Amid growing concern among the public, psychiatrists, and other mental health professionals, the Canadian government is seeking to delay the legalization of its proposed medical assistance in dying (MAID) for mental illness law that is slated to pass on March 17.

Canada already has the largest number of deaths by MAID of any nation, with 10,064 in 2021, a 32% increase from 2020. With the addition of serious mental illness (SMI) as an eligible category, the country is on track to have the most liberal assisted-death policy in the world.

Concerns about the additional number of patients who could become eligible for MAID, and a lack of evidence-backed standards from disability rights groups, mental health advocates, First Nations leaders, psychiatrists, and other mental health providers, seems to have led the Canadian government to give the proposed law some sober second thought.

“Listening to experts and Canadians, we believe this date needs to be temporarily delayed,” said David Lametti, Canada’s minister of Justice and attorney general of Canada; Jean-Yves Duclos, minister of Health; and  Carolyn Bennett, minister of Mental Health and Addictions, in a Dec. 15, 2022, joint statement.

Canada’s Parliament – which approved the expansion – will now have to vote on whether to okay a pause on the legislation.

However, the Canadian Psychiatric Association has not been calling for a delay in the proposed legislation. In a November 2021 statement, the CPA  said it “does not take a position on the legality or morality of MAID,” but added that to deny MAID to people with mental illness was discriminatory, and that, as it was the law, it must be followed.

“CPA has not taken a position about MAID,” the association’s president Gary Chaimowitz, MBChB, told this news organization. “We know this is coming and our organization is trying to get its members ready for what will be most likely the ability of people with mental conditions to be able to request MAID,” said Dr. Chaimowitz, who is also head of forensic psychiatry at St. Joseph’s Healthcare and a professor of psychiatry at McMaster University, both in Hamilton, Ont.

Dr. Chaimowitz acknowledges that “a majority of psychiatrists do not want to be involved in anything to do with MAID.”

“The idea, certainly in psychiatry, is to get people well and we’ve been taught that people dying from a major mental disorder is something that we’re trained to prevent,” he added.
 

A ‘clinical option’

Assisted medical death is especially fraught in psychiatry, said Rebecca Brendel, MD, president of the American Psychiatric Association. She noted a 25-year life expectancy gap between people with SMI and those who do not have such conditions.

“As a profession we have very serious obligations to advance treatment so that a person with serious mental illness can live [a] full, productive, and healthy [life],” Dr. Brendel, associate director of the Center for Bioethics at Harvard Medical School in Boston, said in an interview.

Under the Canadian proposal, psychiatrists would be allowed to suggest MAID as a “clinical option.”

Harold Braswell, PhD, a fellow with The Hastings Center, a bioethics research institute, calls that problematic.

“It’s not neutral to suggest to someone that it would be theoretically reasonable to end their lives,” Dr. Braswell, associate professor at the Albert Gnaegi Center for Health Care Ethics at Saint Louis University, told this news organization.

It also creates a double standard in the treatment of suicidal ideation, in which suicide prevention is absolute for some, but encouraging it as a possibility for others, he added.  

“To have that come from an authority figure is something that’s very harsh and, in my opinion, very potentially destructive,” especially for vulnerable groups, like First Nations people, who already have elevated rates of suicide, said Dr. Braswell.
 

Fierce debate

Since 2016, Canada has allowed MAID for medical conditions and diseases that will not improve and in cases where the evidence shows that medical providers can accurately predict the condition will not improve.

However, in 2019, a Quebec court ruled that the law unconstitutionally barred euthanasia in people who were not terminally ill. In March 2021, Canada’s criminal code was amended to allow MAID for people whose natural death was not “reasonably foreseeable,” but it excluded SMI for a period of 2 years, ending in March 2023.

The 2-year stay was intended to allow for study and to give mental health providers and MAID assessors time to develop standards.

The federal government charged a 12-member expert panel with determining how to safely allow MAID for SMI. In its final report released in May 2022 it recommended that standards be developed. 

The panel acknowledged that for many conditions it may be impossible to make predictions about whether an individual might improve. However, it did not mention SMI.

In those cases, when MAID is requested, “establishing incurability and irreversibility on the basis of the evolution and response to past interventions is necessary,” the panel noted, adding that these are the criteria used by psychiatrists assessing euthanasia requests in the Netherlands and Belgium.

But the notion that mental illness can be irremediable has been fiercely debated.

Soon after the expert report was released, the Center for Addiction and Mental Health in Toronto noted on its website that there are currently  “no agreed upon standards for psychiatrists or other health care practitioners to use to determine if a person’s mental illness is ‘grievous and irremediable’ for the purposes of MAID.” 

Dr. Chaimowitz acknowledged that “there’s no agreed-upon definition of incurability” in mental illness. Some psychiatrists “will argue that there’s always another treatment that can be attempted,” he said, adding that there has been a lack of consensus on irremediability among CPA members.
 

Protecting vulnerable populations

Matt Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado at Denver, Aurora, said the question of irremediability is crucial. “Most people with mental illness do get better, especially if they’re in treatment,” Dr. Wynia said.

For MAID assessors it may be difficult to know when someone has tried all possible treatments, especially given the wide array of options, including psychedelics, said Dr. Wynia.

Dr. Braswell said there is not enough evidence that mental illness is incurable. With SMI, “there’s a lot more potential for the causes of the individual’s suffering to be ameliorated. By offering MAID, you’re going to kill people who might have been able to get out of this through other nonlethal means.”

Currently, MAID is provided for an irremediable medical condition, “in other words, a condition that will not improve and that we can predict will not improve,” said Karandeep S. Gaind, MD, chief of psychiatry at Toronto’s Humber River Hospital and physician chair of the hospital’s MAID team.

“If that’s the premise, then I think we cannot provide MAID for sole mental illness,” Dr. Gaind said. “Because we can’t honestly make those predictions” with mental illness, he added.

Dr. Gaind does not support MAID for mental illness and believes that it will put the vulnerable – including those living in poverty – at particular risk.

With the proposed expansion, MAID is “now becoming something which is being sought as a way to escape a painful life rather than to avoid a painful death,” said Dr. Gaind, who is also a past president of the CPA.

One member of the federal government’s expert panel – Ellen Cohen, who had a psychiatric condition – wrote in The Globe and Mail that she quit early on when it became apparent that the panel was not seriously considering her own experiences or the possibility that poverty and lack of access to care or social supports could strongly influence a request for MAID.
 

Social determinants of suffering

People with mental illness often are without homes, have substance use disorders, have been stigmatized and discriminated against, and have poor social supports, said Dr. Wynia. “You worry that it’s all of those things that are making them want to end their lives,” he said.

The Daily Mail ran a story in December 2022 about a 65-year-old Canadian who said he’d applied for MAID solely because of fears that his disability benefits for various chronic health conditions were being cut off and that he didn’t want to live in poverty.

A 51-year-old Ontario woman with multiple chemical sensitivities was granted MAID after she said she could not find housing that could keep her safe, according to an August report by CTV News.

Tarek Rajji, MD, chief of the Adult Neurodevelopment and Geriatric Psychiatry Division at CAMH, said social determinants of health need to be considered in standards created to guide MAID for mental illness.

“We’re very mindful of the fact that the suffering, that is, the grievousness that the person is living with, in the context of mental illness, many times is due to the social determinants of their illness and the social determinants of their suffering,” Dr. Rajji said.

Many are also concerned that it will be difficult to separate out suicidality from sheer hopelessness.

The CPA has advised a group that’s working on developing guidelines for MAID in SMI and is also developing a curriculum for mental health providers, Dr. Chaimowitz said. As part of that, there will be a process to ensure that someone who is actively suicidal is not granted MAID.

“I do not believe that it’s contemplated that MAID is going to accelerate or facilitate suicidal ideation,” he said. Someone who is suicidal will be referred to treatment, said Dr. Chaimowitz.

“People with depression often feel hopeless,” and may refuse treatments that have worked in the past, countered Dr. Gaind. Some of his patients “are absolutely convinced that nothing will help,” he said.
 

Troublesome cases

The expert panel said in its final report that “it is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time,” are necessary to establish “irreversibility” of mental illness.

Dr. Chaimowitz said MAID will not be offered to anyone “refusing treatment for their condition without any good reason.” They will be “unlikely to meet criteria for incurable,” as they will have needed to avail themselves of the array of treatments available, he said. 

That would be similar to rules in Belgium and the Netherlands, which allow euthanasia for psychiatric conditions. 

An estimated 100-300 psychiatric patients receive euthanasia each year in those countries, according to a 2021 commentary in Psychiatric Times (Jun 7;38[6]) by Mark S. Komrad, MD, a Towson, Maryland-based psychiatrist.

There are still troublesome cases. 

As previously reported by this news organization, many in Belgium were distressed recently at the news that a 23-year-old woman who had survived a terrorist attack, Shanti De Corte, requested and was granted euthanasia.

As the deadline for implementation of MAID grew closer, calls for delay grew louder, especially given the lack of concrete standards for providers.

During the waning months of 2022, Dr. Gaind – who said he was suspended from CPA for “unprofessional interactions” and allegedly misrepresenting CPA’s processes and governance matters – announced the launch of a new organization, the Society of Canadian Psychiatry, in November calling for a delay in MAID of at least 1 year so that evidence-based safeguards could be implemented. The petition has been signed by more than 200 psychiatrists, along with several dozen physicians, MAID assessors, and individuals with mental illness and family members.

The Association of Chairs of Psychiatry in Canada, the Canadian Association for Suicide Prevention, the Council of Canadians with Disabilities, a group of indigenous leaders, and the Ontario Association for ACT and FACT, psychiatrists who provide care to individuals with severe mental illness, among other groups, joined the call for a delay.

In its December announcement, the Canadian federal ministers said a factor in seeking a delay was that standards guiding clinicians would not be delivered until at least February – too close to when applications would be opened.

Upon hearing about the federal government’s intentions, the chair of the expert panel, Mona Gupta, MD, told The Canadian Press that she did not think it was necessary to put off implementation because necessary safeguards were already in place.

Dr. Chaimowitz awaits the standards but is optimistic that for mental illness, “the process will be tightly controlled, closely monitored, and open to scrutiny,” he said.

Dr. Braswell is not convinced. The concern is that adding people with mental illness is “going to overload the capacity of the government to monitor this practice,” he said.
 

Is the United States next?

Although Canada and the United States share a border, it’s unlikely that U.S. states will allow aid in dying for nonterminal illness, much less for psychiatric conditions any time soon, said Dr. Braswell and others.

Ten states – California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington – have laws allowing assistance in dying, but for terminal illness only.

In 2016, the APA adopted the American Medical Association policy on medical euthanasia, stating, “that a psychiatrist should not prescribe or administer any intervention to a nonterminally ill person for the purpose of causing death.”

Dr. Brendel said the field is acutely aware that people with mental illness do suffer, but that more work needs to be done – and is being done – on “distinguishing wishes to hasten death or end one’s life from these historical or traditional notions that any premature death is a suicide.”

There is also increasing discussion within the medical community, not just psychiatry, about a physician’s duty to relieve suffering, said Dr. Wynia. “There’s debate basically about whether we stand for preserving life essentially at all costs and never being involved in the taking of life, or whether we stand for reduction of suffering and being the advocate for the patients that we serve,” he said.

“Those are both legitimate,” said Dr. Wynia, adding, “there are good reasons to want both of those to be true.”

“I suspect that 20 years from now we will still be having conversations about how physicians, how psychiatrists ought to participate in preserving life and in shepherding death,” said Dr. Brendel.

But to Dr. Gaind, the debate is not just esoteric, it’s a soon-to-be reality in Canada. “When we’re providing death to people who aren’t dying, to me that’s like providing what amounts to a wrongful death,” he said.

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

Amid growing concern among the public, psychiatrists, and other mental health professionals, the Canadian government is seeking to delay the legalization of its proposed medical assistance in dying (MAID) for mental illness law that is slated to pass on March 17.

Canada already has the largest number of deaths by MAID of any nation, with 10,064 in 2021, a 32% increase from 2020. With the addition of serious mental illness (SMI) as an eligible category, the country is on track to have the most liberal assisted-death policy in the world.

Concerns about the additional number of patients who could become eligible for MAID, and a lack of evidence-backed standards from disability rights groups, mental health advocates, First Nations leaders, psychiatrists, and other mental health providers, seems to have led the Canadian government to give the proposed law some sober second thought.

“Listening to experts and Canadians, we believe this date needs to be temporarily delayed,” said David Lametti, Canada’s minister of Justice and attorney general of Canada; Jean-Yves Duclos, minister of Health; and  Carolyn Bennett, minister of Mental Health and Addictions, in a Dec. 15, 2022, joint statement.

