizations, in addition to the horrors of the Holocaust during World War II, and the anti-Semitic chants in Charlottesville, Va., from just 3 years ago – with gun-carrying militants doing the chanting.
Obviously, in certain circles, we still have private clubs, plus neighborhoods and residential buildings that exclude people for a variety of reasons.
Coming from a medical family, years ago I heard stories that, if you were Roman Catholic, it would be hard to get into certain medical schools – which might explain the establishment of Catholic medical schools that often were open to people of other faiths. Then we had medical school discrimination toward Jewish students, which was followed by the establishment of medical schools focused on admitting more Jewish students. The African American community also responded to discrimination by establishing medical schools, such as the school at Howard University in Washington.
Furthermore, we cannot forget the discrimination that women faced in institutions of higher learning. My father had two women in his medical school class, I was told. In my era, I would say at least 30% were women, and today, in the United States, medical school classes are more equally balanced with men and women. Some schools have more women than men.
The question I ask, is: How did all those women feel for so many years knowing that, for reasons beyond their control, they were prevented from achieving their chosen goals? Some might have felt badly, and others might have internalized the rejection. Others might have developed PTSD based on feelings of rejection.
However, the question here mainly is: Can PTSD result when exclusion and prejudice induce fear and terror in those on the receiving end – especially innocent children? Children separated from their parents at the U.S.-Mexico border and those who witness their parents being shot immediately come to mind. This trauma can last well beyond childhood.
and make us realize the extent to which the African American community has been traumatized. Perhaps we should not be surprised by a study that found that the prevalence of PTSD among African Americans is 9.1%, compared with 6.8% for Whites (J Anxiety Dis. 2009 Jun;23[5]:573-90). Speaking with Black colleagues, friends, and patients, reading books such “The Warmth of Other Suns,” and watching films such as “Green Book,” give us a sense of how dangerous it was for Black families to travel in certain parts of the country in the recent past. I recall as a child hearing that, in Miami Beach, people of color could not stay overnight. (Even as a child I was surprised – having never heard anything like that. After all, I went to school with people of many religions and backgrounds. My parents thought those practices were terrible, and were appalled when they learned that some hotels were closed to Jews and others closed to Catholics.)
DSM-5, ICD-10 fall short
The DSM-5 describes trauma using a more or less one-dimensional set of guidelines as the focus. Those guidelines include exposure to direct violence, manmade or natural disasters, war, or torture, as well as exposure to a disaster or a life-threatening situation affecting a loved one. The ICD-10 is less restrictive about trauma but still has some limitations.
While considering potential PTSD, I try to use a less rigid diagnostic multidimensional approach, where I assess individual differences and experiences that play a role in those experiences as well as the patient’s vulnerability to the causation of PTSD – which also has to include any exposure to trauma (Curr Opin Psychol. 2017 Apr;14:29-34) before age 11 or 12. The data suggest that such early exposure leaves people more vulnerable to PTSD as adults (Soc Sci Med. 2018 Feb;199:230-40).
In my view, if individuals are frightened because of who they are – be it tied to their religion, race, sexual identity, or ethnicity – and what harm may come to them, and if they live in fear and avoidance of these potential traumatic situations that affect their mental stability and the way they live their lives, they might fit the PTSD model.
If we clinicians focus on what’s currently being brought vividly into the public eye today regarding the African American community, we would see that some of the ongoing fears of racism – whether tied to residential or workplace discrimination, unfair treatment by figures of authority, harassment, health inequities, or microaggressions – may give rise to PTSD. I know we can do better. We should broaden our definition and awareness of this very serious disorder – and be prepared to treat it.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
I have been studying, writing about, and treating posttraumatic stress disorder for many years. Over this time, I have seen PTSD expand to more and more areas of life, including my own view of a “subthreshold” version, which occurs in vulnerable people who experience a job loss, divorce, financial setbacks, or any number of painful life events.
As I noted in my recent book, “Find Freedom Fast,” for some people, PTSD can be triggered in the wake of events that are not life-threatening yet catastrophic for them and not tied to manmade or natural disasters, torture, assault, or war zone experiences.
The expansion of PTSD has led to the disorder being recognized in ICU patients during and after recovery (Crit Care Med. 2015 May;43[5]:1121-9), as well as in people diagnosed with cancer (Lancet Psychiatry. 2017 Apr;4[4]:330-8) and other illnesses that may cause emotional trauma – where one feels that one’s life is threatened. In some instances, the person’s life might indeed be in danger, not unlike what can happen in disasters, wars, torture, and even in some encounters with law enforcement.
This leads me to yet another circumstance that in some, may be tied to PTSD – and that is racial, religious, ethnic, and gender-related bigotry. In these cases, individuals feel threatened just for who they are in a society. Being on the receiving end of a circumstance that threatens a person’s very existence would seem to me to place a person as a potential survivor of PTSD, as well as any number of disorders, including anxiety, depression, or even paranoia.
Yes, discrimination and prejudice have been with us for a long time, and what concerns me is the psychological effect it has on children as well as adults. Friends of Irish descent remind me of hearing stories from parents and grandparents about employment signs reading, “Irish need not apply.” Certainly, those of Italian ancestry will easily recall the prejudice focused against them. And members of the Jewish community also can easily remember the bigotry and exclusion they have been subject to in certain neighborhoods and organizations, in addition to the horrors of the Holocaust during World War II, and the anti-Semitic chants in Charlottesville, Va., from just 3 years ago – with gun-carrying militants doing the chanting.
Obviously, in certain circles, we still have private clubs, plus neighborhoods and residential buildings that exclude people for a variety of reasons.
Coming from a medical family, years ago I heard stories that, if you were Roman Catholic, it would be hard to get into certain medical schools – which might explain the establishment of Catholic medical schools that often were open to people of other faiths. Then we had medical school discrimination toward Jewish students, which was followed by the establishment of medical schools focused on admitting more Jewish students. The African American community also responded to discrimination by establishing medical schools, such as the school at Howard University in Washington.
Furthermore, we cannot forget the discrimination that women faced in institutions of higher learning. My father had two women in his medical school class, I was told. In my era, I would say at least 30% were women, and today, in the United States, medical school classes are more equally balanced with men and women. Some schools have more women than men.
The question I ask, is: How did all those women feel for so many years knowing that, for reasons beyond their control, they were prevented from achieving their chosen goals? Some might have felt badly, and others might have internalized the rejection. Others might have developed PTSD based on feelings of rejection.
However, the question here mainly is: Can PTSD result when exclusion and prejudice induce fear and terror in those on the receiving end – especially innocent children? Children separated from their parents at the U.S.-Mexico border and those who witness their parents being shot immediately come to mind. This trauma can last well beyond childhood.
and make us realize the extent to which the African American community has been traumatized. Perhaps we should not be surprised by a study that found that the prevalence of PTSD among African Americans is 9.1%, compared with 6.8% for Whites (J Anxiety Dis. 2009 Jun;23[5]:573-90). Speaking with Black colleagues, friends, and patients, reading books such “The Warmth of Other Suns,” and watching films such as “Green Book,” give us a sense of how dangerous it was for Black families to travel in certain parts of the country in the recent past. I recall as a child hearing that, in Miami Beach, people of color could not stay overnight. (Even as a child I was surprised – having never heard anything like that. After all, I went to school with people of many religions and backgrounds. My parents thought those practices were terrible, and were appalled when they learned that some hotels were closed to Jews and others closed to Catholics.)
DSM-5, ICD-10 fall short
The DSM-5 describes trauma using a more or less one-dimensional set of guidelines as the focus. Those guidelines include exposure to direct violence, manmade or natural disasters, war, or torture, as well as exposure to a disaster or a life-threatening situation affecting a loved one. The ICD-10 is less restrictive about trauma but still has some limitations.
While considering potential PTSD, I try to use a less rigid diagnostic multidimensional approach, where I assess individual differences and experiences that play a role in those experiences as well as the patient’s vulnerability to the causation of PTSD – which also has to include any exposure to trauma (Curr Opin Psychol. 2017 Apr;14:29-34) before age 11 or 12. The data suggest that such early exposure leaves people more vulnerable to PTSD as adults (Soc Sci Med. 2018 Feb;199:230-40).
In my view, if individuals are frightened because of who they are – be it tied to their religion, race, sexual identity, or ethnicity – and what harm may come to them, and if they live in fear and avoidance of these potential traumatic situations that affect their mental stability and the way they live their lives, they might fit the PTSD model.
If we clinicians focus on what’s currently being brought vividly into the public eye today regarding the African American community, we would see that some of the ongoing fears of racism – whether tied to residential or workplace discrimination, unfair treatment by figures of authority, harassment, health inequities, or microaggressions – may give rise to PTSD. I know we can do better. We should broaden our definition and awareness of this very serious disorder – and be prepared to treat it.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
I have been studying, writing about, and treating posttraumatic stress disorder for many years. Over this time, I have seen PTSD expand to more and more areas of life, including my own view of a “subthreshold” version, which occurs in vulnerable people who experience a job loss, divorce, financial setbacks, or any number of painful life events.
As I noted in my recent book, “Find Freedom Fast,” for some people, PTSD can be triggered in the wake of events that are not life-threatening yet catastrophic for them and not tied to manmade or natural disasters, torture, assault, or war zone experiences.
The expansion of PTSD has led to the disorder being recognized in ICU patients during and after recovery (Crit Care Med. 2015 May;43[5]:1121-9), as well as in people diagnosed with cancer (Lancet Psychiatry. 2017 Apr;4[4]:330-8) and other illnesses that may cause emotional trauma – where one feels that one’s life is threatened. In some instances, the person’s life might indeed be in danger, not unlike what can happen in disasters, wars, torture, and even in some encounters with law enforcement.
This leads me to yet another circumstance that in some, may be tied to PTSD – and that is racial, religious, ethnic, and gender-related bigotry. In these cases, individuals feel threatened just for who they are in a society. Being on the receiving end of a circumstance that threatens a person’s very existence would seem to me to place a person as a potential survivor of PTSD, as well as any number of disorders, including anxiety, depression, or even paranoia.
