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Geriatrician advises on use of vitamin D supplementation, lecanemab, and texting for her patients
Vitamin D supplementation and incident fractures
Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.
A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.1 In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.
The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”
With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).
In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
Lecanemab for mild cognitive impairment and early Alzheimer’s dementia
On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.2
The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.3
Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.2
Social isolation and dementia risk
There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.4
A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.
Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.5
Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).6 These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.
Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.
References
1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.
2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.
3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.
4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.
5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.
6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.
Vitamin D supplementation and incident fractures
Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.
A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.1 In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.
The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”
With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).
In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
Lecanemab for mild cognitive impairment and early Alzheimer’s dementia
On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.2
The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.3
Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.2
Social isolation and dementia risk
There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.4
A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.
Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.5
Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).6 These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.
Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.
References
1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.
2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.
3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.
4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.
5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.
6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.
Vitamin D supplementation and incident fractures
Vitamin D supplementation is a commonly recommended intervention for bone health, but data to support its impact on reducing fracture risk has been variable.
A study in the New England Journal of Medicine by LeBoff and colleagues has garnered much attention since its publication in July 2022.1 In the ancillary study of the Vitamin D and Omega-3-Trial (VITAL), the authors examined the impact of vitamin D supplementation versus placebo on incident fractures. The study found that vitamin D supplementation, as compared with placebo, led to no significant difference in the incidence of total, nonvertebral, and hip fractures in midlife and older adults over the 5-year period of follow-up.
The generalizability of these findings has been raised as a concern as the study does not describe adults at higher risk for fracture. The authors of the study specified in their conclusion that vitamin D supplementation does not reduce fracture risk in “generally healthy midlife and older adults who were not selected for vitamin D deficiency, low bone mass or osteoporosis.”
With a mean participant age of 67 and exclusion of participants with a history of cardiovascular disease, stroke, cirrhosis and other serious illnesses, the study does not reflect the multimorbid older adult population that geriatricians typically care for. Furthermore, efficacy of vitamin D supplementation on fracture risk may be the most impactful in those with osteoporosis and with severe vitamin D deficiency (defined by vitamin D 25[OH]D level less than 12 ng/mL).
In post hoc analyses, there was no significant difference in fracture risk in these subgroups, however the authors acknowledged that the findings may be limited by the small percentage of participants with severe vitamin D deficiency (2.4%) and osteoporosis included in the study (5%).
Lecanemab for mild cognitive impairment and early Alzheimer’s dementia
On Jan. 6, 2023, the Food and Drug Administration approved lecanemab, the second-ever disease-modifying treatment for Alzheimer’s dementia following the approval of aducanumab in 2021. Lecanemab is a monoclonal antibody targeting larger amyloid-beta oligomers, which has been shown in vitro to have higher affinity for amyloid-beta, compared with aducanumab. FDA approval followed shortly after the publication of the CLARITY-AD trial, which investigated the effect of lecanemab versus placebo on cognitive decline and burden of amyloid in adults with mild cognitive impairment and mild Alzheimer’s dementia. Over an 18-month period, the study found that participants who received lecanemab, compared with placebo, had a significantly smaller decline in cognition and function, and reduction in amyloid burden on PET CT.2
The clinical significance of these findings, however, is unclear. As noted by an editorial published in the Lancet in 2022, the difference in Clinical Dementia Rating-Sum of Boxes (CDR-SB) scale between the treatment and placebo groups was 0.45. On an 18-point scale, prior research has noted that a minimal clinically significance difference of 0.98 is necessary in those with mild cognitive impairment and 1.63 in mild Alzheimer dementia.3
Additionally, the CLARITY-AD trial reported that lecanemab resulted in infusion reactions in 26.4% of participants and brain edema (an amyloid-related imaging abnormality referred to as ARIA-E) in 12.6% of participants. This finding highlights concerns for safety and the need for close monitoring, as well as ongoing implications of economic feasibility and equitable access for all those who qualify for treatment.2
Social isolation and dementia risk
There is growing awareness of the impact of social isolation on health outcomes, particularly among older adults. Prior research has reported that one in four older adults are considered socially isolated and that social isolation increases risk of premature death, dementia, depression, and cardiovascular disease.4
A study by Huang and colleagues is the first nationally representative cohort study examining the association between social isolation and incident dementia for older adults in community dwelling settings. A cohort of 5,022 older adults participating in the National Health and Aging Trends Study was followed from 2011 to 2020. When adjusting for demographic and health factors, including race, level of education, and number of chronic health conditions, socially isolated adults had a greater risk of developing dementia, compared with adults who were not socially isolated (hazard ratio, 1.27; 95% confidence interval, 1.08-1.49). Potential mechanisms to explain this association include the increased risk of cardiovascular disease and depression in older adults who are socially isolated, thereby increasing dementia risk.