Canada’s Parliament – which approved the expansion – will now have to vote on whether to okay a pause on the legislation.

However, the Canadian Psychiatric Association has not been calling for a delay in the proposed legislation. In a November 2021 statement, the CPA  said it “does not take a position on the legality or morality of MAID,” but added that to deny MAID to people with mental illness was discriminatory, and that, as it was the law, it must be followed.

“CPA has not taken a position about MAID,” the association’s president Gary Chaimowitz, MBChB, told this news organization. “We know this is coming and our organization is trying to get its members ready for what will be most likely the ability of people with mental conditions to be able to request MAID,” said Dr. Chaimowitz, who is also head of forensic psychiatry at St. Joseph’s Healthcare and a professor of psychiatry at McMaster University, both in Hamilton, Ont.

Dr. Chaimowitz acknowledges that “a majority of psychiatrists do not want to be involved in anything to do with MAID.”

“The idea, certainly in psychiatry, is to get people well and we’ve been taught that people dying from a major mental disorder is something that we’re trained to prevent,” he added.
 

A ‘clinical option’

Assisted medical death is especially fraught in psychiatry, said Rebecca Brendel, MD, president of the American Psychiatric Association. She noted a 25-year life expectancy gap between people with SMI and those who do not have such conditions.

“As a profession we have very serious obligations to advance treatment so that a person with serious mental illness can live [a] full, productive, and healthy [life],” Dr. Brendel, associate director of the Center for Bioethics at Harvard Medical School in Boston, said in an interview.

Under the Canadian proposal, psychiatrists would be allowed to suggest MAID as a “clinical option.”

Harold Braswell, PhD, a fellow with The Hastings Center, a bioethics research institute, calls that problematic.

“It’s not neutral to suggest to someone that it would be theoretically reasonable to end their lives,” Dr. Braswell, associate professor at the Albert Gnaegi Center for Health Care Ethics at Saint Louis University, told this news organization.

It also creates a double standard in the treatment of suicidal ideation, in which suicide prevention is absolute for some, but encouraging it as a possibility for others, he added.  

“To have that come from an authority figure is something that’s very harsh and, in my opinion, very potentially destructive,” especially for vulnerable groups, like First Nations people, who already have elevated rates of suicide, said Dr. Braswell.
 

Fierce debate

Since 2016, Canada has allowed MAID for medical conditions and diseases that will not improve and in cases where the evidence shows that medical providers can accurately predict the condition will not improve.

However, in 2019, a Quebec court ruled that the law unconstitutionally barred euthanasia in people who were not terminally ill. In March 2021, Canada’s criminal code was amended to allow MAID for people whose natural death was not “reasonably foreseeable,” but it excluded SMI for a period of 2 years, ending in March 2023.

The 2-year stay was intended to allow for study and to give mental health providers and MAID assessors time to develop standards.

The federal government charged a 12-member expert panel with determining how to safely allow MAID for SMI. In its final report released in May 2022 it recommended that standards be developed. 

The panel acknowledged that for many conditions it may be impossible to make predictions about whether an individual might improve. However, it did not mention SMI.

In those cases, when MAID is requested, “establishing incurability and irreversibility on the basis of the evolution and response to past interventions is necessary,” the panel noted, adding that these are the criteria used by psychiatrists assessing euthanasia requests in the Netherlands and Belgium.

But the notion that mental illness can be irremediable has been fiercely debated.

Soon after the expert report was released, the Center for Addiction and Mental Health in Toronto noted on its website that there are currently  “no agreed upon standards for psychiatrists or other health care practitioners to use to determine if a person’s mental illness is ‘grievous and irremediable’ for the purposes of MAID.” 

Dr. Chaimowitz acknowledged that “there’s no agreed-upon definition of incurability” in mental illness. Some psychiatrists “will argue that there’s always another treatment that can be attempted,” he said, adding that there has been a lack of consensus on irremediability among CPA members.
 

Protecting vulnerable populations

Matt Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado at Denver, Aurora, said the question of irremediability is crucial. “Most people with mental illness do get better, especially if they’re in treatment,” Dr. Wynia said.

For MAID assessors it may be difficult to know when someone has tried all possible treatments, especially given the wide array of options, including psychedelics, said Dr. Wynia.

Dr. Braswell said there is not enough evidence that mental illness is incurable. With SMI, “there’s a lot more potential for the causes of the individual’s suffering to be ameliorated. By offering MAID, you’re going to kill people who might have been able to get out of this through other nonlethal means.”

Currently, MAID is provided for an irremediable medical condition, “in other words, a condition that will not improve and that we can predict will not improve,” said Karandeep S. Gaind, MD, chief of psychiatry at Toronto’s Humber River Hospital and physician chair of the hospital’s MAID team.

“If that’s the premise, then I think we cannot provide MAID for sole mental illness,” Dr. Gaind said. “Because we can’t honestly make those predictions” with mental illness, he added.

Dr. Gaind does not support MAID for mental illness and believes that it will put the vulnerable – including those living in poverty – at particular risk.

With the proposed expansion, MAID is “now becoming something which is being sought as a way to escape a painful life rather than to avoid a painful death,” said Dr. Gaind, who is also a past president of the CPA.

One member of the federal government’s expert panel – Ellen Cohen, who had a psychiatric condition – wrote in The Globe and Mail that she quit early on when it became apparent that the panel was not seriously considering her own experiences or the possibility that poverty and lack of access to care or social supports could strongly influence a request for MAID.
 

Social determinants of suffering

People with mental illness often are without homes, have substance use disorders, have been stigmatized and discriminated against, and have poor social supports, said Dr. Wynia. “You worry that it’s all of those things that are making them want to end their lives,” he said.

The Daily Mail ran a story in December 2022 about a 65-year-old Canadian who said he’d applied for MAID solely because of fears that his disability benefits for various chronic health conditions were being cut off and that he didn’t want to live in poverty.

A 51-year-old Ontario woman with multiple chemical sensitivities was granted MAID after she said she could not find housing that could keep her safe, according to an August report by CTV News.

Tarek Rajji, MD, chief of the Adult Neurodevelopment and Geriatric Psychiatry Division at CAMH, said social determinants of health need to be considered in standards created to guide MAID for mental illness.

“We’re very mindful of the fact that the suffering, that is, the grievousness that the person is living with, in the context of mental illness, many times is due to the social determinants of their illness and the social determinants of their suffering,” Dr. Rajji said.

Many are also concerned that it will be difficult to separate out suicidality from sheer hopelessness.

The CPA has advised a group that’s working on developing guidelines for MAID in SMI and is also developing a curriculum for mental health providers, Dr. Chaimowitz said. As part of that, there will be a process to ensure that someone who is actively suicidal is not granted MAID.

“I do not believe that it’s contemplated that MAID is going to accelerate or facilitate suicidal ideation,” he said. Someone who is suicidal will be referred to treatment, said Dr. Chaimowitz.

“People with depression often feel hopeless,” and may refuse treatments that have worked in the past, countered Dr. Gaind. Some of his patients “are absolutely convinced that nothing will help,” he said.
 

Troublesome cases

The expert panel said in its final report that “it is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time,” are necessary to establish “irreversibility” of mental illness.

Dr. Chaimowitz said MAID will not be offered to anyone “refusing treatment for their condition without any good reason.” They will be “unlikely to meet criteria for incurable,” as they will have needed to avail themselves of the array of treatments available, he said. 

That would be similar to rules in Belgium and the Netherlands, which allow euthanasia for psychiatric conditions. 

An estimated 100-300 psychiatric patients receive euthanasia each year in those countries, according to a 2021 commentary in Psychiatric Times (Jun 7;38[6]) by Mark S. Komrad, MD, a Towson, Maryland-based psychiatrist.

There are still troublesome cases. 

As previously reported by this news organization, many in Belgium were distressed recently at the news that a 23-year-old woman who had survived a terrorist attack, Shanti De Corte, requested and was granted euthanasia.

As the deadline for implementation of MAID grew closer, calls for delay grew louder, especially given the lack of concrete standards for providers.

During the waning months of 2022, Dr. Gaind – who said he was suspended from CPA for “unprofessional interactions” and allegedly misrepresenting CPA’s processes and governance matters – announced the launch of a new organization, the Society of Canadian Psychiatry, in November calling for a delay in MAID of at least 1 year so that evidence-based safeguards could be implemented. The petition has been signed by more than 200 psychiatrists, along with several dozen physicians, MAID assessors, and individuals with mental illness and family members.

The Association of Chairs of Psychiatry in Canada, the Canadian Association for Suicide Prevention, the Council of Canadians with Disabilities, a group of indigenous leaders, and the Ontario Association for ACT and FACT, psychiatrists who provide care to individuals with severe mental illness, among other groups, joined the call for a delay.

In its December announcement, the Canadian federal ministers said a factor in seeking a delay was that standards guiding clinicians would not be delivered until at least February – too close to when applications would be opened.

Upon hearing about the federal government’s intentions, the chair of the expert panel, Mona Gupta, MD, told The Canadian Press that she did not think it was necessary to put off implementation because necessary safeguards were already in place.

Dr. Chaimowitz awaits the standards but is optimistic that for mental illness, “the process will be tightly controlled, closely monitored, and open to scrutiny,” he said.

Dr. Braswell is not convinced. The concern is that adding people with mental illness is “going to overload the capacity of the government to monitor this practice,” he said.
 

Is the United States next?

Although Canada and the United States share a border, it’s unlikely that U.S. states will allow aid in dying for nonterminal illness, much less for psychiatric conditions any time soon, said Dr. Braswell and others.

Ten states – California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington – have laws allowing assistance in dying, but for terminal illness only.

In 2016, the APA adopted the American Medical Association policy on medical euthanasia, stating, “that a psychiatrist should not prescribe or administer any intervention to a nonterminally ill person for the purpose of causing death.”

Dr. Brendel said the field is acutely aware that people with mental illness do suffer, but that more work needs to be done – and is being done – on “distinguishing wishes to hasten death or end one’s life from these historical or traditional notions that any premature death is a suicide.”

There is also increasing discussion within the medical community, not just psychiatry, about a physician’s duty to relieve suffering, said Dr. Wynia. “There’s debate basically about whether we stand for preserving life essentially at all costs and never being involved in the taking of life, or whether we stand for reduction of suffering and being the advocate for the patients that we serve,” he said.

“Those are both legitimate,” said Dr. Wynia, adding, “there are good reasons to want both of those to be true.”

“I suspect that 20 years from now we will still be having conversations about how physicians, how psychiatrists ought to participate in preserving life and in shepherding death,” said Dr. Brendel.

But to Dr. Gaind, the debate is not just esoteric, it’s a soon-to-be reality in Canada. “When we’re providing death to people who aren’t dying, to me that’s like providing what amounts to a wrongful death,” he said.

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

Amid growing concern among the public, psychiatrists, and other mental health professionals, the Canadian government is seeking to delay the legalization of its proposed medical assistance in dying (MAID) for mental illness law that is slated to pass on March 17.

Canada already has the largest number of deaths by MAID of any nation, with 10,064 in 2021, a 32% increase from 2020. With the addition of serious mental illness (SMI) as an eligible category, the country is on track to have the most liberal assisted-death policy in the world.

Concerns about the additional number of patients who could become eligible for MAID, and a lack of evidence-backed standards from disability rights groups, mental health advocates, First Nations leaders, psychiatrists, and other mental health providers, seems to have led the Canadian government to give the proposed law some sober second thought.

“Listening to experts and Canadians, we believe this date needs to be temporarily delayed,” said David Lametti, Canada’s minister of Justice and attorney general of Canada; Jean-Yves Duclos, minister of Health; and  Carolyn Bennett, minister of Mental Health and Addictions, in a Dec. 15, 2022, joint statement.

Canada’s Parliament – which approved the expansion – will now have to vote on whether to okay a pause on the legislation.

However, the Canadian Psychiatric Association has not been calling for a delay in the proposed legislation. In a November 2021 statement, the CPA  said it “does not take a position on the legality or morality of MAID,” but added that to deny MAID to people with mental illness was discriminatory, and that, as it was the law, it must be followed.

“CPA has not taken a position about MAID,” the association’s president Gary Chaimowitz, MBChB, told this news organization. “We know this is coming and our organization is trying to get its members ready for what will be most likely the ability of people with mental conditions to be able to request MAID,” said Dr. Chaimowitz, who is also head of forensic psychiatry at St. Joseph’s Healthcare and a professor of psychiatry at McMaster University, both in Hamilton, Ont.

Dr. Chaimowitz acknowledges that “a majority of psychiatrists do not want to be involved in anything to do with MAID.”

“The idea, certainly in psychiatry, is to get people well and we’ve been taught that people dying from a major mental disorder is something that we’re trained to prevent,” he added.
 