Yes, discrimination and prejudice have been with us for a long time, and what concerns me is the psychological effect it has on children as well as adults. Friends of Irish descent remind me of hearing stories from parents and grandparents about employment signs reading, “Irish need not apply.” Certainly, those of Italian ancestry will easily recall the prejudice focused against them. And members of the Jewish community also can easily remember the bigotry and exclusion they have been subject to in certain neighborhoods and organizations, in addition to the horrors of the Holocaust during World War II, and the anti-Semitic chants in Charlottesville, Va., from just 3 years ago – with gun-carrying militants doing the chanting.
Obviously, in certain circles, we still have private clubs, plus neighborhoods and residential buildings that exclude people for a variety of reasons.
Coming from a medical family, years ago I heard stories that, if you were Roman Catholic, it would be hard to get into certain medical schools – which might explain the establishment of Catholic medical schools that often were open to people of other faiths. Then we had medical school discrimination toward Jewish students, which was followed by the establishment of medical schools focused on admitting more Jewish students. The African American community also responded to discrimination by establishing medical schools, such as the school at Howard University in Washington.
Furthermore, we cannot forget the discrimination that women faced in institutions of higher learning. My father had two women in his medical school class, I was told. In my era, I would say at least 30% were women, and today, in the United States, medical school classes are more equally balanced with men and women. Some schools have more women than men.
The question I ask, is: How did all those women feel for so many years knowing that, for reasons beyond their control, they were prevented from achieving their chosen goals? Some might have felt badly, and others might have internalized the rejection. Others might have developed PTSD based on feelings of rejection.
However, the question here mainly is: Can PTSD result when exclusion and prejudice induce fear and terror in those on the receiving end – especially innocent children? Children separated from their parents at the U.S.-Mexico border and those who witness their parents being shot immediately come to mind. This trauma can last well beyond childhood.
and make us realize the extent to which the African American community has been traumatized. Perhaps we should not be surprised by a study that found that the prevalence of PTSD among African Americans is 9.1%, compared with 6.8% for Whites (J Anxiety Dis. 2009 Jun;23[5]:573-90). Speaking with Black colleagues, friends, and patients, reading books such “The Warmth of Other Suns,” and watching films such as “Green Book,” give us a sense of how dangerous it was for Black families to travel in certain parts of the country in the recent past. I recall as a child hearing that, in Miami Beach, people of color could not stay overnight. (Even as a child I was surprised – having never heard anything like that. After all, I went to school with people of many religions and backgrounds. My parents thought those practices were terrible, and were appalled when they learned that some hotels were closed to Jews and others closed to Catholics.)
DSM-5, ICD-10 fall short
The DSM-5 describes trauma using a more or less one-dimensional set of guidelines as the focus. Those guidelines include exposure to direct violence, manmade or natural disasters, war, or torture, as well as exposure to a disaster or a life-threatening situation affecting a loved one. The ICD-10 is less restrictive about trauma but still has some limitations.
While considering potential PTSD, I try to use a less rigid diagnostic multidimensional approach, where I assess individual differences and experiences that play a role in those experiences as well as the patient’s vulnerability to the causation of PTSD – which also has to include any exposure to trauma (Curr Opin Psychol. 2017 Apr;14:29-34) before age 11 or 12. The data suggest that such early exposure leaves people more vulnerable to PTSD as adults (Soc Sci Med. 2018 Feb;199:230-40).
In my view, if individuals are frightened because of who they are – be it tied to their religion, race, sexual identity, or ethnicity – and what harm may come to them, and if they live in fear and avoidance of these potential traumatic situations that affect their mental stability and the way they live their lives, they might fit the PTSD model.
If we clinicians focus on what’s currently being brought vividly into the public eye today regarding the African American community, we would see that some of the ongoing fears of racism – whether tied to residential or workplace discrimination, unfair treatment by figures of authority, harassment, health inequities, or microaggressions – may give rise to PTSD. I know we can do better. We should broaden our definition and awareness of this very serious disorder – and be prepared to treat it.
Dr. London has been a practicing psychiatrist for 4 decades and a newspaper columnist for almost as long. He has a private practice in New York and is author of “Find Freedom Fast: Short-Term Therapy That Works” (New York: Kettlehole Publishing, 2019). Dr. London has no conflicts of interest.
Worry over family, friends the main driver of COVID-19 stress
Individuals are more worried about family members becoming ill with COVID-19 or about unknowingly transmitting the disease to family members than they are about contracting it themselves, results of a new survey show.
Investigators surveyed over 3,000 adults, using an online questionnaire. Of the respondents, about 20% were health care workers, and most were living in locations with active stay-at-home orders at the time of the survey.
Close to half of participants were worried about family members contracting the virus, one third were worried about unknowingly infecting others, and 20% were worried about contracting the virus themselves.
“We were a little surprised to see that people were more concerned about others than about themselves, specifically worrying about whether a family member would contract COVID-19 and whether they might unintentionally infect others,” lead author Ran Barzilay, MD, PhD, child and adolescent psychiatrist at the Children’s Hospital of Philadelphia (CHOP), told Medscape Medical News.
The study was published online August 20 in Translational Psychiatry.
Interactive platform
“The pandemic has provided a unique opportunity to study resilience in healthcare professionals and others,” said Barzilay, assistant professor at the Lifespan Brain Institute, a collaboration between CHOP and the University of Pennsylvania, under the directorship of Raquel Gur, MD, PhD.
“After the pandemic broke out in March, we launched a website in early April where we surveyed people for levels of resilience, mental health, and well-being during the outbreak,” he added.
Survey participants then shared it with their contacts.
“To date, over 7000 people have completed it – mostly from the US but also from Israel,” Barzilay said.
The survey was anonymous, but participants could choose to have follow-up contact. The survey included an interactive 21-item resilience questionnaire and an assessment of COVID-19-related items related to worries concerning the following: contracting, dying from, or currently having the illness; having a family member contract the illness; unknowingly infecting others; and experiencing significant financial burden.
A total of 1350 participants took a second survey on anxiety and depression that utilized the Generalized Anxiety Disorder–7 and the Patient Health Questionnaire–2.
“What makes the survey unique is that it’s not just a means of collecting data but also an interactive platform that gives participants immediate personalized feedback, based on their responses to the resilience and well-being surveys, with practical tips and recommendations for stress management and ways of boosting resilience,” Barzilay said.
Tend and befriend
Ten days into the survey, data were available on 3,042 participants (64% women, 54% with advanced education, 20.5% health care providers), who ranged in age from 18 to 70 years (mean [SD], 38.9 [11.9] years).
After accounting for covariates, the researchers found that participants reported more distress about family members contracting COVID-19 and about unknowingly infecting others than about getting COVID-19 themselves (48.5% and 36% vs. 19.9%, respectively; P < .0005).
Increased COVID-19-related worries were associated with 22% higher anxiety and 16.1% higher depression scores; women had higher scores than men on both.
Each 1-SD increase in the composite score of COVID-19 worries was associated with over twice the increased probability of generalized anxiety and depression (odds ratio, 2.23; 95% confidence interval, 1.88-2.65; and OR, 1.67; 95% CI, 1.41-1.98, respectively; for both, P < .001).
On the other hand, for every 1-SD increase in the resilience score, there was a 64.9% decrease in the possibility of screening positive for generalized anxiety disorder and a 69.3% decrease in the possibility of screening positive for depression (for both, P < .0001).
Compared to participants from Israel, US participants were “more stressed” about contracting, dying from, and currently having COVID-19 themselves. Overall, Israeli participants scored higher than US participants on the resilience scale.
Rates of anxiety and depression did not differ significantly between healthcare providers and others. Health care providers worried more about contracting COVID-19 themselves and worried less about finances after COVID-19.
The authors propose that survey participants were more worried about others than about themselves because of “prosocial behavior under stress” and “tend-and-befriend,” whereby, “in response to threat, humans tend to protect their close ones (tending) and seek out their social group for mutual defense (befriending).”
This type of altruistic behavior has been “described in acute situations throughout history” and has been “linked to mechanisms of resilience for overcoming adversity,” the authors indicate.
Demographic biases
Commenting on the findings for Medscape Medical News, Golnaz Tabibnia, PhD, a neuroscientist at the University of California, Irvine, who was not involved in the research, suggested that although higher resilience scores were associated with lower COVID-related worries, it is possible, “as the authors suggest, that having more resilience resources makes you less worried, but the causality could go the other direction as well, and less worry/rumination may lead to more resilience.”
Also commenting on the study for Medscape Medical News, Christiaan Vinkers, MD, PhD, a psychiatrist at the Amsterdam University Medical Center, Amsterdam, the Netherlands, said it was noteworthy that healthcare providers reported similar levels of mood and anxiety symptoms, compared to others.
“This is encouraging, as it suggests adequate resilience levels in professionals who work in the front lines of the COVID-19 pandemic,” he said.
Resilience occurs not only at the individual level but also at the community level, which may help explain the striking differences in COVID-19-related worries and anxiety between participants from the United States and Israel, Vinkers added.
E. Alison Holman, PhD, professor, Sue and Bill Gross School of Nursing, University of California, Irvine, noted that respondents were predominantly white, female, and had relatively high incomes, “suggesting strong demographic biases in those who chose to participate.”
Holman, who was not involved with the study, told Medscape Medical News that the “findings do not address the real impact of COVID-19 on the hardest-hit communities in America – poor, Black, and Latinx communities, where a large proportion of essential workers live.”
Barzilay acknowledged that, “unfortunately, because of the way the study was circulated, it did not reach minorities, which is one of the things we want to improve.”
The study is ongoing and has been translated into Spanish, French, and Hebrew. The team plans to collect data on diverse populations.
The study was supported by grants from the National Institute of Mental Health, the Lifespan Brain Institute of Children’s Hospital of Philadelphia, Penn Medicine, the University of Pennsylvania, and in part by the Zuckerman STEM Leadership Program. Barzilay serves on the scientific board and reports stock ownership in Taliaz Health. The other authors, Golnaz, Vinkers, and Holman have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Individuals are more worried about family members becoming ill with COVID-19 or about unknowingly transmitting the disease to family members than they are about contracting it themselves, results of a new survey show.
Investigators surveyed over 3,000 adults, using an online questionnaire. Of the respondents, about 20% were health care workers, and most were living in locations with active stay-at-home orders at the time of the survey.
Close to half of participants were worried about family members contracting the virus, one third were worried about unknowingly infecting others, and 20% were worried about contracting the virus themselves.