Decreased cognitive activity/engagement and access to resources such as caregiving and health care may also be linked to the increased risk of dementia in socially isolated older adults.5
Another observational cohort study from the National Health and Aging Trends Study investigated whether access and use of technology can lower the risk of social isolation. The study found that older adults who used email or text messaging had a lower risk of social isolation than older adults who did not use technology (incidence rate ratio, 0.64; 95% CI, 0.51-0.80).6 These findings highlight the importance of addressing social isolation as an important modifiable health risk factor, and the need for providing equitable access to technology in vulnerable populations as health intervention.
Dr. Mengru “Ruru” Wang is a geriatrician and internist at the University of Washington, Seattle. She practices full-spectrum medicine, seeing patients in primary care, nursing homes, and acute care. Dr. Wang has no disclosures related to this piece.
References
1. LeBoff MS et al. Supplemental vitamin D and incident fractures in midlife and older adults. N Engl J Med. 2022;387(4):299-30.
2. van Dyck CH et al. Lecanemab in early Alzheimer’s disease. N Engl J Med. 2023;388(1):9-21.
3. The Lancet. Lecanemab for Alzheimer’s disease: tempering hype and hope. Lancet. 2022; 400:1899.
4. National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: 2020, The National Academies Press.
5. Huang, AR et al. Social isolation and 9-year dementia risk in community dwelling Medicare beneficiaries in the United States. J Am Geriatr Soc. 2023 Jan 11. doi: 10.1111/jgs18140.
6. Umoh ME etal. Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study. J Am Geriatr Soc. 2022 Dec 15. doi 10.1111/jgs.18179.
Canadian Task Force recommendation on screening for postpartum depression misses the mark
Postpartum/perinatal depression (PPD) remains the most common complication in modern obstetrics, with a prevalence of 10%-15% based on multiple studies over the last 2 decades. Over those same 2 decades, there has been growing interest and motivation across the country – from small community hospitals to major academic centers – to promote screening. Such screening is integrated into obstetrical practices, typically using the Edinburgh Postnatal Depression Scale (EPDS), the most widely used validated screen for PPD globally.
As mentioned in previous columns, the U.S. Preventive Services Task Force recommended screening for PPD in 2016, which includes screening women at highest risk, and both acutely treating and preventing PPD.
Since then, screening women for a common clinical problem like PPD has been widely adopted by clinicians representing a broad spectrum of interdisciplinary care. Providers who are engaged in the treatment of postpartum women – obstetricians, psychiatrists, doulas, lactation consultants, facilitators of postpartum support groups, and advocacy groups among others – are included.
An open question and one of great concern recently to our group and others has been what happens after screening. It is clear that identification of PPD per se is not necessarily a challenge, and we have multiple effective treatments from antidepressants to mindfulness-based cognitive therapy to cognitive-behavioral interventions. There is also a growing number of digital applications aimed at mitigation of depressive symptoms in women with postpartum major depressive disorder. One unanswered question is how to engage women after identification of PPD and how to facilitate access to care in a way that maximizes the likelihood that women who actually are suffering from PPD get adequate treatment.
The “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression. This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well?
With that backdrop, it is surprising that the Canadian Task Force on Preventive Health Care has recently recommended against screening with systematic questionnaires, noting that benefits were unclear and not a particular advantage relative to standard practice. The recommendation carries an assumption that standard practice involves queries about mental health. While the task force continues to recommend screening for PPD, their recommendation against screening with a standardized questionnaire represents a bold, sweeping, if not myopic view.