A ‘clinical option’

Assisted medical death is especially fraught in psychiatry, said Rebecca Brendel, MD, president of the American Psychiatric Association. She noted a 25-year life expectancy gap between people with SMI and those who do not have such conditions.

“As a profession we have very serious obligations to advance treatment so that a person with serious mental illness can live [a] full, productive, and healthy [life],” Dr. Brendel, associate director of the Center for Bioethics at Harvard Medical School in Boston, said in an interview.

Under the Canadian proposal, psychiatrists would be allowed to suggest MAID as a “clinical option.”

Harold Braswell, PhD, a fellow with The Hastings Center, a bioethics research institute, calls that problematic.

“It’s not neutral to suggest to someone that it would be theoretically reasonable to end their lives,” Dr. Braswell, associate professor at the Albert Gnaegi Center for Health Care Ethics at Saint Louis University, told this news organization.

It also creates a double standard in the treatment of suicidal ideation, in which suicide prevention is absolute for some, but encouraging it as a possibility for others, he added.  

“To have that come from an authority figure is something that’s very harsh and, in my opinion, very potentially destructive,” especially for vulnerable groups, like First Nations people, who already have elevated rates of suicide, said Dr. Braswell.
 

Fierce debate

Since 2016, Canada has allowed MAID for medical conditions and diseases that will not improve and in cases where the evidence shows that medical providers can accurately predict the condition will not improve.

However, in 2019, a Quebec court ruled that the law unconstitutionally barred euthanasia in people who were not terminally ill. In March 2021, Canada’s criminal code was amended to allow MAID for people whose natural death was not “reasonably foreseeable,” but it excluded SMI for a period of 2 years, ending in March 2023.

The 2-year stay was intended to allow for study and to give mental health providers and MAID assessors time to develop standards.

The federal government charged a 12-member expert panel with determining how to safely allow MAID for SMI. In its final report released in May 2022 it recommended that standards be developed. 

The panel acknowledged that for many conditions it may be impossible to make predictions about whether an individual might improve. However, it did not mention SMI.

In those cases, when MAID is requested, “establishing incurability and irreversibility on the basis of the evolution and response to past interventions is necessary,” the panel noted, adding that these are the criteria used by psychiatrists assessing euthanasia requests in the Netherlands and Belgium.

But the notion that mental illness can be irremediable has been fiercely debated.

Soon after the expert report was released, the Center for Addiction and Mental Health in Toronto noted on its website that there are currently  “no agreed upon standards for psychiatrists or other health care practitioners to use to determine if a person’s mental illness is ‘grievous and irremediable’ for the purposes of MAID.” 

Dr. Chaimowitz acknowledged that “there’s no agreed-upon definition of incurability” in mental illness. Some psychiatrists “will argue that there’s always another treatment that can be attempted,” he said, adding that there has been a lack of consensus on irremediability among CPA members.
 

Protecting vulnerable populations

Matt Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at the University of Colorado at Denver, Aurora, said the question of irremediability is crucial. “Most people with mental illness do get better, especially if they’re in treatment,” Dr. Wynia said.

For MAID assessors it may be difficult to know when someone has tried all possible treatments, especially given the wide array of options, including psychedelics, said Dr. Wynia.

Dr. Braswell said there is not enough evidence that mental illness is incurable. With SMI, “there’s a lot more potential for the causes of the individual’s suffering to be ameliorated. By offering MAID, you’re going to kill people who might have been able to get out of this through other nonlethal means.”

Currently, MAID is provided for an irremediable medical condition, “in other words, a condition that will not improve and that we can predict will not improve,” said Karandeep S. Gaind, MD, chief of psychiatry at Toronto’s Humber River Hospital and physician chair of the hospital’s MAID team.

“If that’s the premise, then I think we cannot provide MAID for sole mental illness,” Dr. Gaind said. “Because we can’t honestly make those predictions” with mental illness, he added.

Dr. Gaind does not support MAID for mental illness and believes that it will put the vulnerable – including those living in poverty – at particular risk.

With the proposed expansion, MAID is “now becoming something which is being sought as a way to escape a painful life rather than to avoid a painful death,” said Dr. Gaind, who is also a past president of the CPA.

One member of the federal government’s expert panel – Ellen Cohen, who had a psychiatric condition – wrote in The Globe and Mail that she quit early on when it became apparent that the panel was not seriously considering her own experiences or the possibility that poverty and lack of access to care or social supports could strongly influence a request for MAID.
 

Social determinants of suffering

People with mental illness often are without homes, have substance use disorders, have been stigmatized and discriminated against, and have poor social supports, said Dr. Wynia. “You worry that it’s all of those things that are making them want to end their lives,” he said.

The Daily Mail ran a story in December 2022 about a 65-year-old Canadian who said he’d applied for MAID solely because of fears that his disability benefits for various chronic health conditions were being cut off and that he didn’t want to live in poverty.

A 51-year-old Ontario woman with multiple chemical sensitivities was granted MAID after she said she could not find housing that could keep her safe, according to an August report by CTV News.

Tarek Rajji, MD, chief of the Adult Neurodevelopment and Geriatric Psychiatry Division at CAMH, said social determinants of health need to be considered in standards created to guide MAID for mental illness.

“We’re very mindful of the fact that the suffering, that is, the grievousness that the person is living with, in the context of mental illness, many times is due to the social determinants of their illness and the social determinants of their suffering,” Dr. Rajji said.

Many are also concerned that it will be difficult to separate out suicidality from sheer hopelessness.

The CPA has advised a group that’s working on developing guidelines for MAID in SMI and is also developing a curriculum for mental health providers, Dr. Chaimowitz said. As part of that, there will be a process to ensure that someone who is actively suicidal is not granted MAID.

“I do not believe that it’s contemplated that MAID is going to accelerate or facilitate suicidal ideation,” he said. Someone who is suicidal will be referred to treatment, said Dr. Chaimowitz.

“People with depression often feel hopeless,” and may refuse treatments that have worked in the past, countered Dr. Gaind. Some of his patients “are absolutely convinced that nothing will help,” he said.
 

Troublesome cases

The expert panel said in its final report that “it is not possible to provide fixed rules for how many attempts at interventions, how many types of interventions, and over how much time,” are necessary to establish “irreversibility” of mental illness.

Dr. Chaimowitz said MAID will not be offered to anyone “refusing treatment for their condition without any good reason.” They will be “unlikely to meet criteria for incurable,” as they will have needed to avail themselves of the array of treatments available, he said. 

That would be similar to rules in Belgium and the Netherlands, which allow euthanasia for psychiatric conditions. 

An estimated 100-300 psychiatric patients receive euthanasia each year in those countries, according to a 2021 commentary in Psychiatric Times (Jun 7;38[6]) by Mark S. Komrad, MD, a Towson, Maryland-based psychiatrist.

There are still troublesome cases. 

As previously reported by this news organization, many in Belgium were distressed recently at the news that a 23-year-old woman who had survived a terrorist attack, Shanti De Corte, requested and was granted euthanasia.

As the deadline for implementation of MAID grew closer, calls for delay grew louder, especially given the lack of concrete standards for providers.

During the waning months of 2022, Dr. Gaind – who said he was suspended from CPA for “unprofessional interactions” and allegedly misrepresenting CPA’s processes and governance matters – announced the launch of a new organization, the Society of Canadian Psychiatry, in November calling for a delay in MAID of at least 1 year so that evidence-based safeguards could be implemented. The petition has been signed by more than 200 psychiatrists, along with several dozen physicians, MAID assessors, and individuals with mental illness and family members.

The Association of Chairs of Psychiatry in Canada, the Canadian Association for Suicide Prevention, the Council of Canadians with Disabilities, a group of indigenous leaders, and the Ontario Association for ACT and FACT, psychiatrists who provide care to individuals with severe mental illness, among other groups, joined the call for a delay.

In its December announcement, the Canadian federal ministers said a factor in seeking a delay was that standards guiding clinicians would not be delivered until at least February – too close to when applications would be opened.

Upon hearing about the federal government’s intentions, the chair of the expert panel, Mona Gupta, MD, told The Canadian Press that she did not think it was necessary to put off implementation because necessary safeguards were already in place.

Dr. Chaimowitz awaits the standards but is optimistic that for mental illness, “the process will be tightly controlled, closely monitored, and open to scrutiny,” he said.

Dr. Braswell is not convinced. The concern is that adding people with mental illness is “going to overload the capacity of the government to monitor this practice,” he said.
 

Is the United States next?

Although Canada and the United States share a border, it’s unlikely that U.S. states will allow aid in dying for nonterminal illness, much less for psychiatric conditions any time soon, said Dr. Braswell and others.

Ten states – California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington – have laws allowing assistance in dying, but for terminal illness only.

In 2016, the APA adopted the American Medical Association policy on medical euthanasia, stating, “that a psychiatrist should not prescribe or administer any intervention to a nonterminally ill person for the purpose of causing death.”

Dr. Brendel said the field is acutely aware that people with mental illness do suffer, but that more work needs to be done – and is being done – on “distinguishing wishes to hasten death or end one’s life from these historical or traditional notions that any premature death is a suicide.”

There is also increasing discussion within the medical community, not just psychiatry, about a physician’s duty to relieve suffering, said Dr. Wynia. “There’s debate basically about whether we stand for preserving life essentially at all costs and never being involved in the taking of life, or whether we stand for reduction of suffering and being the advocate for the patients that we serve,” he said.

“Those are both legitimate,” said Dr. Wynia, adding, “there are good reasons to want both of those to be true.”

“I suspect that 20 years from now we will still be having conversations about how physicians, how psychiatrists ought to participate in preserving life and in shepherding death,” said Dr. Brendel.

But to Dr. Gaind, the debate is not just esoteric, it’s a soon-to-be reality in Canada. “When we’re providing death to people who aren’t dying, to me that’s like providing what amounts to a wrongful death,” he said.

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

For Tammy Rainey, finding a health care provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.

As a transgender woman, Ms. Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Ms. Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’ ”

So Ms. Rainey drives around 170 miles round trip every 6 months to get a supply of estrogen from a clinic in Memphis, Tenn., to take home with her.

The obstacles Ms. Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural United States often face: A general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Morissa Ladinsky, MD, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama–Birmingham (UAB).

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states to estimate that roughly one in six transgender adults in the United States live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.

One in three trans people in rural areas experienced discrimination by a health care provider in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. A third of all trans individuals report having to teach their doctors about their health care needs to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as are all transgender adults to travel 25-49 miles for routine care.

In Colorado, for example, many trans people outside Denver struggle to find proper care. Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, with half providing three or fewer classes on this topic.

Perhaps because of this, almost 77% of students from 10 medical schools in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Justin Bailey, MD, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Dr. Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Ms. Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a 4-week boot camp in 2021 for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Caroline Kirsch, DO, director of osteopathic education at the University of Wyoming Family Medicine Residency Program–Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Dr. Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide experience a rise in harassment and threats. For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the target of far-right hate on social media last year. After growing pressure from Tennessee’s Republican lawmakers, the clinic paused gender-affirmation surgeries on patients younger than 18, potentially leaving many trans individuals without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”
 

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

For Tammy Rainey, finding a health care provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.

As a transgender woman, Ms. Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Ms. Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’ ”

So Ms. Rainey drives around 170 miles round trip every 6 months to get a supply of estrogen from a clinic in Memphis, Tenn., to take home with her.

The obstacles Ms. Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural United States often face: A general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Morissa Ladinsky, MD, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama–Birmingham (UAB).

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states to estimate that roughly one in six transgender adults in the United States live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.

One in three trans people in rural areas experienced discrimination by a health care provider in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. A third of all trans individuals report having to teach their doctors about their health care needs to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as are all transgender adults to travel 25-49 miles for routine care.

In Colorado, for example, many trans people outside Denver struggle to find proper care. Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, with half providing three or fewer classes on this topic.

Perhaps because of this, almost 77% of students from 10 medical schools in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Justin Bailey, MD, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Dr. Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Ms. Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a 4-week boot camp in 2021 for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Caroline Kirsch, DO, director of osteopathic education at the University of Wyoming Family Medicine Residency Program–Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Dr. Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide experience a rise in harassment and threats. For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the target of far-right hate on social media last year. After growing pressure from Tennessee’s Republican lawmakers, the clinic paused gender-affirmation surgeries on patients younger than 18, potentially leaving many trans individuals without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”
 

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

For Tammy Rainey, finding a health care provider who knows about gender-affirming care has been a challenge in the rural northern Mississippi town where she lives.

As a transgender woman, Ms. Rainey needs the hormone estrogen, which allows her to physically transition by developing more feminine features. But when she asked her doctor for an estrogen prescription, he said he couldn’t provide that type of care.