“We were a little surprised to see that people were more concerned about others than about themselves, specifically worrying about whether a family member would contract COVID-19 and whether they might unintentionally infect others,” lead author Ran Barzilay, MD, PhD, child and adolescent psychiatrist at the Children’s Hospital of Philadelphia (CHOP), told Medscape Medical News.
The study was published online August 20 in Translational Psychiatry.
Interactive platform
“The pandemic has provided a unique opportunity to study resilience in healthcare professionals and others,” said Barzilay, assistant professor at the Lifespan Brain Institute, a collaboration between CHOP and the University of Pennsylvania, under the directorship of Raquel Gur, MD, PhD.
“After the pandemic broke out in March, we launched a website in early April where we surveyed people for levels of resilience, mental health, and well-being during the outbreak,” he added.
Survey participants then shared it with their contacts.
“To date, over 7000 people have completed it – mostly from the US but also from Israel,” Barzilay said.
The survey was anonymous, but participants could choose to have follow-up contact. The survey included an interactive 21-item resilience questionnaire and an assessment of COVID-19-related items related to worries concerning the following: contracting, dying from, or currently having the illness; having a family member contract the illness; unknowingly infecting others; and experiencing significant financial burden.
A total of 1350 participants took a second survey on anxiety and depression that utilized the Generalized Anxiety Disorder–7 and the Patient Health Questionnaire–2.
“What makes the survey unique is that it’s not just a means of collecting data but also an interactive platform that gives participants immediate personalized feedback, based on their responses to the resilience and well-being surveys, with practical tips and recommendations for stress management and ways of boosting resilience,” Barzilay said.
Tend and befriend
Ten days into the survey, data were available on 3,042 participants (64% women, 54% with advanced education, 20.5% health care providers), who ranged in age from 18 to 70 years (mean [SD], 38.9 [11.9] years).
After accounting for covariates, the researchers found that participants reported more distress about family members contracting COVID-19 and about unknowingly infecting others than about getting COVID-19 themselves (48.5% and 36% vs. 19.9%, respectively; P < .0005).
Increased COVID-19-related worries were associated with 22% higher anxiety and 16.1% higher depression scores; women had higher scores than men on both.
Each 1-SD increase in the composite score of COVID-19 worries was associated with over twice the increased probability of generalized anxiety and depression (odds ratio, 2.23; 95% confidence interval, 1.88-2.65; and OR, 1.67; 95% CI, 1.41-1.98, respectively; for both, P < .001).
On the other hand, for every 1-SD increase in the resilience score, there was a 64.9% decrease in the possibility of screening positive for generalized anxiety disorder and a 69.3% decrease in the possibility of screening positive for depression (for both, P < .0001).
Compared to participants from Israel, US participants were “more stressed” about contracting, dying from, and currently having COVID-19 themselves. Overall, Israeli participants scored higher than US participants on the resilience scale.
Rates of anxiety and depression did not differ significantly between healthcare providers and others. Health care providers worried more about contracting COVID-19 themselves and worried less about finances after COVID-19.
The authors propose that survey participants were more worried about others than about themselves because of “prosocial behavior under stress” and “tend-and-befriend,” whereby, “in response to threat, humans tend to protect their close ones (tending) and seek out their social group for mutual defense (befriending).”
This type of altruistic behavior has been “described in acute situations throughout history” and has been “linked to mechanisms of resilience for overcoming adversity,” the authors indicate.
Demographic biases
Commenting on the findings for Medscape Medical News, Golnaz Tabibnia, PhD, a neuroscientist at the University of California, Irvine, who was not involved in the research, suggested that although higher resilience scores were associated with lower COVID-related worries, it is possible, “as the authors suggest, that having more resilience resources makes you less worried, but the causality could go the other direction as well, and less worry/rumination may lead to more resilience.”
Also commenting on the study for Medscape Medical News, Christiaan Vinkers, MD, PhD, a psychiatrist at the Amsterdam University Medical Center, Amsterdam, the Netherlands, said it was noteworthy that healthcare providers reported similar levels of mood and anxiety symptoms, compared to others.
“This is encouraging, as it suggests adequate resilience levels in professionals who work in the front lines of the COVID-19 pandemic,” he said.
Resilience occurs not only at the individual level but also at the community level, which may help explain the striking differences in COVID-19-related worries and anxiety between participants from the United States and Israel, Vinkers added.
E. Alison Holman, PhD, professor, Sue and Bill Gross School of Nursing, University of California, Irvine, noted that respondents were predominantly white, female, and had relatively high incomes, “suggesting strong demographic biases in those who chose to participate.”
Holman, who was not involved with the study, told Medscape Medical News that the “findings do not address the real impact of COVID-19 on the hardest-hit communities in America – poor, Black, and Latinx communities, where a large proportion of essential workers live.”
Barzilay acknowledged that, “unfortunately, because of the way the study was circulated, it did not reach minorities, which is one of the things we want to improve.”
The study is ongoing and has been translated into Spanish, French, and Hebrew. The team plans to collect data on diverse populations.
The study was supported by grants from the National Institute of Mental Health, the Lifespan Brain Institute of Children’s Hospital of Philadelphia, Penn Medicine, the University of Pennsylvania, and in part by the Zuckerman STEM Leadership Program. Barzilay serves on the scientific board and reports stock ownership in Taliaz Health. The other authors, Golnaz, Vinkers, and Holman have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Individuals are more worried about family members becoming ill with COVID-19 or about unknowingly transmitting the disease to family members than they are about contracting it themselves, results of a new survey show.
Investigators surveyed over 3,000 adults, using an online questionnaire. Of the respondents, about 20% were health care workers, and most were living in locations with active stay-at-home orders at the time of the survey.
Close to half of participants were worried about family members contracting the virus, one third were worried about unknowingly infecting others, and 20% were worried about contracting the virus themselves.
“We were a little surprised to see that people were more concerned about others than about themselves, specifically worrying about whether a family member would contract COVID-19 and whether they might unintentionally infect others,” lead author Ran Barzilay, MD, PhD, child and adolescent psychiatrist at the Children’s Hospital of Philadelphia (CHOP), told Medscape Medical News.
The study was published online August 20 in Translational Psychiatry.
Interactive platform
“The pandemic has provided a unique opportunity to study resilience in healthcare professionals and others,” said Barzilay, assistant professor at the Lifespan Brain Institute, a collaboration between CHOP and the University of Pennsylvania, under the directorship of Raquel Gur, MD, PhD.
“After the pandemic broke out in March, we launched a website in early April where we surveyed people for levels of resilience, mental health, and well-being during the outbreak,” he added.
Survey participants then shared it with their contacts.
“To date, over 7000 people have completed it – mostly from the US but also from Israel,” Barzilay said.
The survey was anonymous, but participants could choose to have follow-up contact. The survey included an interactive 21-item resilience questionnaire and an assessment of COVID-19-related items related to worries concerning the following: contracting, dying from, or currently having the illness; having a family member contract the illness; unknowingly infecting others; and experiencing significant financial burden.
A total of 1350 participants took a second survey on anxiety and depression that utilized the Generalized Anxiety Disorder–7 and the Patient Health Questionnaire–2.
“What makes the survey unique is that it’s not just a means of collecting data but also an interactive platform that gives participants immediate personalized feedback, based on their responses to the resilience and well-being surveys, with practical tips and recommendations for stress management and ways of boosting resilience,” Barzilay said.
Tend and befriend
Ten days into the survey, data were available on 3,042 participants (64% women, 54% with advanced education, 20.5% health care providers), who ranged in age from 18 to 70 years (mean [SD], 38.9 [11.9] years).
After accounting for covariates, the researchers found that participants reported more distress about family members contracting COVID-19 and about unknowingly infecting others than about getting COVID-19 themselves (48.5% and 36% vs. 19.9%, respectively; P < .0005).
Increased COVID-19-related worries were associated with 22% higher anxiety and 16.1% higher depression scores; women had higher scores than men on both.
Each 1-SD increase in the composite score of COVID-19 worries was associated with over twice the increased probability of generalized anxiety and depression (odds ratio, 2.23; 95% confidence interval, 1.88-2.65; and OR, 1.67; 95% CI, 1.41-1.98, respectively; for both, P < .001).
On the other hand, for every 1-SD increase in the resilience score, there was a 64.9% decrease in the possibility of screening positive for generalized anxiety disorder and a 69.3% decrease in the possibility of screening positive for depression (for both, P < .0001).
Compared to participants from Israel, US participants were “more stressed” about contracting, dying from, and currently having COVID-19 themselves. Overall, Israeli participants scored higher than US participants on the resilience scale.
Rates of anxiety and depression did not differ significantly between healthcare providers and others. Health care providers worried more about contracting COVID-19 themselves and worried less about finances after COVID-19.
The authors propose that survey participants were more worried about others than about themselves because of “prosocial behavior under stress” and “tend-and-befriend,” whereby, “in response to threat, humans tend to protect their close ones (tending) and seek out their social group for mutual defense (befriending).”
This type of altruistic behavior has been “described in acute situations throughout history” and has been “linked to mechanisms of resilience for overcoming adversity,” the authors indicate.
Demographic biases
Commenting on the findings for Medscape Medical News, Golnaz Tabibnia, PhD, a neuroscientist at the University of California, Irvine, who was not involved in the research, suggested that although higher resilience scores were associated with lower COVID-related worries, it is possible, “as the authors suggest, that having more resilience resources makes you less worried, but the causality could go the other direction as well, and less worry/rumination may lead to more resilience.”
Also commenting on the study for Medscape Medical News, Christiaan Vinkers, MD, PhD, a psychiatrist at the Amsterdam University Medical Center, Amsterdam, the Netherlands, said it was noteworthy that healthcare providers reported similar levels of mood and anxiety symptoms, compared to others.
“This is encouraging, as it suggests adequate resilience levels in professionals who work in the front lines of the COVID-19 pandemic,” he said.
Resilience occurs not only at the individual level but also at the community level, which may help explain the striking differences in COVID-19-related worries and anxiety between participants from the United States and Israel, Vinkers added.
E. Alison Holman, PhD, professor, Sue and Bill Gross School of Nursing, University of California, Irvine, noted that respondents were predominantly white, female, and had relatively high incomes, “suggesting strong demographic biases in those who chose to participate.”
Holman, who was not involved with the study, told Medscape Medical News that the “findings do not address the real impact of COVID-19 on the hardest-hit communities in America – poor, Black, and Latinx communities, where a large proportion of essential workers live.”