While the Canadian Task Force on Preventive Health Care made their recommendation based on a single randomized controlled trial with the assumption that women were getting mental health counseling, and that women liked getting mental health engagement around their depression, that is not a uniform part of practice. Thus, it is puzzling why the task force would make the recommendation based on such sparse data.
The way to optimize access to care and referral systems for women who are suffering from PPD is not to remove a part of the system that’s already working. Well-validated questionnaires such as the EPDS are easy to administer and are routinely integrated into the electronic health systems records of both small and large centers. These questionnaires are an inexpensive way to increase the likelihood that women get identified and referred for a spectrum of potentially helpful interventions.
PPD is also easy to treat with medications and a wide spectrum of nonpharmacologic interventions. Novel interventions are also being explored to maximize access for women with postpartum mood and anxiety disorders such as peer-delivered behavioral activation and cognitive-behavioral therapy, which could be community based and implemented from urban to rural settings across the United States.
What may need the greatest study is the path to accessing effective treatments and resources for these women and this problem has prompted our group to explore these issues in our more recent investigations. Better understanding of those factors that limit access to mental health providers with expertise in perinatal mental health to the logistical issues of navigating the health care system for sleep-deprived new moms and their families demands greater attention and clearer answers.
The whole field has an obligation to postpartum women to figure out the amalgam of practitioners, resources, and platforms that need to be used to engage women so that they get effective treatment – because we have effective treatments. But the solution to improving perinatal mental health outcomes, unlike the approach of our colleagues in Canada, is not to be found in abandoning questionnaire-based screening, but in identifying the best ways to prevent PPD and to maximize access to care.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
Postpartum/perinatal depression (PPD) remains the most common complication in modern obstetrics, with a prevalence of 10%-15% based on multiple studies over the last 2 decades. Over those same 2 decades, there has been growing interest and motivation across the country – from small community hospitals to major academic centers – to promote screening. Such screening is integrated into obstetrical practices, typically using the Edinburgh Postnatal Depression Scale (EPDS), the most widely used validated screen for PPD globally.
As mentioned in previous columns, the U.S. Preventive Services Task Force recommended screening for PPD in 2016, which includes screening women at highest risk, and both acutely treating and preventing PPD.
Since then, screening women for a common clinical problem like PPD has been widely adopted by clinicians representing a broad spectrum of interdisciplinary care. Providers who are engaged in the treatment of postpartum women – obstetricians, psychiatrists, doulas, lactation consultants, facilitators of postpartum support groups, and advocacy groups among others – are included.
An open question and one of great concern recently to our group and others has been what happens after screening. It is clear that identification of PPD per se is not necessarily a challenge, and we have multiple effective treatments from antidepressants to mindfulness-based cognitive therapy to cognitive-behavioral interventions. There is also a growing number of digital applications aimed at mitigation of depressive symptoms in women with postpartum major depressive disorder. One unanswered question is how to engage women after identification of PPD and how to facilitate access to care in a way that maximizes the likelihood that women who actually are suffering from PPD get adequate treatment.
The “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression. This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well?
With that backdrop, it is surprising that the Canadian Task Force on Preventive Health Care has recently recommended against screening with systematic questionnaires, noting that benefits were unclear and not a particular advantage relative to standard practice. The recommendation carries an assumption that standard practice involves queries about mental health. While the task force continues to recommend screening for PPD, their recommendation against screening with a standardized questionnaire represents a bold, sweeping, if not myopic view.
While the Canadian Task Force on Preventive Health Care made their recommendation based on a single randomized controlled trial with the assumption that women were getting mental health counseling, and that women liked getting mental health engagement around their depression, that is not a uniform part of practice. Thus, it is puzzling why the task force would make the recommendation based on such sparse data.
The way to optimize access to care and referral systems for women who are suffering from PPD is not to remove a part of the system that’s already working. Well-validated questionnaires such as the EPDS are easy to administer and are routinely integrated into the electronic health systems records of both small and large centers. These questionnaires are an inexpensive way to increase the likelihood that women get identified and referred for a spectrum of potentially helpful interventions.
PPD is also easy to treat with medications and a wide spectrum of nonpharmacologic interventions. Novel interventions are also being explored to maximize access for women with postpartum mood and anxiety disorders such as peer-delivered behavioral activation and cognitive-behavioral therapy, which could be community based and implemented from urban to rural settings across the United States.