“He’s generally a good guy and doesn’t act prejudiced. He gets my name and pronouns right,” said Ms. Rainey. “But when I asked him about hormones, he said, ‘I just don’t feel like I know enough about that. I don’t want to get involved in that.’ ”

So Ms. Rainey drives around 170 miles round trip every 6 months to get a supply of estrogen from a clinic in Memphis, Tenn., to take home with her.

The obstacles Ms. Rainey overcomes to access care illustrate a type of medical inequity that transgender people who live in the rural United States often face: A general lack of education about trans-related care among small-town health professionals who might also be reluctant to learn.

“Medical communities across the country are seeing clearly that there is a knowledge gap in the provision of gender-affirming care,” said Morissa Ladinsky, MD, a pediatrician who co-leads the Youth Multidisciplinary Gender Team at the University of Alabama–Birmingham (UAB).

Accurately counting the number of transgender people in rural America is hindered by a lack of U.S. census data and uniform state data. However, the Movement Advancement Project, a nonprofit organization that advocates for LGBTQ+ issues, used 2014-17 Centers for Disease Control and Prevention data from selected ZIP codes in 35 states to estimate that roughly one in six transgender adults in the United States live in a rural area. When that report was released in 2019, there were an estimated 1.4 million transgender people 13 and older nationwide. That number is now at least 1.6 million, according to the Williams Institute, a nonprofit think tank at the UCLA School of Law.

One in three trans people in rural areas experienced discrimination by a health care provider in the year leading up to the 2015 U.S. Transgender Survey Report, according to an analysis by MAP. A third of all trans individuals report having to teach their doctors about their health care needs to receive appropriate care, and 62% worry about being negatively judged by a health care provider because of their sexual orientation or gender identity, according to data collected by the Williams Institute and other organizations.

A lack of local rural providers knowledgeable in trans care can mean long drives to gender-affirming clinics in metropolitan areas. Rural trans people are three times as likely as are all transgender adults to travel 25-49 miles for routine care.

In Colorado, for example, many trans people outside Denver struggle to find proper care. Those who do have a trans-inclusive provider are more likely to receive wellness exams, less likely to delay care due to discrimination, and less likely to attempt suicide, according to results from the Colorado Transgender Health Survey published in 2018.

Much of the lack of care experienced by trans people is linked to insufficient education on LGBTQ+ health in medical schools across the country. In 2014, the Association of American Medical Colleges, which represents 170 accredited medical schools in the United States and Canada, released its first curriculum guidelines on caring for LGBTQ+ patients. As of 2018, 76% of medical schools included LGBTQ health themes in their curriculum, with half providing three or fewer classes on this topic.

Perhaps because of this, almost 77% of students from 10 medical schools in New England felt “not competent” or “somewhat not competent” in treating gender minority patients, according to a 2018 pilot study. Another paper, published last year, found that even clinicians who work in trans-friendly clinics lack knowledge about hormones, gender-affirming surgical options, and how to use appropriate pronouns and trans-inclusive language.

Throughout medical school, trans care was only briefly mentioned in endocrinology class, said Justin Bailey, MD, who received his medical degree from UAB in 2021 and is now a resident there. “I don’t want to say the wrong thing or use the wrong pronouns, so I was hesitant and a little bit tepid in my approach to interviewing and treating this population of patients,” he said.

On top of insufficient medical school education, some practicing doctors don’t take the time to teach themselves about trans people, said Kathie Moehlig, founder of TransFamily Support Services, a nonprofit organization that offers a range of services to transgender people and their families. They are very well intentioned yet uneducated when it comes to transgender care, she said.

Some medical schools, like the one at UAB, have pushed for change. Since 2017, Dr. Ladinsky and her colleagues have worked to include trans people in their standardized patient program, which gives medical students hands-on experience and feedback by interacting with “patients” in simulated clinical environments.

For example, a trans individual acting as a patient will simulate acid reflux by pretending to have pain in their stomach and chest. Then, over the course of the examination, they will reveal that they are transgender.

In the early years of this program, some students’ bedside manner would change once the patient’s gender identity was revealed, said Elaine Stephens, a trans woman who participates in UAB’s standardized patient program. “Sometimes they would immediately start asking about sexual activity,” Stephens said.

Since UAB launched its program, students’ reactions have improved significantly, she said.

This progress is being replicated by other medical schools, said Ms. Moehlig. “But it’s a slow start, and these are large institutions that take a long time to move forward.”

Advocates also are working outside medical schools to improve care in rural areas. In Colorado, the nonprofit Extension for Community Health Outcomes, or ECHO Colorado, has been offering monthly virtual classes on gender-affirming care to rural providers since 2020. The classes became so popular that the organization created a 4-week boot camp in 2021 for providers to learn about hormone therapy management, proper terminologies, surgical options, and supporting patients’ mental health.

For many years, doctors failed to recognize the need to learn about gender-affirming care, said Caroline Kirsch, DO, director of osteopathic education at the University of Wyoming Family Medicine Residency Program–Casper. In Casper, this led to “a number of patients traveling to Colorado to access care, which is a large burden for them financially,” said Dr. Kirsch, who has participated in the ECHO Colorado program.

“Things that haven’t been as well taught historically in medical school are things that I think many physicians feel anxious about initially,” she said. “The earlier you learn about this type of care in your career, the more likely you are to see its potential and be less anxious about it.”

Educating more providers about trans-related care has become increasingly vital in recent years as gender-affirming clinics nationwide experience a rise in harassment and threats. For instance, Vanderbilt University Medical Center’s Clinic for Transgender Health became the target of far-right hate on social media last year. After growing pressure from Tennessee’s Republican lawmakers, the clinic paused gender-affirmation surgeries on patients younger than 18, potentially leaving many trans individuals without necessary care.

Stephens hopes to see more medical schools include coursework on trans health care. She also wishes for doctors to treat trans people as they would any other patient.

“Just provide quality health care,” she tells the medical students at UAB. “We need health care like everyone else does.”
 

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Watching a screen more than an hour a day as a toddler is directly linked with poorer communication and daily living skills at age 4, but outdoor play may lessen some of the effects, new research suggests.

The results point to outdoor play as a potential targeted intervention to counter suboptimal brain development in young children who are watching screens at increasingly younger ages.

The findings were published online in JAMA Pediatrics.

The researchers first investigated whether higher screen time (more than 1 hour a day on a device or watching television) at age 2 years is associated with neurodevelopmental outcomes at age 4.

They found the 885 children in the sample from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children who had more screen time had lower scores on communication and daily living skills than children who watched less than an hour a day.

Scores were based on the Vineland Adaptive Behavior Scale according to parent responses to questions. The children included were born between December 2007 and March 2012 and were followed from 18 months to 4 years.

After finding the connection between screen time and lower scores, the researchers investigated whether outdoor play (at least 30 minutes a day) introduced at a 2 years and 8 months made a difference. They considered 6 or 7 days per week frequent outdoor play.
 

Outdoor play mitigated poorer daily living scores

The researchers found that the outdoor play intervention mitigated 18% of the association between high screen time and lower daily living scores but did not mitigate the lower communication scores.

They also found that more screen time at age 2 was significantly linked with infrequent outdoor play at age 32 months (odds ratio, 2.03; 95% confidence interval, 1.48-2.76).

The associations were consistent after taking into account factors including a child’s sex, parental education, and any autism spectrum disorder symptoms at age 18 months.

The authors noted that neurodevelopment concerns with screen use are particularly troubling as the age for use is getting younger.

A recent meta-analysis found that 75% of children younger than 2 use or watch screens, even though guidelines recommend against any screen time before 2.

In addition, the “COVID-19 pandemic led to children having more screen time, less outdoor play, and less physical activity, putting them at potentially greater risk for neurodevelopmental problems,” the authors noted.

“What is concerning is that data show screen time has not decreased after seclusion measures were lifted,” they added.
 

Proven benefits for outdoor play

Jennifer Cross, MD,* assistant professor and section chief for developmental pediatrics at Weill Cornell Medicine, New York, who was not part of the study, said the mitigation properties of outdoor play were something she hadn’t seen before but the concept makes sense.

“The overwhelming evidence is that screen time is not helpful for young children under the age of 2,” she said.

Outdoor play, on the other hand, has proven benefits.

“Physical activity has been shown to be good for physical and mental health so there’s no reason to believe it wouldn’t be good for 2-and-a-half-year olds,” Dr. Cross said. “It’s also good for developmental health. You want them to be engaged in imaginative play and be interactive.”

“[Outdoor play] gets them away from screens and gives them an opportunity to experience another environment and work on their motor skills and motor planning,” she added. “Exercise will change, briefly, the way our brains process information.”

Dr. Cross added that a lot of motor skills are involved in daily living skills, such as feeding, dressing, and toileting.

Screen time is increasing

The authors acknowledged that screen time may be underestimated by parents. They also noted that they did not have access to what children were watching on the screens.

“This should have been collected because the effect of high screen time differs depending on the type of program,” the authors wrote.

They added that children born in the 2020s may have been exposed to more screen time than the children reared in the early 2010s in this study.

Dr. Cross said screen use in the 2020s may be higher than estimated here and higher in certain populations globally, so it’s not easy to tell if the intervention in this study would have the same mitigating effect on a real-world population.

However, she said, the effect of outdoor play is always going to be helpful for brain development and there’s no downside.

“Exercise is just as important for little kids as it is for grown-ups,” she said.

The authors reported no relevant financial disclosures. Dr. Cross reported no relevant financial disclosures.

*Dr. Jennifer Cross is the correct name, not Dr. Jennifer Frost. The correction was made on Jan. 27, 2023.

Watching a screen more than an hour a day as a toddler is directly linked with poorer communication and daily living skills at age 4, but outdoor play may lessen some of the effects, new research suggests.

The results point to outdoor play as a potential targeted intervention to counter suboptimal brain development in young children who are watching screens at increasingly younger ages.

The findings were published online in JAMA Pediatrics.

The researchers first investigated whether higher screen time (more than 1 hour a day on a device or watching television) at age 2 years is associated with neurodevelopmental outcomes at age 4.

They found the 885 children in the sample from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children who had more screen time had lower scores on communication and daily living skills than children who watched less than an hour a day.

Scores were based on the Vineland Adaptive Behavior Scale according to parent responses to questions. The children included were born between December 2007 and March 2012 and were followed from 18 months to 4 years.

After finding the connection between screen time and lower scores, the researchers investigated whether outdoor play (at least 30 minutes a day) introduced at a 2 years and 8 months made a difference. They considered 6 or 7 days per week frequent outdoor play.
 

Outdoor play mitigated poorer daily living scores

The researchers found that the outdoor play intervention mitigated 18% of the association between high screen time and lower daily living scores but did not mitigate the lower communication scores.

They also found that more screen time at age 2 was significantly linked with infrequent outdoor play at age 32 months (odds ratio, 2.03; 95% confidence interval, 1.48-2.76).

The associations were consistent after taking into account factors including a child’s sex, parental education, and any autism spectrum disorder symptoms at age 18 months.

The authors noted that neurodevelopment concerns with screen use are particularly troubling as the age for use is getting younger.

A recent meta-analysis found that 75% of children younger than 2 use or watch screens, even though guidelines recommend against any screen time before 2.

In addition, the “COVID-19 pandemic led to children having more screen time, less outdoor play, and less physical activity, putting them at potentially greater risk for neurodevelopmental problems,” the authors noted.

“What is concerning is that data show screen time has not decreased after seclusion measures were lifted,” they added.
 

Proven benefits for outdoor play

Jennifer Cross, MD,* assistant professor and section chief for developmental pediatrics at Weill Cornell Medicine, New York, who was not part of the study, said the mitigation properties of outdoor play were something she hadn’t seen before but the concept makes sense.

“The overwhelming evidence is that screen time is not helpful for young children under the age of 2,” she said.

Outdoor play, on the other hand, has proven benefits.

“Physical activity has been shown to be good for physical and mental health so there’s no reason to believe it wouldn’t be good for 2-and-a-half-year olds,” Dr. Cross said. “It’s also good for developmental health. You want them to be engaged in imaginative play and be interactive.”

“[Outdoor play] gets them away from screens and gives them an opportunity to experience another environment and work on their motor skills and motor planning,” she added. “Exercise will change, briefly, the way our brains process information.”

Dr. Cross added that a lot of motor skills are involved in daily living skills, such as feeding, dressing, and toileting.

Screen time is increasing

The authors acknowledged that screen time may be underestimated by parents. They also noted that they did not have access to what children were watching on the screens.

“This should have been collected because the effect of high screen time differs depending on the type of program,” the authors wrote.

They added that children born in the 2020s may have been exposed to more screen time than the children reared in the early 2010s in this study.