Barzilay acknowledged that, “unfortunately, because of the way the study was circulated, it did not reach minorities, which is one of the things we want to improve.”
The study is ongoing and has been translated into Spanish, French, and Hebrew. The team plans to collect data on diverse populations.
The study was supported by grants from the National Institute of Mental Health, the Lifespan Brain Institute of Children’s Hospital of Philadelphia, Penn Medicine, the University of Pennsylvania, and in part by the Zuckerman STEM Leadership Program. Barzilay serves on the scientific board and reports stock ownership in Taliaz Health. The other authors, Golnaz, Vinkers, and Holman have disclosed no relevant financial relationships.
This article first appeared on Medscape.com.
Sleep EEG may predict later antidepressant response
A change in rapid eye movement sleeping pattern as measured by quantitative EEG in patients with major depressive disorder after just a single week on a first-line antidepressant predicts eventual clinical response or nonresponse to the medication weeks later, Thorsten Mikoteit, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
This finding from a small, randomized, controlled trial opens the door to a novel biomarker-based treatment strategy: namely, an immediate switch to a different antidepressant in predicted nonresponders to the first agent. The goal is to improve the final treatment response rate while collapsing the time required to get there, explained Dr. Mikoteit, a psychiatrist affiliated with the University of Basel (Switzerland).
“In real terms, it means that patients, often in the depths of despair, might not need to wait weeks to see if their therapy is working before modifying their treatment,” he observed.
There is a huge unmet need for a biomarker predictive of response to antidepressant medication in patients with major depression, the psychiatrist added. At present, the treatment response rate is unsatisfactory. Moreover, clinical improvement takes a long time to achieve, often requiring several rounds of therapeutic trials during which patients are exposed to weeks of unpleasant side effects of drugs that are ultimately switched out for lack of efficacy or poor tolerance.
The quantitative EEG biomarker under investigation is prefrontal theta cordance (PTC) during REM sleep. It is computed from the absolute and relative theta power in tonic REM sleep. PTC has been shown to correlate with frontocingulate brain activity and cerebral blood perfusion. In an earlier pilot study, Dr. Mikoteit and coinvestigators demonstrated in 33 patients who were experiencing a depressive episode that an increase in PTC after their first week on an antidepressant was associated a significantly increased treatment response rate at the end of the fourth week on the drug, while nonresponders failed to show such increase (J Psychiatr Res. 2017 Sep;92:64-73).
At ECNP 2020, Dr. Mikoteit presented preliminary results from an ongoing randomized, controlled trial including 37 patients hospitalized for major depressive disorder. All underwent baseline evaluation using the Hamilton Depression Rating Scale (HAMD) and were placed on the first-line antidepressant of their psychiatrist’s choice. After 1 week of therapy, participants underwent polysomnography with PTC measurement during tonic REM sleep.
Twenty-two patients were randomized to the intervention arm, in which investigators informed treating psychiatrists of the PTC results. The clinicians were instructed to change to another antidepressant if the biomarker predicted nonresponse or stay the course if the PTC results were favorable. Polysomnography was repeated 1 week later in the intervention arm, and the second-line antidepressant was either continued or switched out depending on the PTC findings. In the control arm, psychiatrists weren’t informed of the PTC results and patients continued on their initial antidepressant. The intervention and control groups were comparable in terms of age, sex, and severity of depression, with an average baseline HAMD score of 22.
A treatment response was defined as at least a 50% reduction in HAMD score from baseline to week 5. About 86% of patients who switched antidepressants based upon their 1-week quantitative EEG findings were categorized as treatment responders at week 5, compared with 20% of controls.
The overall 5-week response rate in the intervention group was 73%, compared with 60% in the control arm. This favorable trend didn’t achieve statistical significance, presumably because of the study’s sample size; however, the study is continuing to enroll participants in order to achieve a definitive result.
Dr. Mikoteit noted that the cost and inconvenience of spending a night in a sleep laboratory would be worthwhile if it resulted in the ability to give effective treatment much sooner. This would be particularly advantageous in patients at increased risk for suicide.
he said.
Study could have “enormous implications”
Of note, in the landmark National Institute of Mental Health–sponsored Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, slightly less than half of patients with major depressive disorder achieved a treatment response to their first-line antidepressant, and it took an average of 6 weeks of therapy to do. About one in four nonresponders who chose to switch to a different antidepressant got better.
“The STAR*D trial is still the gold standard for understanding antidepressant response, and so being able to see if an antidepressant works within 1 week would be a real breakthrough,” Catherine Harmer, DPhil, said in an interview.
“Most of the time, patients need to wait for around 4 weeks before they can tell if they are responding to a particular antidepressant or not. This is a hugely disabling and lengthy process, and often a different treatment then needs to be started,” added Dr. Harmer, professor of cognitive neuroscience and director of the Psychopharmacology and Emotional Research Lab at the University of Oxford (England).
“If the study results presented by Dr. Mikoteit are replicated in a larger blinded study, then it would have enormous implications for the future treatment of individuals with depression,” according to Dr. Harmer, who was not involved in the study and has no conflicts of interest related to it.
Dr. Mikoteit reported having no financial conflicts regarding the study, funded by the Psychiatric University Hospital of Basel.
SOURCE: Mikoteit T et al. ECNP 2020, Abstract P.733.
A change in rapid eye movement sleeping pattern as measured by quantitative EEG in patients with major depressive disorder after just a single week on a first-line antidepressant predicts eventual clinical response or nonresponse to the medication weeks later, Thorsten Mikoteit, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
This finding from a small, randomized, controlled trial opens the door to a novel biomarker-based treatment strategy: namely, an immediate switch to a different antidepressant in predicted nonresponders to the first agent. The goal is to improve the final treatment response rate while collapsing the time required to get there, explained Dr. Mikoteit, a psychiatrist affiliated with the University of Basel (Switzerland).
“In real terms, it means that patients, often in the depths of despair, might not need to wait weeks to see if their therapy is working before modifying their treatment,” he observed.
There is a huge unmet need for a biomarker predictive of response to antidepressant medication in patients with major depression, the psychiatrist added. At present, the treatment response rate is unsatisfactory. Moreover, clinical improvement takes a long time to achieve, often requiring several rounds of therapeutic trials during which patients are exposed to weeks of unpleasant side effects of drugs that are ultimately switched out for lack of efficacy or poor tolerance.
The quantitative EEG biomarker under investigation is prefrontal theta cordance (PTC) during REM sleep. It is computed from the absolute and relative theta power in tonic REM sleep. PTC has been shown to correlate with frontocingulate brain activity and cerebral blood perfusion. In an earlier pilot study, Dr. Mikoteit and coinvestigators demonstrated in 33 patients who were experiencing a depressive episode that an increase in PTC after their first week on an antidepressant was associated a significantly increased treatment response rate at the end of the fourth week on the drug, while nonresponders failed to show such increase (J Psychiatr Res. 2017 Sep;92:64-73).
At ECNP 2020, Dr. Mikoteit presented preliminary results from an ongoing randomized, controlled trial including 37 patients hospitalized for major depressive disorder. All underwent baseline evaluation using the Hamilton Depression Rating Scale (HAMD) and were placed on the first-line antidepressant of their psychiatrist’s choice. After 1 week of therapy, participants underwent polysomnography with PTC measurement during tonic REM sleep.
Twenty-two patients were randomized to the intervention arm, in which investigators informed treating psychiatrists of the PTC results. The clinicians were instructed to change to another antidepressant if the biomarker predicted nonresponse or stay the course if the PTC results were favorable. Polysomnography was repeated 1 week later in the intervention arm, and the second-line antidepressant was either continued or switched out depending on the PTC findings. In the control arm, psychiatrists weren’t informed of the PTC results and patients continued on their initial antidepressant. The intervention and control groups were comparable in terms of age, sex, and severity of depression, with an average baseline HAMD score of 22.
A treatment response was defined as at least a 50% reduction in HAMD score from baseline to week 5. About 86% of patients who switched antidepressants based upon their 1-week quantitative EEG findings were categorized as treatment responders at week 5, compared with 20% of controls.
The overall 5-week response rate in the intervention group was 73%, compared with 60% in the control arm. This favorable trend didn’t achieve statistical significance, presumably because of the study’s sample size; however, the study is continuing to enroll participants in order to achieve a definitive result.
Dr. Mikoteit noted that the cost and inconvenience of spending a night in a sleep laboratory would be worthwhile if it resulted in the ability to give effective treatment much sooner. This would be particularly advantageous in patients at increased risk for suicide.
he said.
Study could have “enormous implications”
Of note, in the landmark National Institute of Mental Health–sponsored Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, slightly less than half of patients with major depressive disorder achieved a treatment response to their first-line antidepressant, and it took an average of 6 weeks of therapy to do. About one in four nonresponders who chose to switch to a different antidepressant got better.
“The STAR*D trial is still the gold standard for understanding antidepressant response, and so being able to see if an antidepressant works within 1 week would be a real breakthrough,” Catherine Harmer, DPhil, said in an interview.
“Most of the time, patients need to wait for around 4 weeks before they can tell if they are responding to a particular antidepressant or not. This is a hugely disabling and lengthy process, and often a different treatment then needs to be started,” added Dr. Harmer, professor of cognitive neuroscience and director of the Psychopharmacology and Emotional Research Lab at the University of Oxford (England).
“If the study results presented by Dr. Mikoteit are replicated in a larger blinded study, then it would have enormous implications for the future treatment of individuals with depression,” according to Dr. Harmer, who was not involved in the study and has no conflicts of interest related to it.
Dr. Mikoteit reported having no financial conflicts regarding the study, funded by the Psychiatric University Hospital of Basel.
SOURCE: Mikoteit T et al. ECNP 2020, Abstract P.733.
A change in rapid eye movement sleeping pattern as measured by quantitative EEG in patients with major depressive disorder after just a single week on a first-line antidepressant predicts eventual clinical response or nonresponse to the medication weeks later, Thorsten Mikoteit, MD, reported at the virtual congress of the European College of Neuropsychopharmacology.
This finding from a small, randomized, controlled trial opens the door to a novel biomarker-based treatment strategy: namely, an immediate switch to a different antidepressant in predicted nonresponders to the first agent. The goal is to improve the final treatment response rate while collapsing the time required to get there, explained Dr. Mikoteit, a psychiatrist affiliated with the University of Basel (Switzerland).