What may need the greatest study is the path to accessing effective treatments and resources for these women and this problem has prompted our group to explore these issues in our more recent investigations. Better understanding of those factors that limit access to mental health providers with expertise in perinatal mental health to the logistical issues of navigating the health care system for sleep-deprived new moms and their families demands greater attention and clearer answers.
The whole field has an obligation to postpartum women to figure out the amalgam of practitioners, resources, and platforms that need to be used to engage women so that they get effective treatment – because we have effective treatments. But the solution to improving perinatal mental health outcomes, unlike the approach of our colleagues in Canada, is not to be found in abandoning questionnaire-based screening, but in identifying the best ways to prevent PPD and to maximize access to care.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
Postpartum/perinatal depression (PPD) remains the most common complication in modern obstetrics, with a prevalence of 10%-15% based on multiple studies over the last 2 decades. Over those same 2 decades, there has been growing interest and motivation across the country – from small community hospitals to major academic centers – to promote screening. Such screening is integrated into obstetrical practices, typically using the Edinburgh Postnatal Depression Scale (EPDS), the most widely used validated screen for PPD globally.
As mentioned in previous columns, the U.S. Preventive Services Task Force recommended screening for PPD in 2016, which includes screening women at highest risk, and both acutely treating and preventing PPD.
Since then, screening women for a common clinical problem like PPD has been widely adopted by clinicians representing a broad spectrum of interdisciplinary care. Providers who are engaged in the treatment of postpartum women – obstetricians, psychiatrists, doulas, lactation consultants, facilitators of postpartum support groups, and advocacy groups among others – are included.
An open question and one of great concern recently to our group and others has been what happens after screening. It is clear that identification of PPD per se is not necessarily a challenge, and we have multiple effective treatments from antidepressants to mindfulness-based cognitive therapy to cognitive-behavioral interventions. There is also a growing number of digital applications aimed at mitigation of depressive symptoms in women with postpartum major depressive disorder. One unanswered question is how to engage women after identification of PPD and how to facilitate access to care in a way that maximizes the likelihood that women who actually are suffering from PPD get adequate treatment.
The “perinatal treatment cascade” refers to the majority of women who, on the other side of identification of PPD, fail to receive adequate treatment and continue to have persistent depression. This is perhaps the greatest challenge to the field and to clinicians – how do we, on the other side of screening, see that these women get access to care and get well?
With that backdrop, it is surprising that the Canadian Task Force on Preventive Health Care has recently recommended against screening with systematic questionnaires, noting that benefits were unclear and not a particular advantage relative to standard practice. The recommendation carries an assumption that standard practice involves queries about mental health. While the task force continues to recommend screening for PPD, their recommendation against screening with a standardized questionnaire represents a bold, sweeping, if not myopic view.
While the Canadian Task Force on Preventive Health Care made their recommendation based on a single randomized controlled trial with the assumption that women were getting mental health counseling, and that women liked getting mental health engagement around their depression, that is not a uniform part of practice. Thus, it is puzzling why the task force would make the recommendation based on such sparse data.
The way to optimize access to care and referral systems for women who are suffering from PPD is not to remove a part of the system that’s already working. Well-validated questionnaires such as the EPDS are easy to administer and are routinely integrated into the electronic health systems records of both small and large centers. These questionnaires are an inexpensive way to increase the likelihood that women get identified and referred for a spectrum of potentially helpful interventions.
PPD is also easy to treat with medications and a wide spectrum of nonpharmacologic interventions. Novel interventions are also being explored to maximize access for women with postpartum mood and anxiety disorders such as peer-delivered behavioral activation and cognitive-behavioral therapy, which could be community based and implemented from urban to rural settings across the United States.
What may need the greatest study is the path to accessing effective treatments and resources for these women and this problem has prompted our group to explore these issues in our more recent investigations. Better understanding of those factors that limit access to mental health providers with expertise in perinatal mental health to the logistical issues of navigating the health care system for sleep-deprived new moms and their families demands greater attention and clearer answers.