Dr. Cross said screen use in the 2020s may be higher than estimated here and higher in certain populations globally, so it’s not easy to tell if the intervention in this study would have the same mitigating effect on a real-world population.

However, she said, the effect of outdoor play is always going to be helpful for brain development and there’s no downside.

“Exercise is just as important for little kids as it is for grown-ups,” she said.

The authors reported no relevant financial disclosures. Dr. Cross reported no relevant financial disclosures.

*Dr. Jennifer Cross is the correct name, not Dr. Jennifer Frost. The correction was made on Jan. 27, 2023.

Watching a screen more than an hour a day as a toddler is directly linked with poorer communication and daily living skills at age 4, but outdoor play may lessen some of the effects, new research suggests.

The results point to outdoor play as a potential targeted intervention to counter suboptimal brain development in young children who are watching screens at increasingly younger ages.

The findings were published online in JAMA Pediatrics.

The researchers first investigated whether higher screen time (more than 1 hour a day on a device or watching television) at age 2 years is associated with neurodevelopmental outcomes at age 4.

They found the 885 children in the sample from the Japanese Hamamatsu Birth Cohort Study for Mothers and Children who had more screen time had lower scores on communication and daily living skills than children who watched less than an hour a day.

Scores were based on the Vineland Adaptive Behavior Scale according to parent responses to questions. The children included were born between December 2007 and March 2012 and were followed from 18 months to 4 years.

After finding the connection between screen time and lower scores, the researchers investigated whether outdoor play (at least 30 minutes a day) introduced at a 2 years and 8 months made a difference. They considered 6 or 7 days per week frequent outdoor play.
 

Outdoor play mitigated poorer daily living scores

The researchers found that the outdoor play intervention mitigated 18% of the association between high screen time and lower daily living scores but did not mitigate the lower communication scores.

They also found that more screen time at age 2 was significantly linked with infrequent outdoor play at age 32 months (odds ratio, 2.03; 95% confidence interval, 1.48-2.76).

The associations were consistent after taking into account factors including a child’s sex, parental education, and any autism spectrum disorder symptoms at age 18 months.

The authors noted that neurodevelopment concerns with screen use are particularly troubling as the age for use is getting younger.

A recent meta-analysis found that 75% of children younger than 2 use or watch screens, even though guidelines recommend against any screen time before 2.

In addition, the “COVID-19 pandemic led to children having more screen time, less outdoor play, and less physical activity, putting them at potentially greater risk for neurodevelopmental problems,” the authors noted.

“What is concerning is that data show screen time has not decreased after seclusion measures were lifted,” they added.
 

Proven benefits for outdoor play

Jennifer Cross, MD,* assistant professor and section chief for developmental pediatrics at Weill Cornell Medicine, New York, who was not part of the study, said the mitigation properties of outdoor play were something she hadn’t seen before but the concept makes sense.

“The overwhelming evidence is that screen time is not helpful for young children under the age of 2,” she said.

Outdoor play, on the other hand, has proven benefits.

“Physical activity has been shown to be good for physical and mental health so there’s no reason to believe it wouldn’t be good for 2-and-a-half-year olds,” Dr. Cross said. “It’s also good for developmental health. You want them to be engaged in imaginative play and be interactive.”

“[Outdoor play] gets them away from screens and gives them an opportunity to experience another environment and work on their motor skills and motor planning,” she added. “Exercise will change, briefly, the way our brains process information.”

Dr. Cross added that a lot of motor skills are involved in daily living skills, such as feeding, dressing, and toileting.

Screen time is increasing

The authors acknowledged that screen time may be underestimated by parents. They also noted that they did not have access to what children were watching on the screens.

“This should have been collected because the effect of high screen time differs depending on the type of program,” the authors wrote.

They added that children born in the 2020s may have been exposed to more screen time than the children reared in the early 2010s in this study.

Dr. Cross said screen use in the 2020s may be higher than estimated here and higher in certain populations globally, so it’s not easy to tell if the intervention in this study would have the same mitigating effect on a real-world population.

However, she said, the effect of outdoor play is always going to be helpful for brain development and there’s no downside.

“Exercise is just as important for little kids as it is for grown-ups,” she said.

The authors reported no relevant financial disclosures. Dr. Cross reported no relevant financial disclosures.

*Dr. Jennifer Cross is the correct name, not Dr. Jennifer Frost. The correction was made on Jan. 27, 2023.

Children with chronically elevated externalizing symptoms, such as behavioral problems, or internalizing symptoms, such as mental health concerns, have an increased risk for poor economic and social outcomes in adulthood, data from a new study suggest.

Children with comorbid externalizing and internalizing symptoms were especially vulnerable to long-term economic and social exclusion.

“Research has mostly studied the outcomes of children with either behavioral problems or depression-anxiety problems. However, comorbidity is the rule rather than the exception in clinical practice,” senior author Massimilliano Orri, PhD, an assistant professor of psychiatry at McGill University and clinical psychologist with the Douglas Mental Health University Institute, both in Montreal, said in an interview.

“Our findings are important, as they show that comorbidity between externalizing and internalizing problems is associated with real-life outcomes that profoundly influence a youth’s chances to participate in society later in life,” he said.

The study was published in JAMA Network Open.
 

Analyzing associations

Dr. Orri and colleagues analyzed data for 3,017 children in the Quebec Longitudinal Study of Kindergarten Children, a population-based birth cohort that enrolled participants in 1986-1987 and 1987-1988 while they were attending kindergarten. The sample included 2,000 children selected at random and 1,017 children who scored at or above the 80th percentile for disruptive behavior problems.

The research team looked at the association between childhood behavioral profiles and economic and social outcomes for ages 19-37 years, including employment earnings, receipt of welfare, intimate partnerships, and having children living in the household. They obtained the outcome data from participants’ tax returns for 1998-2017.

During enrollment in the study, the children’s teachers assessed behavioral symptoms annually for ages 6-12 years using the Social Behavior Questionnaire. Based on the assessments, the research team categorized the students as having no or low symptoms, high externalizing symptoms only (such as hyperactivity, impulsivity, aggression, and rule violation), high internalizing symptoms only (such as anxiety, depression, worry, and social withdrawal), or comorbid symptoms. They looked at other variables as well, including the child’s sex, the parents’ age at the birth of their first child, the parents’ years of education, family structure, and the parents’ household income.

Among the 3,017 participants, 45.4% of children had no or low symptoms, 29.2% had high externalizing symptoms, 11.7% had high internalizing symptoms, and 13.7% had comorbid symptoms. About 53% were boys, and 47% were girls.

In general, boys were more likely to exhibit high externalizing symptoms, and girls were more likely to exhibit high internalizing symptoms. In the comorbid group, about 82% were boys, and they were more likely to have younger mothers, come from households with lower earnings when they were ages 3-5 years, and have a nonintact family at age 6 years.

The average age at follow-up was 37 years. Participants earned an average of $32,800 per year at ages 33-37 years (between 2013 and 2017). During the 20 years of follow-up, participants received welfare support for about 1.5 years, had an intimate partner for 7.4 years, and had children living in the household for 11 years.

Overall, participants in the high externalizing and high internalizing symptom profiles – and especially those in the comorbid profile – had lower earnings and a higher incidence of annual welfare receipt across early adulthood, compared with participants with low or no symptoms. They were also less likely to have an intimate partner or have children living in the household. Participants with a comorbid symptom profile earned $15,031 less per year and had a 3.79-times higher incidence of annual welfare receipt.
 

Lower earnings

Across the sample, men were more likely to have higher earnings and less likely to receive welfare each year, but they also were less likely to have an intimate partner or have children in the household. Among those with the high externalizing profile, men were significantly less likely to receive welfare. Among the comorbid profile, men were less likely to have children in the household.

Compared with the no-symptom or low-symptom profile, those in the high externalizing profile earned $5,904 less per year and had a two-times–higher incidence of welfare receipt. Those in the high internalizing profile earned $8,473 less per year, had a 2.07-times higher incidence of welfare receipt, and had a lower incidence of intimate partnership.

Compared with the high externalizing profile, those in the comorbid profile earned $9,126 less per year, had a higher incidence of annual welfare receipt, had a lower incidence of intimate partnership, and were less likely to have children in the household. Similarly, compared with the high internalizing profile, those in the comorbid profile earned $6,558 less per year and were more likely to exhibit the other poor long-term outcomes. Participants in the high internalizing profile earned $2,568 less per year than those in the high externalizing profile.

During a 40-year working career, the estimated lost personal employment earnings were $140,515 for the high externalizing profile, $201,657 for the high internalizing profile, and $357,737 for the comorbid profile, compared with those in the no-symptom or low-symptom profile.

“We know that children with externalizing and internalizing symptoms can have many problems in the short term – like social difficulties and lower education attainment – but it’s important to also understand the potential long-term outcomes,” study author Francis Vergunst, DPhil/PhD, an associate professor of child psychosocial difficulties at the University of Oslo, told this news organization.

“For example, when people have insufficient income, are forced to seek welfare support, or lack the social support structure that comes from an intimate partnership, it can have profound consequences for their mental health and well-being – and for society as a whole,” he said. “Understanding this helps to build the case for early prevention programs that can reduce childhood externalizing and internalizing problems and improve long-term outcomes.”

Several mechanisms could explain the associations found across the childhood symptom profiles, the study authors wrote. For instance, children with early behavior problems may be more likely to engage in risky adolescent activities, such as substance use, delinquent peer affiliations, and academic underachievement, which affects their transition to adulthood and accumulation of social and economic capital throughout life. Those with comorbid symptoms likely experience a compounded effect.

Future studies should investigate how to intervene effectively to support children, particularly those with comorbid externalizing and internalizing symptoms, the study authors write.

“Currently, most published studies focus on children with either externalizing or internalizing problems (and these programs can be effective, especially for externalizing problems), but we know very little about how to improve long-term outcomes for children with comorbid symptoms,” Dr. Vergunst said. “Given the large costs of these problems for individuals and society, this is a critical area for further research.”
 

‘Solid evidence’

Commenting on the findings, Ian Colman, PhD, a professor of epidemiology and public health and director of the Applied Psychiatric Epidemiology Across the Life course (APEAL) lab at the University of Ottawa, said, “Research like this provides solid evidence that if we do not provide appropriate supports for children who are struggling with their mental health or related behaviors, then these children are more likely to face a life of social and economic exclusion.”

Dr. Colman, who wasn’t involved with this study, has researched long-term psychosocial outcomes among adolescents with depression, as well as those with externalizing behaviors. He and colleagues have found poorer outcomes among those who exhibit mild or severe difficulties during childhood.

“Studying the long-term outcomes associated with child and adolescent mental and behavioral disorders gives us an idea of how concerned we should be about their future,” he said.

Dr. Vergunst was funded by the Canadian Institute of Health Research and Fonds de Recherche du Quebec Santé postdoctoral fellowships. Dr. Orri and Dr. Colman report no relevant financial relationships.

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

Children with chronically elevated externalizing symptoms, such as behavioral problems, or internalizing symptoms, such as mental health concerns, have an increased risk for poor economic and social outcomes in adulthood, data from a new study suggest.

Children with comorbid externalizing and internalizing symptoms were especially vulnerable to long-term economic and social exclusion.

“Research has mostly studied the outcomes of children with either behavioral problems or depression-anxiety problems. However, comorbidity is the rule rather than the exception in clinical practice,” senior author Massimilliano Orri, PhD, an assistant professor of psychiatry at McGill University and clinical psychologist with the Douglas Mental Health University Institute, both in Montreal, said in an interview.

“Our findings are important, as they show that comorbidity between externalizing and internalizing problems is associated with real-life outcomes that profoundly influence a youth’s chances to participate in society later in life,” he said.

The study was published in JAMA Network Open.
 

Analyzing associations

Dr. Orri and colleagues analyzed data for 3,017 children in the Quebec Longitudinal Study of Kindergarten Children, a population-based birth cohort that enrolled participants in 1986-1987 and 1987-1988 while they were attending kindergarten. The sample included 2,000 children selected at random and 1,017 children who scored at or above the 80th percentile for disruptive behavior problems.

The research team looked at the association between childhood behavioral profiles and economic and social outcomes for ages 19-37 years, including employment earnings, receipt of welfare, intimate partnerships, and having children living in the household. They obtained the outcome data from participants’ tax returns for 1998-2017.

During enrollment in the study, the children’s teachers assessed behavioral symptoms annually for ages 6-12 years using the Social Behavior Questionnaire. Based on the assessments, the research team categorized the students as having no or low symptoms, high externalizing symptoms only (such as hyperactivity, impulsivity, aggression, and rule violation), high internalizing symptoms only (such as anxiety, depression, worry, and social withdrawal), or comorbid symptoms. They looked at other variables as well, including the child’s sex, the parents’ age at the birth of their first child, the parents’ years of education, family structure, and the parents’ household income.