“In real terms, it means that patients, often in the depths of despair, might not need to wait weeks to see if their therapy is working before modifying their treatment,” he observed.
There is a huge unmet need for a biomarker predictive of response to antidepressant medication in patients with major depression, the psychiatrist added. At present, the treatment response rate is unsatisfactory. Moreover, clinical improvement takes a long time to achieve, often requiring several rounds of therapeutic trials during which patients are exposed to weeks of unpleasant side effects of drugs that are ultimately switched out for lack of efficacy or poor tolerance.
The quantitative EEG biomarker under investigation is prefrontal theta cordance (PTC) during REM sleep. It is computed from the absolute and relative theta power in tonic REM sleep. PTC has been shown to correlate with frontocingulate brain activity and cerebral blood perfusion. In an earlier pilot study, Dr. Mikoteit and coinvestigators demonstrated in 33 patients who were experiencing a depressive episode that an increase in PTC after their first week on an antidepressant was associated a significantly increased treatment response rate at the end of the fourth week on the drug, while nonresponders failed to show such increase (J Psychiatr Res. 2017 Sep;92:64-73).
At ECNP 2020, Dr. Mikoteit presented preliminary results from an ongoing randomized, controlled trial including 37 patients hospitalized for major depressive disorder. All underwent baseline evaluation using the Hamilton Depression Rating Scale (HAMD) and were placed on the first-line antidepressant of their psychiatrist’s choice. After 1 week of therapy, participants underwent polysomnography with PTC measurement during tonic REM sleep.
Twenty-two patients were randomized to the intervention arm, in which investigators informed treating psychiatrists of the PTC results. The clinicians were instructed to change to another antidepressant if the biomarker predicted nonresponse or stay the course if the PTC results were favorable. Polysomnography was repeated 1 week later in the intervention arm, and the second-line antidepressant was either continued or switched out depending on the PTC findings. In the control arm, psychiatrists weren’t informed of the PTC results and patients continued on their initial antidepressant. The intervention and control groups were comparable in terms of age, sex, and severity of depression, with an average baseline HAMD score of 22.
A treatment response was defined as at least a 50% reduction in HAMD score from baseline to week 5. About 86% of patients who switched antidepressants based upon their 1-week quantitative EEG findings were categorized as treatment responders at week 5, compared with 20% of controls.
The overall 5-week response rate in the intervention group was 73%, compared with 60% in the control arm. This favorable trend didn’t achieve statistical significance, presumably because of the study’s sample size; however, the study is continuing to enroll participants in order to achieve a definitive result.
Dr. Mikoteit noted that the cost and inconvenience of spending a night in a sleep laboratory would be worthwhile if it resulted in the ability to give effective treatment much sooner. This would be particularly advantageous in patients at increased risk for suicide.
he said.
Study could have “enormous implications”
Of note, in the landmark National Institute of Mental Health–sponsored Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, slightly less than half of patients with major depressive disorder achieved a treatment response to their first-line antidepressant, and it took an average of 6 weeks of therapy to do. About one in four nonresponders who chose to switch to a different antidepressant got better.
“The STAR*D trial is still the gold standard for understanding antidepressant response, and so being able to see if an antidepressant works within 1 week would be a real breakthrough,” Catherine Harmer, DPhil, said in an interview.
“Most of the time, patients need to wait for around 4 weeks before they can tell if they are responding to a particular antidepressant or not. This is a hugely disabling and lengthy process, and often a different treatment then needs to be started,” added Dr. Harmer, professor of cognitive neuroscience and director of the Psychopharmacology and Emotional Research Lab at the University of Oxford (England).
“If the study results presented by Dr. Mikoteit are replicated in a larger blinded study, then it would have enormous implications for the future treatment of individuals with depression,” according to Dr. Harmer, who was not involved in the study and has no conflicts of interest related to it.
Dr. Mikoteit reported having no financial conflicts regarding the study, funded by the Psychiatric University Hospital of Basel.
SOURCE: Mikoteit T et al. ECNP 2020, Abstract P.733.
FROM ECNP 2020
COVID-19: New guidance to stem mental health crisis in frontline HCPs
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.
Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.
“Support needs to be deployed in multiple dimensions – including individual, organizational, and societal levels – and include training in resilience, stress reduction, emotional awareness, and self-care strategies,” lead author Rachel Schwartz, PhD, health services researcher, Stanford (Calif.) University, said in an interview.
The review was published Aug. 21 in the Annals of Internal Medicine.
An opportune moment
Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”
Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.
Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.
“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.
The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.
Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.
Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
‘Uniquely isolated’
Dr. Margolis noted that
“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.
Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.
Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.
Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.
“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
‘Battle buddies’
Dr. Margolis recommended the “battle buddy” model for mutual peer support.
Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.
“We connect residents with each other, and they form pairs to support each other and watch for warning signs such as withdrawal from colleagues, being frequently tearful, not showing up at work or showing up late, missing assignments, making mistakes at work, increased use of alcohol, or verbalizing serious concerns,” Dr. Anand said.
If the buddy shows any of these warning signs, he or she can be directed to appropriate resources to get help.
Since the pandemic has interfered with the ability to connect with colleagues and family members, attention should be paid to addressing the social support needs of clinicians.
Dr. Anand suggested that clinicians maintain contact with counselors, friends, and family, even if they cannot be together in person and must connect “virtually.”
Resilience and strength training are “key” components of reducing clinician distress, but trainings as well as processing groups and support workshops should be offered during protected time, Dr. Margolis advised, since it can be burdensome for clinicians to wake up early or stay late to attend these sessions.
Leaders and administrators should “model self-care and well-being,” she noted. For example, sending emails to clinicians late at night or on weekends creates an expectation of a rapid reply, which leads to additional pressure for the clinician.
“This is of the most powerful unspoken curricula we can develop,” Dr. Margolis emphasized.
Self-care critical
Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”
Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.
The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”
They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.
The authors and Dr. Shaker disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
When worry is excessive: Easing the burden of GAD
THE CASE
Sandra H,* a 24-year-old single woman with a history of asthma, presented to our family medicine clinic as a new patient. Ms. H said she lived at home with her mother. She completed high school but never attended college due to anxiety. She had held several jobs since high school and recently decided to apply to a local college, which prompted a desire to gain control over the anxiety that had been present since middle school. She reported feeling anxious, having difficulty breathing, shaking all over, having difficulty concentrating, and experiencing numbness and tingling in her fingers. She was often irritable at home, which she attributed partly to anxiety but mostly to disrupted sleep. We administered the 7-question Generalized Anxiety Disorder (GAD-7) questionnaire and she scored 15 (of a possible 21) points, indicative of severe anxiety.
●
* The patient’s name has been changed to protect her identity.
Approximately 1 in 5 patients presenting to primary care clinics have at least 1 anxiety disorder and 7.6% have generalized anxiety disorder (GAD).1 Yet many go untreated. The lifetime prevalence of GAD is 3.7% worldwide and 7.8% in the United States.2 Only 5% of cases emerge by age 13,2 but incidence increases through adolescence and young adulthood, with a quarter of all cases occurring by age 25.2 GAD occurs about twice as often in women as it does in men. It is typically recurrent, and many patients require ongoing treatment.2
GAD diagnostic criteria and differential considerations
Diagnosis of GAD requires at least 6 months of excessive worry or anxiety about a variety of circumstances, occurring on most days and for more than half the day.3 The worry or anxiety in GAD is difficult to control, disrupts meaningful areas of life, and surrounds everyday concerns, such as finances, health, or family-related issues. Among adolescents with GAD, worries typically include school performance and may often present as perfectionism.4 At least 3 of the following 6 symptoms result from chronic anxiety: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.2
Rule out other conditions. Make sure symptoms of GAD are not better explained by another medical problem, including other mental disorders or substance use disorders.3 Complaints of anxiety in the context of mania, hypomania, or withdrawal from alcohol or a sedative hypnotic suggest a different underlying cause, thereby requiring a complete history with symptom chronology and collateral information. The pattern of anxiety seen in GAD also differs from the focused sources of anxiety found in disorders such as social anxiety disorder (SAD) and post-traumatic stress disorder. For example, SAD might center on embarrassment in a social setting rather than reflect a pattern of general worry.5
Consider comorbidities. Further complicating diagnosis and treatment, GAD has been linked to higher rates of comorbidity and higher health care utilization. About 90% of GAD patients experience psychiatric comorbidity, with major depressive disorder co-occurring about 60% of the time.6 Substance use disorders co-occur with GAD more than 20% of the time.2 Despite comorbidities, it is the somatic complaints in GAD that often drive patient requests for medical care.7,8 GAD itself is an independent predictor of heart disease9 and is linked to increased risk of chronic or severe headaches10 and suicide.11,12
Continue to: Work with patients and family toward a diagnosis
Work with patients and family toward a diagnosis
Despite the potential benefits of early identification and treatment of GAD,13 the average elapsed time from symptom onset to initial medication treatment is 7 years.14 Multiple factors likely account for this delay. Clinical presentations can be highly variable,6 with 1 patient presenting primarily with sleep complaints and another with gastrointestinal symptoms. Some medical conditions (TABLE 1)15 and substances (TABLE 2)16-18 can cause secondary anxiety symptoms, and their presence should prompt a thorough evaluation.
Address the mind-body connection. Because uncertainty and ambiguity surrounding a diagnosis often drive worry,19 anxious patients or their family members commonly seek additional medical visits and tests in search of answers. In such instances, it helps to explain the physiologic connection between somatic complaints and anxiety.8 Describe how areas of the brain that manage fear and stress can also cause muscle tension, gastrointestinal complaints, hyperarousal, or sleep disturbance.
Empathy and early psychoeducation on the reason anxiety is being considered can decrease stigma and enable appropriate follow-up and treatment. You might introduce the connection between health complaints and GAD specifically by exploring the amount of worry surrounding the presenting symptoms, followed by a question such as, “Sometimes your worry will fit the situation and sometimes it’ll be too much. Has anyone ever told you that you worry too much?” The patient’s response to such a question could signal a need to use the GAD-7 screening tool1 as an aid to diagnosis and as a baseline measure for monitoring subsequent treatment progress.