The whole field has an obligation to postpartum women to figure out the amalgam of practitioners, resources, and platforms that need to be used to engage women so that they get effective treatment – because we have effective treatments. But the solution to improving perinatal mental health outcomes, unlike the approach of our colleagues in Canada, is not to be found in abandoning questionnaire-based screening, but in identifying the best ways to prevent PPD and to maximize access to care.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
Two short-term exposure therapies linked to PTSD reductions
Two forms of short-term exposure therapy may help reduce symptoms of posttraumatic stress disorder, new research suggests.
In addition, remission rates of around 50% were sustained in both groups up to the 6-month mark.
“With about two-thirds of study participants reporting clinically meaningful symptom improvement and more than half losing their PTSD diagnosis, this study provides important new evidence that combat-related PTSD can be effectively treated – in as little as 3 weeks,” lead investigator Alan Peterson, PhD, told this news organization.
Dr. Peterson, professor of psychiatry and behavioral sciences at the University of Texas Health Science Center, San Antonio, and director of the Consortium to Alleviate PTSD, noted that while condensed treatments may not be feasible for everyone, “results show that compressed formats adapted to the military context resulted in significant, meaningful, and lasting improvements in PTSD, disability, and functional impairments for most participants.”
The findings were published online in JAMA Network Open.
Breathing, direct exposure, education
The investigators randomly recruited 234 military personnel and veterans from two military treatment facilities and two Veterans Affairs facilities in south and central Texas.
Participants (78% men; mean age, 39 years) were active-duty service members or veterans who had deployed post Sept. 11 and met diagnostic criteria for PTSD. They could receive psychotropic medications at stable doses and were excluded if they had mania, substance abuse, psychosis, or suicidality.
The sample included 44% White participants, 26% Black participants, and 25% Hispanic participants.
The researchers randomly assigned the participants to receive either massed-PE (n = 117) or IOP-PE (n = 117).
PE, the foundation of both protocols, includes psychoeducation about trauma, diaphragmatic breathing, direct and imaginal exposure, and processing of the trauma.
The massed-PE protocol was delivered in 15 daily 90-minute sessions over 3 consecutive weeks, as was the IOP-PE. However, the IOP-PE also included eight additional multiple daily feedback sessions, homework, social support from friends or family, and three booster sessions post treatment.
The investigators conducted baseline assessments and follow-up assessments at 1 month, 3 months, and 6 months. At the 6-month follow-up, there were 57 participants left to analyze in the massed-PE group and 57 in the IOP-PE group.
Significantly decreased symptoms
As measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), PTSD symptoms decreased significantly from baseline to the 1-month follow-up in both groups (massed-PE mean change, –14.13; P < .001; IOP-PE mean change, –13.85; P < .001).
Both groups also failed to meet PTSD diagnostic criteria at 1-, 3-, and 6-month follow-ups.
At the 1-month follow-up, 62% of participants who received massed-PE and 48% of those who received IOP-PE no longer met diagnostic criteria on the CAPS-5. Diagnostic remission was maintained in more than half of the massed-PE group (52%) and the IOP-PE group (53%) at the 6-month follow-up.
Disability scores as measured by the Sheehan Disability Scale also decreased significantly in both groups (P < .001) from baseline to the 1-month follow-up mark; as did psychosocial functioning scores, as reflected by the Brief Inventory of Psychosocial Functioning (P < .001).
Dr. Peterson noted that the condensed treatment format could be an essential option to consider even in other countries, such as Ukraine, where there are concerns about PTSD in military personnel.
Study limitations included the lack of a placebo or inactive comparison group, and the lack of generalizability of the results to the entire population of U.S. service members and veterans outside of Texas.
Dr. Peterson said he plans to continue his research and that the compressed treatment formats studied “are well-suited for the evaluation of alternative modes of therapy combining cognitive-behavioral treatments with medications and medical devices.”
Generalizability limited?
Commenting on the research, Joshua Morganstein, MD, chair of the American Psychiatric Association’s committee on the psychiatric dimensions of disaster, said he was reassured to see participants achieve and keep improvements throughout the study.
“One of the biggest challenges we have, particularly with trauma and stress disorders, is keeping people in therapy” because of the difficult nature of the exposure therapy, said Dr. Morganstein, who was not involved with the research.