Among the 3,017 participants, 45.4% of children had no or low symptoms, 29.2% had high externalizing symptoms, 11.7% had high internalizing symptoms, and 13.7% had comorbid symptoms. About 53% were boys, and 47% were girls.

In general, boys were more likely to exhibit high externalizing symptoms, and girls were more likely to exhibit high internalizing symptoms. In the comorbid group, about 82% were boys, and they were more likely to have younger mothers, come from households with lower earnings when they were ages 3-5 years, and have a nonintact family at age 6 years.

The average age at follow-up was 37 years. Participants earned an average of $32,800 per year at ages 33-37 years (between 2013 and 2017). During the 20 years of follow-up, participants received welfare support for about 1.5 years, had an intimate partner for 7.4 years, and had children living in the household for 11 years.

Overall, participants in the high externalizing and high internalizing symptom profiles – and especially those in the comorbid profile – had lower earnings and a higher incidence of annual welfare receipt across early adulthood, compared with participants with low or no symptoms. They were also less likely to have an intimate partner or have children living in the household. Participants with a comorbid symptom profile earned $15,031 less per year and had a 3.79-times higher incidence of annual welfare receipt.
 

Lower earnings

Across the sample, men were more likely to have higher earnings and less likely to receive welfare each year, but they also were less likely to have an intimate partner or have children in the household. Among those with the high externalizing profile, men were significantly less likely to receive welfare. Among the comorbid profile, men were less likely to have children in the household.

Compared with the no-symptom or low-symptom profile, those in the high externalizing profile earned $5,904 less per year and had a two-times–higher incidence of welfare receipt. Those in the high internalizing profile earned $8,473 less per year, had a 2.07-times higher incidence of welfare receipt, and had a lower incidence of intimate partnership.

Compared with the high externalizing profile, those in the comorbid profile earned $9,126 less per year, had a higher incidence of annual welfare receipt, had a lower incidence of intimate partnership, and were less likely to have children in the household. Similarly, compared with the high internalizing profile, those in the comorbid profile earned $6,558 less per year and were more likely to exhibit the other poor long-term outcomes. Participants in the high internalizing profile earned $2,568 less per year than those in the high externalizing profile.

During a 40-year working career, the estimated lost personal employment earnings were $140,515 for the high externalizing profile, $201,657 for the high internalizing profile, and $357,737 for the comorbid profile, compared with those in the no-symptom or low-symptom profile.

“We know that children with externalizing and internalizing symptoms can have many problems in the short term – like social difficulties and lower education attainment – but it’s important to also understand the potential long-term outcomes,” study author Francis Vergunst, DPhil/PhD, an associate professor of child psychosocial difficulties at the University of Oslo, told this news organization.

“For example, when people have insufficient income, are forced to seek welfare support, or lack the social support structure that comes from an intimate partnership, it can have profound consequences for their mental health and well-being – and for society as a whole,” he said. “Understanding this helps to build the case for early prevention programs that can reduce childhood externalizing and internalizing problems and improve long-term outcomes.”

Several mechanisms could explain the associations found across the childhood symptom profiles, the study authors wrote. For instance, children with early behavior problems may be more likely to engage in risky adolescent activities, such as substance use, delinquent peer affiliations, and academic underachievement, which affects their transition to adulthood and accumulation of social and economic capital throughout life. Those with comorbid symptoms likely experience a compounded effect.

Future studies should investigate how to intervene effectively to support children, particularly those with comorbid externalizing and internalizing symptoms, the study authors write.

“Currently, most published studies focus on children with either externalizing or internalizing problems (and these programs can be effective, especially for externalizing problems), but we know very little about how to improve long-term outcomes for children with comorbid symptoms,” Dr. Vergunst said. “Given the large costs of these problems for individuals and society, this is a critical area for further research.”
 

‘Solid evidence’

Commenting on the findings, Ian Colman, PhD, a professor of epidemiology and public health and director of the Applied Psychiatric Epidemiology Across the Life course (APEAL) lab at the University of Ottawa, said, “Research like this provides solid evidence that if we do not provide appropriate supports for children who are struggling with their mental health or related behaviors, then these children are more likely to face a life of social and economic exclusion.”

Dr. Colman, who wasn’t involved with this study, has researched long-term psychosocial outcomes among adolescents with depression, as well as those with externalizing behaviors. He and colleagues have found poorer outcomes among those who exhibit mild or severe difficulties during childhood.

“Studying the long-term outcomes associated with child and adolescent mental and behavioral disorders gives us an idea of how concerned we should be about their future,” he said.

Dr. Vergunst was funded by the Canadian Institute of Health Research and Fonds de Recherche du Quebec Santé postdoctoral fellowships. Dr. Orri and Dr. Colman report no relevant financial relationships.

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

Children with chronically elevated externalizing symptoms, such as behavioral problems, or internalizing symptoms, such as mental health concerns, have an increased risk for poor economic and social outcomes in adulthood, data from a new study suggest.

Children with comorbid externalizing and internalizing symptoms were especially vulnerable to long-term economic and social exclusion.

“Research has mostly studied the outcomes of children with either behavioral problems or depression-anxiety problems. However, comorbidity is the rule rather than the exception in clinical practice,” senior author Massimilliano Orri, PhD, an assistant professor of psychiatry at McGill University and clinical psychologist with the Douglas Mental Health University Institute, both in Montreal, said in an interview.

“Our findings are important, as they show that comorbidity between externalizing and internalizing problems is associated with real-life outcomes that profoundly influence a youth’s chances to participate in society later in life,” he said.

The study was published in JAMA Network Open.
 

Analyzing associations

Dr. Orri and colleagues analyzed data for 3,017 children in the Quebec Longitudinal Study of Kindergarten Children, a population-based birth cohort that enrolled participants in 1986-1987 and 1987-1988 while they were attending kindergarten. The sample included 2,000 children selected at random and 1,017 children who scored at or above the 80th percentile for disruptive behavior problems.

The research team looked at the association between childhood behavioral profiles and economic and social outcomes for ages 19-37 years, including employment earnings, receipt of welfare, intimate partnerships, and having children living in the household. They obtained the outcome data from participants’ tax returns for 1998-2017.

During enrollment in the study, the children’s teachers assessed behavioral symptoms annually for ages 6-12 years using the Social Behavior Questionnaire. Based on the assessments, the research team categorized the students as having no or low symptoms, high externalizing symptoms only (such as hyperactivity, impulsivity, aggression, and rule violation), high internalizing symptoms only (such as anxiety, depression, worry, and social withdrawal), or comorbid symptoms. They looked at other variables as well, including the child’s sex, the parents’ age at the birth of their first child, the parents’ years of education, family structure, and the parents’ household income.

Among the 3,017 participants, 45.4% of children had no or low symptoms, 29.2% had high externalizing symptoms, 11.7% had high internalizing symptoms, and 13.7% had comorbid symptoms. About 53% were boys, and 47% were girls.

In general, boys were more likely to exhibit high externalizing symptoms, and girls were more likely to exhibit high internalizing symptoms. In the comorbid group, about 82% were boys, and they were more likely to have younger mothers, come from households with lower earnings when they were ages 3-5 years, and have a nonintact family at age 6 years.

The average age at follow-up was 37 years. Participants earned an average of $32,800 per year at ages 33-37 years (between 2013 and 2017). During the 20 years of follow-up, participants received welfare support for about 1.5 years, had an intimate partner for 7.4 years, and had children living in the household for 11 years.

Overall, participants in the high externalizing and high internalizing symptom profiles – and especially those in the comorbid profile – had lower earnings and a higher incidence of annual welfare receipt across early adulthood, compared with participants with low or no symptoms. They were also less likely to have an intimate partner or have children living in the household. Participants with a comorbid symptom profile earned $15,031 less per year and had a 3.79-times higher incidence of annual welfare receipt.
 

Lower earnings

Across the sample, men were more likely to have higher earnings and less likely to receive welfare each year, but they also were less likely to have an intimate partner or have children in the household. Among those with the high externalizing profile, men were significantly less likely to receive welfare. Among the comorbid profile, men were less likely to have children in the household.

Compared with the no-symptom or low-symptom profile, those in the high externalizing profile earned $5,904 less per year and had a two-times–higher incidence of welfare receipt. Those in the high internalizing profile earned $8,473 less per year, had a 2.07-times higher incidence of welfare receipt, and had a lower incidence of intimate partnership.

Compared with the high externalizing profile, those in the comorbid profile earned $9,126 less per year, had a higher incidence of annual welfare receipt, had a lower incidence of intimate partnership, and were less likely to have children in the household. Similarly, compared with the high internalizing profile, those in the comorbid profile earned $6,558 less per year and were more likely to exhibit the other poor long-term outcomes. Participants in the high internalizing profile earned $2,568 less per year than those in the high externalizing profile.

During a 40-year working career, the estimated lost personal employment earnings were $140,515 for the high externalizing profile, $201,657 for the high internalizing profile, and $357,737 for the comorbid profile, compared with those in the no-symptom or low-symptom profile.

“We know that children with externalizing and internalizing symptoms can have many problems in the short term – like social difficulties and lower education attainment – but it’s important to also understand the potential long-term outcomes,” study author Francis Vergunst, DPhil/PhD, an associate professor of child psychosocial difficulties at the University of Oslo, told this news organization.

“For example, when people have insufficient income, are forced to seek welfare support, or lack the social support structure that comes from an intimate partnership, it can have profound consequences for their mental health and well-being – and for society as a whole,” he said. “Understanding this helps to build the case for early prevention programs that can reduce childhood externalizing and internalizing problems and improve long-term outcomes.”

Several mechanisms could explain the associations found across the childhood symptom profiles, the study authors wrote. For instance, children with early behavior problems may be more likely to engage in risky adolescent activities, such as substance use, delinquent peer affiliations, and academic underachievement, which affects their transition to adulthood and accumulation of social and economic capital throughout life. Those with comorbid symptoms likely experience a compounded effect.

Future studies should investigate how to intervene effectively to support children, particularly those with comorbid externalizing and internalizing symptoms, the study authors write.

“Currently, most published studies focus on children with either externalizing or internalizing problems (and these programs can be effective, especially for externalizing problems), but we know very little about how to improve long-term outcomes for children with comorbid symptoms,” Dr. Vergunst said. “Given the large costs of these problems for individuals and society, this is a critical area for further research.”
 

‘Solid evidence’

Commenting on the findings, Ian Colman, PhD, a professor of epidemiology and public health and director of the Applied Psychiatric Epidemiology Across the Life course (APEAL) lab at the University of Ottawa, said, “Research like this provides solid evidence that if we do not provide appropriate supports for children who are struggling with their mental health or related behaviors, then these children are more likely to face a life of social and economic exclusion.”

Dr. Colman, who wasn’t involved with this study, has researched long-term psychosocial outcomes among adolescents with depression, as well as those with externalizing behaviors. He and colleagues have found poorer outcomes among those who exhibit mild or severe difficulties during childhood.

“Studying the long-term outcomes associated with child and adolescent mental and behavioral disorders gives us an idea of how concerned we should be about their future,” he said.

Dr. Vergunst was funded by the Canadian Institute of Health Research and Fonds de Recherche du Quebec Santé postdoctoral fellowships. Dr. Orri and Dr. Colman report no relevant financial relationships.

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

Key clinical point: Continuous 6-month therapy with interleukin-6 receptor inhibitors (IL-6Ri) vs tumor necrosis factor inhibitors (TNFi) or Janus kinase inhibitors (JAKi) demonstrated greater improvements in hemoglobin and C-reactive protein (CRP) levels regardless of baseline levels in patients with rheumatoid arthritis (RA).

Major finding: Six months of continuous therapy with IL-6Ri vs TNFi and JAKi led to significantly greater improvements in hemoglobin levels (adjusted odds ratios for achieving normal hemoglobin levels 3.15 and 3.85, respectively; both P < .001) and greater reductions in CRP levels (P < .01) regardless of baseline levels.

Study details: The data come from an analysis of 2772 patients with RA who received continuous TNFi, IL-6Ri, or JAKi treatment for ≥6 months.

Disclosures: This study was funded by Sanofi, and the RA registry was sponsored by CorEvitas, LLC. Six authors declared being current or former employees of, consultants for, or holding shares or stocks or stock options in Sanofi or CorEvitas LLC.