Psycho- and pharmacotherapy aspects of management
Let patients choose from among various coping strategies. Be prepared to offer patients user-friendly handouts, reading material, or links to educational Web sites. Many patients are interested in using smartphone applications to learn and practice coping strategies. Although these apps can encourage the regular practice of coping skills, caution teens and parents about privacy issues and the lack of evidence supporting this approach as stand-alone therapy.21 Offering several choices (TABLE 4)
Continue to: For patients who remain focused...
For patients who remain focused on somatic complaints and resist adopting coping skills or treatment, pushing certain recommendations can actually increase resistance to proper treatment.22 Instead, explore their ambivalence, offer facts, express concern about the current course of the illness, and emphasize the need to revisit the discussion at a future appointment. Offer follow-up monitoring to assess the course of the illness and readiness for GAD treatment.
Initiate treatment in a stepwise manner13 for the patient who is ready for GAD treatment. This approach includes education and monitoring; low-intensity interventions (eg, treatment workbooks or group sessions); medication and/or referral for psychotherapy; referral for outpatient psychiatric care; and hospitalization for patients who pose a danger to self or others.13 Studies suggest that patients receiving both psychotherapy and pharmacotherapy benefit from the complementary targeting of symptoms, exhibit increased adherence, and report fewer adverse effects.23
Patients are most likely to benefit from therapy when they have the capacity for introspection and forming friendships (ie, can form a therapeutic alliance). With such patients who have mild or moderate symptoms of GAD, offer cognitive behavioral therapy (CBT) or applied relaxation training. Consider a trial of medication when symptoms are severe, when psychotherapy is not a good option, or when response to psychotherapy is inadequate.13 Medications work by targeting primitive parts of the brain such as the amygdala (bottom up), while psychotherapy targets the cortex or more evolved part of the brain, teaching it to modulate the lower or more primitive structures (top down).24
Medication considerations. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy for adult and adolescent patients with GAD.20 However, in adolescents, no SSRIs are approved by the US Food and Drug Administration (FDA) to treat anxiety disorders unassociated with obsessive-compulsive disorder. Use caution if prescribing an SSRI for off-label treatment in an adolescent; talk with the patient and family about the FDA’s black-box warning regarding the potential for suicidality in adolescents.
For adults, selective norepinephrine reuptake inhibitors (SNRIs) are also considered a first-line treatment option.23 SSRIs and SNRIs are well-studied, effective, safe, and better tolerated than earlier antidepressants. However, be aware that both SSRIs and SNRIs are often associated with headache, nausea, and sexual dysfunction. They are dosed once daily and have not been shown to cause dependence. Inform patients that onset of action is often delayed 4 to 8 weeks23 and that there is a risk for anxiety-producing effects early in treatment. To minimize these effects, consider starting treatment at a lower dose and titrate upward more gradually than when treating depression.
Continue to: Continue treatment for 12 months...
Continue treatment for 12 months to reduce the risk of recurrence.23 If response to treatment is insufficient after 2 adequate trials of an SSRI or SNRI, consider second-line agents such as azapirones or benzodiazepines for adults, keeping in mind the risk for dependence with benzodiazepines.13
Evidence supports GABAergic drugs such as gabapentin and pregabalin as off-label treatments for GAD in refractory adult cases.25 In the European Union, pregabalin is approved for use in GAD. Caution is recommended with both drugs due to abuse potential. Next steps for an inadequate response should include referral to Psychiatry or for inpatient care when risk of harm to self or others is high.
CASE
Considering Ms. H’s ability to work and complete daily activities, we talked to her about CBT as a first step and referred her to a therapist in the community. One month after her initial visit with us, Ms. H returned for a follow-up visit and scored a 17 on her GAD-7, still in the severe range. After one CBT session, she had cancelled her second and third appointments due to work conflicts. She had missed some work from oversleeping after worried sleepless nights. Her worries concerned friendships, paying bills, physical appearance, not being able to exercise and therefore gaining weight, and troubles at work and with her mother. She also described several episodes of nightmares after breaking up with a boyfriend.
She agreed to try an SSRI, and we started her on fluoxetine 10 mg/d. We counseled her on SSRI risks and benefits, including the potential for increased suicidal ideation and how to respond if such thoughts developed. Three weeks after starting fluoxetine, Ms. H reported improvement with no adverse effects from the medication, except for decreased appetite and some weight loss, which she welcomed. She had registered for college courses, and her third score on the GAD-7 was an 8.
We increased her fluoxetine dose to 20 mg/d for maintenance. We encouraged her to return to her therapist for CBT and she scheduled that appointment. Therapy records noted a GAD-7 score of 5 at follow-up 8 weeks later. Ms. H reported improved sleep, reduced irritability at home, and better relationships with her mother and friends. She had begun college classes and was writing about her thoughts and worries as part of her CBT homework. She continued follow-up appointments with both her family physician and her therapist.
CORRESPONDENCE
Christopher A. Ebberwein, PhD, Wesley Family Medicine Residency, 850 North Hillside, Wichita, KS 67214; chris. ebberwein@wesleymc.com.
1. Kroenke K, Spitzer RL, Williams JBW, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-325.
2. Ruscio AM, Hallion LS, Lim CCW, et al. Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiatry. 2017;74:465-475.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.
4. Fernandez S. Anxiety disorders in childhood and adolescence: a primary care approach. Pediatr Ann. 2017;46:e213-e216.
5. Connolly SD, Bernstein GA. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.
6. Reinhold JA, Rickels K. Pharmacological treatments for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother. 2015;16:1669-1681.
7. Kujanpää TS, Jokelainen J, Auvinen JP, et al. The association of generalized anxiety disorder and somatic symptoms with frequent attendance to healthcare services: a cross-sectional study from the Northern Finland Birth Cohort 1966. Int J Psychiatry Med. 2017:52:147-159.
8. Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch Pediatr Adolesc Med. 2010;164:965-972. doi:10.1001/archpediatrics.2010.170.
9. Barger SD, Sydeman SJ. Does generalized anxiety disorder predict coronary heart disease risk factors independently of major depressive disorder? J Affect Disord. 2005;88:87-91.
10. Bruffaerts R, Demyttenaere K, Kessler RC, et al. The associations between preexisting mental disorders and subsequent onset of chronic headaches: a worldwide epidemiologic perspective. J Pain. 2015;16:42-52.
11. Husky MM, Olfson M, He J, et al. Twelve-month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey. Psychiatr Serv. 2012;63:989-996.
12. Nepon J, Belik S, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791–798.
13. National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder adults: management. nice.org.uk/guidance/cg113. Accessed August 20, 2020.
14. Dell’Osso B, Camuri G, Benatti B, et al. Differences in latency to first pharmacological treatment (duration of untreated illness) in anxiety disorders: a study on patients with panic disorder, generalized anxiety disorder and obsessive-compulsive disorder. Early Interv Psychiatry. 2013;7:374-380.
15. Hales RE, Yudofsky SC, Roberts LW, eds. Textbook of Psychiatry, 6th ed. Arlington, VA: American Psychiatric Publishing: 2014:391-430.
16. Fernandez F, Levy JK, Lachar BL, et al. The management of depression and anxiety in the elderly. J Clin Psychiatry. 1995;56(suppl 2):20-29.
17. Kirkwood CK, Hayes PE. Anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach, 3rd ed. Stamford, Conn: Appleton & Lange;1997:1443-1462.
18. Culpepper L. Generalized anxiety disorder and medical illness. J Clin Psychiatry. 2009;70(suppl 2):20-24.
19. Anderson KG, Dugas MJ, Koerner N, et al. Interpretive style and intolerance of uncertainty in individuals with anxiety disorders: a focus on generalized anxiety disorder. J Anxiety Disord. 2012;26:823-832.
20. Satterfield JM, Feldman MD. Anxiety. In Feldman MD, Christensen JF, Satterfield JM, eds. Behavioral Medicine: A Guide for Clinical Practice. New York: McGraw Hill; 2014:271-282.
21. Grist R, Porter J, Stallard P. Mental health mobile apps for preadolescents and adolescents: A systematic review. J Med Internet Res. 2017;19:e176.
22. Rollnick S, Miller W, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 1st ed. New York: The Guilford Press; 2008:34-35.
23. Strawn JR, Geriacioti L, Rajdev N, et al. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based review. Expert Opin Pharmacother. 2018;19:1057-1070.
24. Ehmke CJ, Nemeroff CB. Paroxetine. In Schatzberg AF, Nemeroff CB, eds. Textbook of Psychopharmacology, 4th ed. Washington, D.C.: American Psychiatric Publishing, Inc.; 2009:321-352.
25. Huh J, Goebert D, Takeshita J, et al. Treatment of generalized anxiety disorder: a comprehensive review of the literature for psychopharmacologic alternatives to newer antidepressants and benzodiazepines. Prim Care Companion CNS Disord. 2011;13: doi:10.4088/PCC.08r00709blu.
THE CASE
Sandra H,* a 24-year-old single woman with a history of asthma, presented to our family medicine clinic as a new patient. Ms. H said she lived at home with her mother. She completed high school but never attended college due to anxiety. She had held several jobs since high school and recently decided to apply to a local college, which prompted a desire to gain control over the anxiety that had been present since middle school. She reported feeling anxious, having difficulty breathing, shaking all over, having difficulty concentrating, and experiencing numbness and tingling in her fingers. She was often irritable at home, which she attributed partly to anxiety but mostly to disrupted sleep. We administered the 7-question Generalized Anxiety Disorder (GAD-7) questionnaire and she scored 15 (of a possible 21) points, indicative of severe anxiety.
●
* The patient’s name has been changed to protect her identity.