Source: Padula AS et al. The effect of targeted rheumatoid arthritis therapeutics on systemic inflammation and anemia: Analysis of data from the CorEvitas RA registry. Arthritis Res Ther. 2022;24:276 (Dec 21). Doi: 10.1186/s13075-022-02955-y

Key clinical point: Continuous 6-month therapy with interleukin-6 receptor inhibitors (IL-6Ri) vs tumor necrosis factor inhibitors (TNFi) or Janus kinase inhibitors (JAKi) demonstrated greater improvements in hemoglobin and C-reactive protein (CRP) levels regardless of baseline levels in patients with rheumatoid arthritis (RA).

Major finding: Six months of continuous therapy with IL-6Ri vs TNFi and JAKi led to significantly greater improvements in hemoglobin levels (adjusted odds ratios for achieving normal hemoglobin levels 3.15 and 3.85, respectively; both P < .001) and greater reductions in CRP levels (P < .01) regardless of baseline levels.

Study details: The data come from an analysis of 2772 patients with RA who received continuous TNFi, IL-6Ri, or JAKi treatment for ≥6 months.

Disclosures: This study was funded by Sanofi, and the RA registry was sponsored by CorEvitas, LLC. Six authors declared being current or former employees of, consultants for, or holding shares or stocks or stock options in Sanofi or CorEvitas LLC.

Source: Padula AS et al. The effect of targeted rheumatoid arthritis therapeutics on systemic inflammation and anemia: Analysis of data from the CorEvitas RA registry. Arthritis Res Ther. 2022;24:276 (Dec 21). Doi: 10.1186/s13075-022-02955-y

Key clinical point: Continuous 6-month therapy with interleukin-6 receptor inhibitors (IL-6Ri) vs tumor necrosis factor inhibitors (TNFi) or Janus kinase inhibitors (JAKi) demonstrated greater improvements in hemoglobin and C-reactive protein (CRP) levels regardless of baseline levels in patients with rheumatoid arthritis (RA).

Major finding: Six months of continuous therapy with IL-6Ri vs TNFi and JAKi led to significantly greater improvements in hemoglobin levels (adjusted odds ratios for achieving normal hemoglobin levels 3.15 and 3.85, respectively; both P < .001) and greater reductions in CRP levels (P < .01) regardless of baseline levels.

Study details: The data come from an analysis of 2772 patients with RA who received continuous TNFi, IL-6Ri, or JAKi treatment for ≥6 months.

Disclosures: This study was funded by Sanofi, and the RA registry was sponsored by CorEvitas, LLC. Six authors declared being current or former employees of, consultants for, or holding shares or stocks or stock options in Sanofi or CorEvitas LLC.

Source: Padula AS et al. The effect of targeted rheumatoid arthritis therapeutics on systemic inflammation and anemia: Analysis of data from the CorEvitas RA registry. Arthritis Res Ther. 2022;24:276 (Dec 21). Doi: 10.1186/s13075-022-02955-y

The bacterial diversity in lesional and nonlesional skin of patients with psoriasis (PsO) with or without psoriatic arthritis (PsA) was significantly lower than that of healthy control skin, based on data from 74 individuals.

Previous studies in humans and animals have suggested that microbes play a role in PsO pathogenesis, but microbial analyses of PsA are lacking, wrote Alba Boix-Amorós, PhD, of the Icahn School of Medicine at Mount Sinai, New York, and colleagues.

“The passage from PsO to PsA may, in part, be driven by microbial triggers, which deserves further investigation,” they wrote.

In a study published in Annals of the Rheumatic Diseases, the researchers recruited 23 patients with PsO and 31 with PsA from the dermatology and rheumatology clinics at the NYU Grossman School of Medicine/NYU Langone Health in New York. An additional 20 healthy individuals with no history of PsA or PsO were recruited from within NYU to serve as controls. All participants were aged 18 years and older, and more than 75% were White. Males made up 65.4%, 47.8%, and 55.0% of the PsA, PsO, and control groups.

The researchers collected skin swabs from lesional and nonlesional skin of individuals with PsO and PsA and from the upper and lower extremities of the healthy controls. The microbiota analysis included 148 samples that were analyzed using 16S rRNA sequencing.

The microbiome diversity was significantly greater in healthy skin, compared with lesional and nonlesional psoriatic skin (P < .05 for both). Specifically, levels of Cutibacterium and Kocuria were significantly higher in healthy skin than in psoriatic skin (P = .016 and P = .011, respectively), while psoriatic skin showed higher levels of Staphylococcus.

No significant microbiome differences were noted between lesional and nonlesional PsO and PsA samples. The finding that the microbiome of nonlesional psoriatic skin was more similar to lesional psoriatic skin than to healthy skin was unexpected, and suggests the development of microbial dysbiosis in psoriatic skin independent of the presence of lesions, the researchers wrote.

The researchers also found that levels of Corynebacterium in nonlesional PsA samples were significantly elevated, compared with nonlesional PsO samples (P < .05), which suggests a possible role for the microbe as a biomarker for disease progression, the researchers said.

“One important application of these data is the potential development of therapeutic options for the treatment of psoriatic disease and/or the prevention of PsA,” the researchers wrote in their discussion.

The findings were limited by several factors, including the combination of samples from upper and lower extremities and the exclusion of data from the scalp, the researchers noted. Other limitations included the use of only 16S rRNA gene sequencing, which presents a less comprehensive view of the microbiome, they said.

However, the results support the role of the skin microbiome in psoriasis pathogenesis, with details on microbiota across the psoriatic disease spectrum, they said.

The study received no outside funding. Dr. Boix-Amorós had no financial conflicts to disclose. Several coauthors disclosed financial relationships with pharmaceutical companies including Janssen, AbbVie, Bristol-Myers Squibb, Johnson & Johnson, Eli Lilly, Pfizer, Novartis, Sanofi, and UCB.

The bacterial diversity in lesional and nonlesional skin of patients with psoriasis (PsO) with or without psoriatic arthritis (PsA) was significantly lower than that of healthy control skin, based on data from 74 individuals.

Previous studies in humans and animals have suggested that microbes play a role in PsO pathogenesis, but microbial analyses of PsA are lacking, wrote Alba Boix-Amorós, PhD, of the Icahn School of Medicine at Mount Sinai, New York, and colleagues.

“The passage from PsO to PsA may, in part, be driven by microbial triggers, which deserves further investigation,” they wrote.

In a study published in Annals of the Rheumatic Diseases, the researchers recruited 23 patients with PsO and 31 with PsA from the dermatology and rheumatology clinics at the NYU Grossman School of Medicine/NYU Langone Health in New York. An additional 20 healthy individuals with no history of PsA or PsO were recruited from within NYU to serve as controls. All participants were aged 18 years and older, and more than 75% were White. Males made up 65.4%, 47.8%, and 55.0% of the PsA, PsO, and control groups.

The researchers collected skin swabs from lesional and nonlesional skin of individuals with PsO and PsA and from the upper and lower extremities of the healthy controls. The microbiota analysis included 148 samples that were analyzed using 16S rRNA sequencing.

The microbiome diversity was significantly greater in healthy skin, compared with lesional and nonlesional psoriatic skin (P < .05 for both). Specifically, levels of Cutibacterium and Kocuria were significantly higher in healthy skin than in psoriatic skin (P = .016 and P = .011, respectively), while psoriatic skin showed higher levels of Staphylococcus.

No significant microbiome differences were noted between lesional and nonlesional PsO and PsA samples. The finding that the microbiome of nonlesional psoriatic skin was more similar to lesional psoriatic skin than to healthy skin was unexpected, and suggests the development of microbial dysbiosis in psoriatic skin independent of the presence of lesions, the researchers wrote.

The researchers also found that levels of Corynebacterium in nonlesional PsA samples were significantly elevated, compared with nonlesional PsO samples (P < .05), which suggests a possible role for the microbe as a biomarker for disease progression, the researchers said.

“One important application of these data is the potential development of therapeutic options for the treatment of psoriatic disease and/or the prevention of PsA,” the researchers wrote in their discussion.

The findings were limited by several factors, including the combination of samples from upper and lower extremities and the exclusion of data from the scalp, the researchers noted. Other limitations included the use of only 16S rRNA gene sequencing, which presents a less comprehensive view of the microbiome, they said.

However, the results support the role of the skin microbiome in psoriasis pathogenesis, with details on microbiota across the psoriatic disease spectrum, they said.

The study received no outside funding. Dr. Boix-Amorós had no financial conflicts to disclose. Several coauthors disclosed financial relationships with pharmaceutical companies including Janssen, AbbVie, Bristol-Myers Squibb, Johnson & Johnson, Eli Lilly, Pfizer, Novartis, Sanofi, and UCB.

The bacterial diversity in lesional and nonlesional skin of patients with psoriasis (PsO) with or without psoriatic arthritis (PsA) was significantly lower than that of healthy control skin, based on data from 74 individuals.

Previous studies in humans and animals have suggested that microbes play a role in PsO pathogenesis, but microbial analyses of PsA are lacking, wrote Alba Boix-Amorós, PhD, of the Icahn School of Medicine at Mount Sinai, New York, and colleagues.

“The passage from PsO to PsA may, in part, be driven by microbial triggers, which deserves further investigation,” they wrote.

In a study published in Annals of the Rheumatic Diseases, the researchers recruited 23 patients with PsO and 31 with PsA from the dermatology and rheumatology clinics at the NYU Grossman School of Medicine/NYU Langone Health in New York. An additional 20 healthy individuals with no history of PsA or PsO were recruited from within NYU to serve as controls. All participants were aged 18 years and older, and more than 75% were White. Males made up 65.4%, 47.8%, and 55.0% of the PsA, PsO, and control groups.

The researchers collected skin swabs from lesional and nonlesional skin of individuals with PsO and PsA and from the upper and lower extremities of the healthy controls. The microbiota analysis included 148 samples that were analyzed using 16S rRNA sequencing.

The microbiome diversity was significantly greater in healthy skin, compared with lesional and nonlesional psoriatic skin (P < .05 for both). Specifically, levels of Cutibacterium and Kocuria were significantly higher in healthy skin than in psoriatic skin (P = .016 and P = .011, respectively), while psoriatic skin showed higher levels of Staphylococcus.

No significant microbiome differences were noted between lesional and nonlesional PsO and PsA samples. The finding that the microbiome of nonlesional psoriatic skin was more similar to lesional psoriatic skin than to healthy skin was unexpected, and suggests the development of microbial dysbiosis in psoriatic skin independent of the presence of lesions, the researchers wrote.

The researchers also found that levels of Corynebacterium in nonlesional PsA samples were significantly elevated, compared with nonlesional PsO samples (P < .05), which suggests a possible role for the microbe as a biomarker for disease progression, the researchers said.

“One important application of these data is the potential development of therapeutic options for the treatment of psoriatic disease and/or the prevention of PsA,” the researchers wrote in their discussion.

The findings were limited by several factors, including the combination of samples from upper and lower extremities and the exclusion of data from the scalp, the researchers noted. Other limitations included the use of only 16S rRNA gene sequencing, which presents a less comprehensive view of the microbiome, they said.

However, the results support the role of the skin microbiome in psoriasis pathogenesis, with details on microbiota across the psoriatic disease spectrum, they said.

The study received no outside funding. Dr. Boix-Amorós had no financial conflicts to disclose. Several coauthors disclosed financial relationships with pharmaceutical companies including Janssen, AbbVie, Bristol-Myers Squibb, Johnson & Johnson, Eli Lilly, Pfizer, Novartis, Sanofi, and UCB.

Key clinical point: Subcutaneous vs intravenous infliximab demonstrated improved efficacy in patients with rheumatoid arthritis (RA) who were inadequate responders to methotrexate (methotrexate-IR).

Major finding: At week 30, subcutaneous vs intravenous infliximab led to significantly lower Disease Activity Scores in 28 joints-C-reactive protein (DAS28-CRP; mean 3.07 vs 3.58; P  =  .0001) and significantly higher proportion of patients achieving DAS28-CRP low disease activity and remission (53.3% vs 38.5%; P  =  .0062), with no significant between-group difference after the switch to subcutaneous infliximab.

Study details: This post hoc analysis of a phase 3 trial included 339 patients with active RA who were methotrexate-IR and were randomly assigned to receive subcutaneous or intravenous infliximab; patients assigned to receive intravenous infliximab switched to subcutaneous infliximab from week 30 to 54.

Disclosures: This study was supported by Celltrion Healthcare Co., Ltd. Five authors declared being full-time employees of or receiving personal fees for advisory board and speaker’s bureau and research grants from Celltrion outside this work. Several authors reported ties with other various sources.

Source: Constantin A et al. Efficacy of subcutaneous vs intravenous infliximab in rheumatoid arthritis: A post-hoc analysis of a randomised phase III trial. Rheumatology (Oxford). 2022 (Dec 19). Doi: 10.1093/rheumatology/keac689

Key clinical point: Subcutaneous vs intravenous infliximab demonstrated improved efficacy in patients with rheumatoid arthritis (RA) who were inadequate responders to methotrexate (methotrexate-IR).

Major finding: At week 30, subcutaneous vs intravenous infliximab led to significantly lower Disease Activity Scores in 28 joints-C-reactive protein (DAS28-CRP; mean 3.07 vs 3.58; P  =  .0001) and significantly higher proportion of patients achieving DAS28-CRP low disease activity and remission (53.3% vs 38.5%; P  =  .0062), with no significant between-group difference after the switch to subcutaneous infliximab.

Study details: This post hoc analysis of a phase 3 trial included 339 patients with active RA who were methotrexate-IR and were randomly assigned to receive subcutaneous or intravenous infliximab; patients assigned to receive intravenous infliximab switched to subcutaneous infliximab from week 30 to 54.

Disclosures: This study was supported by Celltrion Healthcare Co., Ltd. Five authors declared being full-time employees of or receiving personal fees for advisory board and speaker’s bureau and research grants from Celltrion outside this work. Several authors reported ties with other various sources.

Source: Constantin A et al. Efficacy of subcutaneous vs intravenous infliximab in rheumatoid arthritis: A post-hoc analysis of a randomised phase III trial. Rheumatology (Oxford). 2022 (Dec 19). Doi: 10.1093/rheumatology/keac689

Key clinical point: Subcutaneous vs intravenous infliximab demonstrated improved efficacy in patients with rheumatoid arthritis (RA) who were inadequate responders to methotrexate (methotrexate-IR).

Major finding: At week 30, subcutaneous vs intravenous infliximab led to significantly lower Disease Activity Scores in 28 joints-C-reactive protein (DAS28-CRP; mean 3.07 vs 3.58; P  =  .0001) and significantly higher proportion of patients achieving DAS28-CRP low disease activity and remission (53.3% vs 38.5%; P  =  .0062), with no significant between-group difference after the switch to subcutaneous infliximab.

Study details: This post hoc analysis of a phase 3 trial included 339 patients with active RA who were methotrexate-IR and were randomly assigned to receive subcutaneous or intravenous infliximab; patients assigned to receive intravenous infliximab switched to subcutaneous infliximab from week 30 to 54.

Disclosures: This study was supported by Celltrion Healthcare Co., Ltd. Five authors declared being full-time employees of or receiving personal fees for advisory board and speaker’s bureau and research grants from Celltrion outside this work. Several authors reported ties with other various sources.

Source: Constantin A et al. Efficacy of subcutaneous vs intravenous infliximab in rheumatoid arthritis: A post-hoc analysis of a randomised phase III trial. Rheumatology (Oxford). 2022 (Dec 19). Doi: 10.1093/rheumatology/keac689

Key clinical point: Tumor necrosis factor inhibitors (TNFi) increased the risk for septic arthritis in patients with seropositive rheumatoid arthritis (RA), with higher incidences within 1 year of initiating TNFi.

Major finding: Patients with seropositive RA treated with infliximab (adjusted hazard ratio [aHR] 2.37), etanercept (aHR 1.82), or adalimumab/golimumab (aHR 1.82; all P < .01) were prone to develop septic arthritis, with the incidence being higher within 1 year of initiating TNFi (incidence rate/1000 person-year 25.51).

Study details: This retrospective study included 145,129 patients with new-onset seropositive RA or ankylosing spondylitis, of which 1170 patients developed septic arthritis.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Kim HW et al. Incidence of septic arthritis in patients with ankylosing spondylitis and seropositive rheumatoid arthritis following TNF-inhibitor therapy. Rheumatology (Oxford). 2022 (Dec 23). Doi: 10.1093/rheumatology/keac721

Key clinical point: Tumor necrosis factor inhibitors (TNFi) increased the risk for septic arthritis in patients with seropositive rheumatoid arthritis (RA), with higher incidences within 1 year of initiating TNFi.

Major finding: Patients with seropositive RA treated with infliximab (adjusted hazard ratio [aHR] 2.37), etanercept (aHR 1.82), or adalimumab/golimumab (aHR 1.82; all P < .01) were prone to develop septic arthritis, with the incidence being higher within 1 year of initiating TNFi (incidence rate/1000 person-year 25.51).

Study details: This retrospective study included 145,129 patients with new-onset seropositive RA or ankylosing spondylitis, of which 1170 patients developed septic arthritis.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Kim HW et al. Incidence of septic arthritis in patients with ankylosing spondylitis and seropositive rheumatoid arthritis following TNF-inhibitor therapy. Rheumatology (Oxford). 2022 (Dec 23). Doi: 10.1093/rheumatology/keac721

Key clinical point: Tumor necrosis factor inhibitors (TNFi) increased the risk for septic arthritis in patients with seropositive rheumatoid arthritis (RA), with higher incidences within 1 year of initiating TNFi.

Major finding: Patients with seropositive RA treated with infliximab (adjusted hazard ratio [aHR] 2.37), etanercept (aHR 1.82), or adalimumab/golimumab (aHR 1.82; all P < .01) were prone to develop septic arthritis, with the incidence being higher within 1 year of initiating TNFi (incidence rate/1000 person-year 25.51).

Study details: This retrospective study included 145,129 patients with new-onset seropositive RA or ankylosing spondylitis, of which 1170 patients developed septic arthritis.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Kim HW et al. Incidence of septic arthritis in patients with ankylosing spondylitis and seropositive rheumatoid arthritis following TNF-inhibitor therapy. Rheumatology (Oxford). 2022 (Dec 23). Doi: 10.1093/rheumatology/keac721

Key clinical point: Cumulative local joint inflammation over time was significantly associated with radiographic joint damage progression in the same joint in patients with early rheumatoid arthritis (RA) who were treated to a target disease activity score (DAS) of ≤2.4 for 10 years.

Major finding: Cumulative joint swelling was positively associated with local joint damage progression in the same joint (β 0.14; 95% CI 0.13-0.15). Each additional visit for joint swelling increased the joint damage score by a 0.13 unit and frequency of joint swelling in same vs other joints better predicted local joint damage progression (P < .001).

Study details: This post hoc analysis of the BeSt study included 473 patients with early RA who were randomly assigned to receive sequential monotherapy, step-up combination therapy, or initial combination therapy with methotrexate with or without sulfasalazine+prednisone or infliximab, with treatment intensification every 3 months until DAS ≤2.4 was achieved.

Disclosures: The BeSt study received funding from the Dutch College of Health Insurances and others. No competing interests were declared.

Source: Heckert SL et al. Frequency of joint inflammation is associated with local joint damage progression in rheumatoid arthritis despite long-term targeted treatment. RMD Open. 2023;9(1):e002552 (Jan 6). Doi: 10.1136/rmdopen-2022-002552

Key clinical point: Cumulative local joint inflammation over time was significantly associated with radiographic joint damage progression in the same joint in patients with early rheumatoid arthritis (RA) who were treated to a target disease activity score (DAS) of ≤2.4 for 10 years.

Major finding: Cumulative joint swelling was positively associated with local joint damage progression in the same joint (β 0.14; 95% CI 0.13-0.15). Each additional visit for joint swelling increased the joint damage score by a 0.13 unit and frequency of joint swelling in same vs other joints better predicted local joint damage progression (P < .001).

Study details: This post hoc analysis of the BeSt study included 473 patients with early RA who were randomly assigned to receive sequential monotherapy, step-up combination therapy, or initial combination therapy with methotrexate with or without sulfasalazine+prednisone or infliximab, with treatment intensification every 3 months until DAS ≤2.4 was achieved.

Disclosures: The BeSt study received funding from the Dutch College of Health Insurances and others. No competing interests were declared.

Source: Heckert SL et al. Frequency of joint inflammation is associated with local joint damage progression in rheumatoid arthritis despite long-term targeted treatment. RMD Open. 2023;9(1):e002552 (Jan 6). Doi: 10.1136/rmdopen-2022-002552

Key clinical point: Cumulative local joint inflammation over time was significantly associated with radiographic joint damage progression in the same joint in patients with early rheumatoid arthritis (RA) who were treated to a target disease activity score (DAS) of ≤2.4 for 10 years.

Major finding: Cumulative joint swelling was positively associated with local joint damage progression in the same joint (β 0.14; 95% CI 0.13-0.15). Each additional visit for joint swelling increased the joint damage score by a 0.13 unit and frequency of joint swelling in same vs other joints better predicted local joint damage progression (P < .001).

Study details: This post hoc analysis of the BeSt study included 473 patients with early RA who were randomly assigned to receive sequential monotherapy, step-up combination therapy, or initial combination therapy with methotrexate with or without sulfasalazine+prednisone or infliximab, with treatment intensification every 3 months until DAS ≤2.4 was achieved.

Disclosures: The BeSt study received funding from the Dutch College of Health Insurances and others. No competing interests were declared.

Source: Heckert SL et al. Frequency of joint inflammation is associated with local joint damage progression in rheumatoid arthritis despite long-term targeted treatment. RMD Open. 2023;9(1):e002552 (Jan 6). Doi: 10.1136/rmdopen-2022-002552

Key clinical point: “Plants for Joints” (PFJ), a 16-week multidisciplinary lifestyle program based on whole food plant-based diet, physical activity, and stress management in addition to usual care, significantly improved disease activity compared with usual care alone in patients with rheumatoid arthritis (RA) and low-to-moderate disease activity.

Major finding: After 16 weeks, patients receiving PFJ vs usual care alone had a greater reduction in disease activity score of 28 joints (DAS28; mean difference −0.90; P < .0001) and were more likely to achieve DAS28 <2.60 (odds ratio [OR] 4.6) and European Alliance of Associations for Rheumatology Good Response (OR 4.3; both P < .001). No serious adverse events were reported.

Study details: This randomized controlled trial, “Plants for Joints,” included 77 patients with RA and low-to-moderate disease activity who were randomly assigned to receive PFJ intervention plus usual care or usual care alone.

Disclosures: The trial was funded by Reade (The Netherlands) and other sources. The authors declared no conflicts of interest.

Source: Walrabenstein W et al. A multidisciplinary lifestyle program for rheumatoid arthritis: The “Plants for Joints” randomized controlled trial. Rheumatology (Oxford). 2023 (Jan 6). Doi: 10.1093/rheumatology/keac693

Key clinical point: “Plants for Joints” (PFJ), a 16-week multidisciplinary lifestyle program based on whole food plant-based diet, physical activity, and stress management in addition to usual care, significantly improved disease activity compared with usual care alone in patients with rheumatoid arthritis (RA) and low-to-moderate disease activity.

Major finding: After 16 weeks, patients receiving PFJ vs usual care alone had a greater reduction in disease activity score of 28 joints (DAS28; mean difference −0.90; P < .0001) and were more likely to achieve DAS28 <2.60 (odds ratio [OR] 4.6) and European Alliance of Associations for Rheumatology Good Response (OR 4.3; both P < .001). No serious adverse events were reported.

Study details: This randomized controlled trial, “Plants for Joints,” included 77 patients with RA and low-to-moderate disease activity who were randomly assigned to receive PFJ intervention plus usual care or usual care alone.

Disclosures: The trial was funded by Reade (The Netherlands) and other sources. The authors declared no conflicts of interest.

Source: Walrabenstein W et al. A multidisciplinary lifestyle program for rheumatoid arthritis: The “Plants for Joints” randomized controlled trial. Rheumatology (Oxford). 2023 (Jan 6). Doi: 10.1093/rheumatology/keac693

Key clinical point: “Plants for Joints” (PFJ), a 16-week multidisciplinary lifestyle program based on whole food plant-based diet, physical activity, and stress management in addition to usual care, significantly improved disease activity compared with usual care alone in patients with rheumatoid arthritis (RA) and low-to-moderate disease activity.

Major finding: After 16 weeks, patients receiving PFJ vs usual care alone had a greater reduction in disease activity score of 28 joints (DAS28; mean difference −0.90; P < .0001) and were more likely to achieve DAS28 <2.60 (odds ratio [OR] 4.6) and European Alliance of Associations for Rheumatology Good Response (OR 4.3; both P < .001). No serious adverse events were reported.

Study details: This randomized controlled trial, “Plants for Joints,” included 77 patients with RA and low-to-moderate disease activity who were randomly assigned to receive PFJ intervention plus usual care or usual care alone.

Disclosures: The trial was funded by Reade (The Netherlands) and other sources. The authors declared no conflicts of interest.

Source: Walrabenstein W et al. A multidisciplinary lifestyle program for rheumatoid arthritis: The “Plants for Joints” randomized controlled trial. Rheumatology (Oxford). 2023 (Jan 6). Doi: 10.1093/rheumatology/keac693