Approximately 1 in 5 patients presenting to primary care clinics have at least 1 anxiety disorder and 7.6% have generalized anxiety disorder (GAD).1 Yet many go untreated. The lifetime prevalence of GAD is 3.7% worldwide and 7.8% in the United States.2 Only 5% of cases emerge by age 13,2 but incidence increases through adolescence and young adulthood, with a quarter of all cases occurring by age 25.2 GAD occurs about twice as often in women as it does in men. It is typically recurrent, and many patients require ongoing treatment.2
GAD diagnostic criteria and differential considerations
Diagnosis of GAD requires at least 6 months of excessive worry or anxiety about a variety of circumstances, occurring on most days and for more than half the day.3 The worry or anxiety in GAD is difficult to control, disrupts meaningful areas of life, and surrounds everyday concerns, such as finances, health, or family-related issues. Among adolescents with GAD, worries typically include school performance and may often present as perfectionism.4 At least 3 of the following 6 symptoms result from chronic anxiety: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.2
Rule out other conditions. Make sure symptoms of GAD are not better explained by another medical problem, including other mental disorders or substance use disorders.3 Complaints of anxiety in the context of mania, hypomania, or withdrawal from alcohol or a sedative hypnotic suggest a different underlying cause, thereby requiring a complete history with symptom chronology and collateral information. The pattern of anxiety seen in GAD also differs from the focused sources of anxiety found in disorders such as social anxiety disorder (SAD) and post-traumatic stress disorder. For example, SAD might center on embarrassment in a social setting rather than reflect a pattern of general worry.5
Consider comorbidities. Further complicating diagnosis and treatment, GAD has been linked to higher rates of comorbidity and higher health care utilization. About 90% of GAD patients experience psychiatric comorbidity, with major depressive disorder co-occurring about 60% of the time.6 Substance use disorders co-occur with GAD more than 20% of the time.2 Despite comorbidities, it is the somatic complaints in GAD that often drive patient requests for medical care.7,8 GAD itself is an independent predictor of heart disease9 and is linked to increased risk of chronic or severe headaches10 and suicide.11,12
Continue to: Work with patients and family toward a diagnosis
Work with patients and family toward a diagnosis
Despite the potential benefits of early identification and treatment of GAD,13 the average elapsed time from symptom onset to initial medication treatment is 7 years.14 Multiple factors likely account for this delay. Clinical presentations can be highly variable,6 with 1 patient presenting primarily with sleep complaints and another with gastrointestinal symptoms. Some medical conditions (TABLE 1)15 and substances (TABLE 2)16-18 can cause secondary anxiety symptoms, and their presence should prompt a thorough evaluation.
Address the mind-body connection. Because uncertainty and ambiguity surrounding a diagnosis often drive worry,19 anxious patients or their family members commonly seek additional medical visits and tests in search of answers. In such instances, it helps to explain the physiologic connection between somatic complaints and anxiety.8 Describe how areas of the brain that manage fear and stress can also cause muscle tension, gastrointestinal complaints, hyperarousal, or sleep disturbance.
Empathy and early psychoeducation on the reason anxiety is being considered can decrease stigma and enable appropriate follow-up and treatment. You might introduce the connection between health complaints and GAD specifically by exploring the amount of worry surrounding the presenting symptoms, followed by a question such as, “Sometimes your worry will fit the situation and sometimes it’ll be too much. Has anyone ever told you that you worry too much?” The patient’s response to such a question could signal a need to use the GAD-7 screening tool1 as an aid to diagnosis and as a baseline measure for monitoring subsequent treatment progress.
Psycho- and pharmacotherapy aspects of management
Let patients choose from among various coping strategies. Be prepared to offer patients user-friendly handouts, reading material, or links to educational Web sites. Many patients are interested in using smartphone applications to learn and practice coping strategies. Although these apps can encourage the regular practice of coping skills, caution teens and parents about privacy issues and the lack of evidence supporting this approach as stand-alone therapy.21 Offering several choices (TABLE 4)
Continue to: For patients who remain focused...
For patients who remain focused on somatic complaints and resist adopting coping skills or treatment, pushing certain recommendations can actually increase resistance to proper treatment.22 Instead, explore their ambivalence, offer facts, express concern about the current course of the illness, and emphasize the need to revisit the discussion at a future appointment. Offer follow-up monitoring to assess the course of the illness and readiness for GAD treatment.
Initiate treatment in a stepwise manner13 for the patient who is ready for GAD treatment. This approach includes education and monitoring; low-intensity interventions (eg, treatment workbooks or group sessions); medication and/or referral for psychotherapy; referral for outpatient psychiatric care; and hospitalization for patients who pose a danger to self or others.13 Studies suggest that patients receiving both psychotherapy and pharmacotherapy benefit from the complementary targeting of symptoms, exhibit increased adherence, and report fewer adverse effects.23
Patients are most likely to benefit from therapy when they have the capacity for introspection and forming friendships (ie, can form a therapeutic alliance). With such patients who have mild or moderate symptoms of GAD, offer cognitive behavioral therapy (CBT) or applied relaxation training. Consider a trial of medication when symptoms are severe, when psychotherapy is not a good option, or when response to psychotherapy is inadequate.13 Medications work by targeting primitive parts of the brain such as the amygdala (bottom up), while psychotherapy targets the cortex or more evolved part of the brain, teaching it to modulate the lower or more primitive structures (top down).24
Medication considerations. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy for adult and adolescent patients with GAD.20 However, in adolescents, no SSRIs are approved by the US Food and Drug Administration (FDA) to treat anxiety disorders unassociated with obsessive-compulsive disorder. Use caution if prescribing an SSRI for off-label treatment in an adolescent; talk with the patient and family about the FDA’s black-box warning regarding the potential for suicidality in adolescents.
For adults, selective norepinephrine reuptake inhibitors (SNRIs) are also considered a first-line treatment option.23 SSRIs and SNRIs are well-studied, effective, safe, and better tolerated than earlier antidepressants. However, be aware that both SSRIs and SNRIs are often associated with headache, nausea, and sexual dysfunction. They are dosed once daily and have not been shown to cause dependence. Inform patients that onset of action is often delayed 4 to 8 weeks23 and that there is a risk for anxiety-producing effects early in treatment. To minimize these effects, consider starting treatment at a lower dose and titrate upward more gradually than when treating depression.
Continue to: Continue treatment for 12 months...
Continue treatment for 12 months to reduce the risk of recurrence.23 If response to treatment is insufficient after 2 adequate trials of an SSRI or SNRI, consider second-line agents such as azapirones or benzodiazepines for adults, keeping in mind the risk for dependence with benzodiazepines.13
Evidence supports GABAergic drugs such as gabapentin and pregabalin as off-label treatments for GAD in refractory adult cases.25 In the European Union, pregabalin is approved for use in GAD. Caution is recommended with both drugs due to abuse potential. Next steps for an inadequate response should include referral to Psychiatry or for inpatient care when risk of harm to self or others is high.
CASE
Considering Ms. H’s ability to work and complete daily activities, we talked to her about CBT as a first step and referred her to a therapist in the community. One month after her initial visit with us, Ms. H returned for a follow-up visit and scored a 17 on her GAD-7, still in the severe range. After one CBT session, she had cancelled her second and third appointments due to work conflicts. She had missed some work from oversleeping after worried sleepless nights. Her worries concerned friendships, paying bills, physical appearance, not being able to exercise and therefore gaining weight, and troubles at work and with her mother. She also described several episodes of nightmares after breaking up with a boyfriend.
She agreed to try an SSRI, and we started her on fluoxetine 10 mg/d. We counseled her on SSRI risks and benefits, including the potential for increased suicidal ideation and how to respond if such thoughts developed. Three weeks after starting fluoxetine, Ms. H reported improvement with no adverse effects from the medication, except for decreased appetite and some weight loss, which she welcomed. She had registered for college courses, and her third score on the GAD-7 was an 8.
We increased her fluoxetine dose to 20 mg/d for maintenance. We encouraged her to return to her therapist for CBT and she scheduled that appointment. Therapy records noted a GAD-7 score of 5 at follow-up 8 weeks later. Ms. H reported improved sleep, reduced irritability at home, and better relationships with her mother and friends. She had begun college classes and was writing about her thoughts and worries as part of her CBT homework. She continued follow-up appointments with both her family physician and her therapist.
CORRESPONDENCE
Christopher A. Ebberwein, PhD, Wesley Family Medicine Residency, 850 North Hillside, Wichita, KS 67214; chris. ebberwein@wesleymc.com.
THE CASE
Sandra H,* a 24-year-old single woman with a history of asthma, presented to our family medicine clinic as a new patient. Ms. H said she lived at home with her mother. She completed high school but never attended college due to anxiety. She had held several jobs since high school and recently decided to apply to a local college, which prompted a desire to gain control over the anxiety that had been present since middle school. She reported feeling anxious, having difficulty breathing, shaking all over, having difficulty concentrating, and experiencing numbness and tingling in her fingers. She was often irritable at home, which she attributed partly to anxiety but mostly to disrupted sleep. We administered the 7-question Generalized Anxiety Disorder (GAD-7) questionnaire and she scored 15 (of a possible 21) points, indicative of severe anxiety.
●
* The patient’s name has been changed to protect her identity.
Approximately 1 in 5 patients presenting to primary care clinics have at least 1 anxiety disorder and 7.6% have generalized anxiety disorder (GAD).1 Yet many go untreated. The lifetime prevalence of GAD is 3.7% worldwide and 7.8% in the United States.2 Only 5% of cases emerge by age 13,2 but incidence increases through adolescence and young adulthood, with a quarter of all cases occurring by age 25.2 GAD occurs about twice as often in women as it does in men. It is typically recurrent, and many patients require ongoing treatment.2
GAD diagnostic criteria and differential considerations
Diagnosis of GAD requires at least 6 months of excessive worry or anxiety about a variety of circumstances, occurring on most days and for more than half the day.3 The worry or anxiety in GAD is difficult to control, disrupts meaningful areas of life, and surrounds everyday concerns, such as finances, health, or family-related issues. Among adolescents with GAD, worries typically include school performance and may often present as perfectionism.4 At least 3 of the following 6 symptoms result from chronic anxiety: restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.2
Rule out other conditions. Make sure symptoms of GAD are not better explained by another medical problem, including other mental disorders or substance use disorders.3 Complaints of anxiety in the context of mania, hypomania, or withdrawal from alcohol or a sedative hypnotic suggest a different underlying cause, thereby requiring a complete history with symptom chronology and collateral information. The pattern of anxiety seen in GAD also differs from the focused sources of anxiety found in disorders such as social anxiety disorder (SAD) and post-traumatic stress disorder. For example, SAD might center on embarrassment in a social setting rather than reflect a pattern of general worry.5
Consider comorbidities. Further complicating diagnosis and treatment, GAD has been linked to higher rates of comorbidity and higher health care utilization. About 90% of GAD patients experience psychiatric comorbidity, with major depressive disorder co-occurring about 60% of the time.6 Substance use disorders co-occur with GAD more than 20% of the time.2 Despite comorbidities, it is the somatic complaints in GAD that often drive patient requests for medical care.7,8 GAD itself is an independent predictor of heart disease9 and is linked to increased risk of chronic or severe headaches10 and suicide.11,12
Continue to: Work with patients and family toward a diagnosis
Work with patients and family toward a diagnosis
Despite the potential benefits of early identification and treatment of GAD,13 the average elapsed time from symptom onset to initial medication treatment is 7 years.14 Multiple factors likely account for this delay. Clinical presentations can be highly variable,6 with 1 patient presenting primarily with sleep complaints and another with gastrointestinal symptoms. Some medical conditions (TABLE 1)15 and substances (TABLE 2)16-18 can cause secondary anxiety symptoms, and their presence should prompt a thorough evaluation.
Address the mind-body connection. Because uncertainty and ambiguity surrounding a diagnosis often drive worry,19 anxious patients or their family members commonly seek additional medical visits and tests in search of answers. In such instances, it helps to explain the physiologic connection between somatic complaints and anxiety.8 Describe how areas of the brain that manage fear and stress can also cause muscle tension, gastrointestinal complaints, hyperarousal, or sleep disturbance.
Empathy and early psychoeducation on the reason anxiety is being considered can decrease stigma and enable appropriate follow-up and treatment. You might introduce the connection between health complaints and GAD specifically by exploring the amount of worry surrounding the presenting symptoms, followed by a question such as, “Sometimes your worry will fit the situation and sometimes it’ll be too much. Has anyone ever told you that you worry too much?” The patient’s response to such a question could signal a need to use the GAD-7 screening tool1 as an aid to diagnosis and as a baseline measure for monitoring subsequent treatment progress.
Psycho- and pharmacotherapy aspects of management
Let patients choose from among various coping strategies. Be prepared to offer patients user-friendly handouts, reading material, or links to educational Web sites. Many patients are interested in using smartphone applications to learn and practice coping strategies. Although these apps can encourage the regular practice of coping skills, caution teens and parents about privacy issues and the lack of evidence supporting this approach as stand-alone therapy.21 Offering several choices (TABLE 4)
Continue to: For patients who remain focused...
For patients who remain focused on somatic complaints and resist adopting coping skills or treatment, pushing certain recommendations can actually increase resistance to proper treatment.22 Instead, explore their ambivalence, offer facts, express concern about the current course of the illness, and emphasize the need to revisit the discussion at a future appointment. Offer follow-up monitoring to assess the course of the illness and readiness for GAD treatment.
Initiate treatment in a stepwise manner13 for the patient who is ready for GAD treatment. This approach includes education and monitoring; low-intensity interventions (eg, treatment workbooks or group sessions); medication and/or referral for psychotherapy; referral for outpatient psychiatric care; and hospitalization for patients who pose a danger to self or others.13 Studies suggest that patients receiving both psychotherapy and pharmacotherapy benefit from the complementary targeting of symptoms, exhibit increased adherence, and report fewer adverse effects.23
Patients are most likely to benefit from therapy when they have the capacity for introspection and forming friendships (ie, can form a therapeutic alliance). With such patients who have mild or moderate symptoms of GAD, offer cognitive behavioral therapy (CBT) or applied relaxation training. Consider a trial of medication when symptoms are severe, when psychotherapy is not a good option, or when response to psychotherapy is inadequate.13 Medications work by targeting primitive parts of the brain such as the amygdala (bottom up), while psychotherapy targets the cortex or more evolved part of the brain, teaching it to modulate the lower or more primitive structures (top down).24
Medication considerations. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy for adult and adolescent patients with GAD.20 However, in adolescents, no SSRIs are approved by the US Food and Drug Administration (FDA) to treat anxiety disorders unassociated with obsessive-compulsive disorder. Use caution if prescribing an SSRI for off-label treatment in an adolescent; talk with the patient and family about the FDA’s black-box warning regarding the potential for suicidality in adolescents.
For adults, selective norepinephrine reuptake inhibitors (SNRIs) are also considered a first-line treatment option.23 SSRIs and SNRIs are well-studied, effective, safe, and better tolerated than earlier antidepressants. However, be aware that both SSRIs and SNRIs are often associated with headache, nausea, and sexual dysfunction. They are dosed once daily and have not been shown to cause dependence. Inform patients that onset of action is often delayed 4 to 8 weeks23 and that there is a risk for anxiety-producing effects early in treatment. To minimize these effects, consider starting treatment at a lower dose and titrate upward more gradually than when treating depression.
Continue to: Continue treatment for 12 months...
Continue treatment for 12 months to reduce the risk of recurrence.23 If response to treatment is insufficient after 2 adequate trials of an SSRI or SNRI, consider second-line agents such as azapirones or benzodiazepines for adults, keeping in mind the risk for dependence with benzodiazepines.13
Evidence supports GABAergic drugs such as gabapentin and pregabalin as off-label treatments for GAD in refractory adult cases.25 In the European Union, pregabalin is approved for use in GAD. Caution is recommended with both drugs due to abuse potential. Next steps for an inadequate response should include referral to Psychiatry or for inpatient care when risk of harm to self or others is high.
CASE
Considering Ms. H’s ability to work and complete daily activities, we talked to her about CBT as a first step and referred her to a therapist in the community. One month after her initial visit with us, Ms. H returned for a follow-up visit and scored a 17 on her GAD-7, still in the severe range. After one CBT session, she had cancelled her second and third appointments due to work conflicts. She had missed some work from oversleeping after worried sleepless nights. Her worries concerned friendships, paying bills, physical appearance, not being able to exercise and therefore gaining weight, and troubles at work and with her mother. She also described several episodes of nightmares after breaking up with a boyfriend.
She agreed to try an SSRI, and we started her on fluoxetine 10 mg/d. We counseled her on SSRI risks and benefits, including the potential for increased suicidal ideation and how to respond if such thoughts developed. Three weeks after starting fluoxetine, Ms. H reported improvement with no adverse effects from the medication, except for decreased appetite and some weight loss, which she welcomed. She had registered for college courses, and her third score on the GAD-7 was an 8.
We increased her fluoxetine dose to 20 mg/d for maintenance. We encouraged her to return to her therapist for CBT and she scheduled that appointment. Therapy records noted a GAD-7 score of 5 at follow-up 8 weeks later. Ms. H reported improved sleep, reduced irritability at home, and better relationships with her mother and friends. She had begun college classes and was writing about her thoughts and worries as part of her CBT homework. She continued follow-up appointments with both her family physician and her therapist.
CORRESPONDENCE
Christopher A. Ebberwein, PhD, Wesley Family Medicine Residency, 850 North Hillside, Wichita, KS 67214; chris. ebberwein@wesleymc.com.
1. Kroenke K, Spitzer RL, Williams JBW, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-325.
2. Ruscio AM, Hallion LS, Lim CCW, et al. Cross-sectional comparison of the epidemiology of DSM-5 generalized anxiety disorder across the globe. JAMA Psychiatry. 2017;74:465-475.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.
4. Fernandez S. Anxiety disorders in childhood and adolescence: a primary care approach. Pediatr Ann. 2017;46:e213-e216.
5. Connolly SD, Bernstein GA. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.
6. Reinhold JA, Rickels K. Pharmacological treatments for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother. 2015;16:1669-1681.
7. Kujanpää TS, Jokelainen J, Auvinen JP, et al. The association of generalized anxiety disorder and somatic symptoms with frequent attendance to healthcare services: a cross-sectional study from the Northern Finland Birth Cohort 1966. Int J Psychiatry Med. 2017:52:147-159.
8. Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch Pediatr Adolesc Med. 2010;164:965-972. doi:10.1001/archpediatrics.2010.170.
9. Barger SD, Sydeman SJ. Does generalized anxiety disorder predict coronary heart disease risk factors independently of major depressive disorder? J Affect Disord. 2005;88:87-91.
10. Bruffaerts R, Demyttenaere K, Kessler RC, et al. The associations between preexisting mental disorders and subsequent onset of chronic headaches: a worldwide epidemiologic perspective. J Pain. 2015;16:42-52.
11. Husky MM, Olfson M, He J, et al. Twelve-month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey. Psychiatr Serv. 2012;63:989-996.
12. Nepon J, Belik S, Bolton J, et al. The relationship between anxiety disorders and suicide attempts: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Depress Anxiety. 2010;27:791–798.
13. National Institute for Health and Care Excellence (NICE). Generalised anxiety disorder and panic disorder adults: management. nice.org.uk/guidance/cg113. Accessed August 20, 2020.
14. Dell’Osso B, Camuri G, Benatti B, et al. Differences in latency to first pharmacological treatment (duration of untreated illness) in anxiety disorders: a study on patients with panic disorder, generalized anxiety disorder and obsessive-compulsive disorder. Early Interv Psychiatry. 2013;7:374-380.
15. Hales RE, Yudofsky SC, Roberts LW, eds. Textbook of Psychiatry, 6th ed. Arlington, VA: American Psychiatric Publishing: 2014:391-430.
16. Fernandez F, Levy JK, Lachar BL, et al. The management of depression and anxiety in the elderly. J Clin Psychiatry. 1995;56(suppl 2):20-29.
17. Kirkwood CK, Hayes PE. Anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach, 3rd ed. Stamford, Conn: Appleton & Lange;1997:1443-1462.
18. Culpepper L. Generalized anxiety disorder and medical illness. J Clin Psychiatry. 2009;70(suppl 2):20-24.
19. Anderson KG, Dugas MJ, Koerner N, et al. Interpretive style and intolerance of uncertainty in individuals with anxiety disorders: a focus on generalized anxiety disorder. J Anxiety Disord. 2012;26:823-832.
20. Satterfield JM, Feldman MD. Anxiety. In Feldman MD, Christensen JF, Satterfield JM, eds. Behavioral Medicine: A Guide for Clinical Practice. New York: McGraw Hill; 2014:271-282.
21. Grist R, Porter J, Stallard P. Mental health mobile apps for preadolescents and adolescents: A systematic review. J Med Internet Res. 2017;19:e176.
22. Rollnick S, Miller W, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 1st ed. New York: The Guilford Press; 2008:34-35.
23. Strawn JR, Geriacioti L, Rajdev N, et al. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based review. Expert Opin Pharmacother. 2018;19:1057-1070.
24. Ehmke CJ, Nemeroff CB. Paroxetine. In Schatzberg AF, Nemeroff CB, eds. Textbook of Psychopharmacology, 4th ed. Washington, D.C.: American Psychiatric Publishing, Inc.; 2009:321-352.
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