“The number of people assigned to each group and who ultimately completed the last follow-up gives a good idea of the utility of the intervention,” he added.
However, Dr. Morganstein noted that some of the exclusion criteria, particularly suicidality and substance abuse, affected the study’s relevance to real-world populations.
“The people in the study become less representative of those who are actually in clinical care,” he said, noting that these two conditions are often comorbid with PTSD.
The study was funded by the Department of Defense, the Defense Health Program, the Psychological Health and Traumatic Brain Injury Research Program, the Department of Veterans Affairs, the Office of Research and Development, and the Clinical Science Research & Development Service. The investigators and Dr. Morganstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Two forms of short-term exposure therapy may help reduce symptoms of posttraumatic stress disorder, new research suggests.
In addition, remission rates of around 50% were sustained in both groups up to the 6-month mark.
“With about two-thirds of study participants reporting clinically meaningful symptom improvement and more than half losing their PTSD diagnosis, this study provides important new evidence that combat-related PTSD can be effectively treated – in as little as 3 weeks,” lead investigator Alan Peterson, PhD, told this news organization.
Dr. Peterson, professor of psychiatry and behavioral sciences at the University of Texas Health Science Center, San Antonio, and director of the Consortium to Alleviate PTSD, noted that while condensed treatments may not be feasible for everyone, “results show that compressed formats adapted to the military context resulted in significant, meaningful, and lasting improvements in PTSD, disability, and functional impairments for most participants.”
The findings were published online in JAMA Network Open.
Breathing, direct exposure, education
The investigators randomly recruited 234 military personnel and veterans from two military treatment facilities and two Veterans Affairs facilities in south and central Texas.
Participants (78% men; mean age, 39 years) were active-duty service members or veterans who had deployed post Sept. 11 and met diagnostic criteria for PTSD. They could receive psychotropic medications at stable doses and were excluded if they had mania, substance abuse, psychosis, or suicidality.
The sample included 44% White participants, 26% Black participants, and 25% Hispanic participants.
The researchers randomly assigned the participants to receive either massed-PE (n = 117) or IOP-PE (n = 117).
PE, the foundation of both protocols, includes psychoeducation about trauma, diaphragmatic breathing, direct and imaginal exposure, and processing of the trauma.
The massed-PE protocol was delivered in 15 daily 90-minute sessions over 3 consecutive weeks, as was the IOP-PE. However, the IOP-PE also included eight additional multiple daily feedback sessions, homework, social support from friends or family, and three booster sessions post treatment.
The investigators conducted baseline assessments and follow-up assessments at 1 month, 3 months, and 6 months. At the 6-month follow-up, there were 57 participants left to analyze in the massed-PE group and 57 in the IOP-PE group.
Significantly decreased symptoms
As measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), PTSD symptoms decreased significantly from baseline to the 1-month follow-up in both groups (massed-PE mean change, –14.13; P < .001; IOP-PE mean change, –13.85; P < .001).
Both groups also failed to meet PTSD diagnostic criteria at 1-, 3-, and 6-month follow-ups.
At the 1-month follow-up, 62% of participants who received massed-PE and 48% of those who received IOP-PE no longer met diagnostic criteria on the CAPS-5. Diagnostic remission was maintained in more than half of the massed-PE group (52%) and the IOP-PE group (53%) at the 6-month follow-up.
Disability scores as measured by the Sheehan Disability Scale also decreased significantly in both groups (P < .001) from baseline to the 1-month follow-up mark; as did psychosocial functioning scores, as reflected by the Brief Inventory of Psychosocial Functioning (P < .001).
Dr. Peterson noted that the condensed treatment format could be an essential option to consider even in other countries, such as Ukraine, where there are concerns about PTSD in military personnel.
Study limitations included the lack of a placebo or inactive comparison group, and the lack of generalizability of the results to the entire population of U.S. service members and veterans outside of Texas.
Dr. Peterson said he plans to continue his research and that the compressed treatment formats studied “are well-suited for the evaluation of alternative modes of therapy combining cognitive-behavioral treatments with medications and medical devices.”
Generalizability limited?
Commenting on the research, Joshua Morganstein, MD, chair of the American Psychiatric Association’s committee on the psychiatric dimensions of disaster, said he was reassured to see participants achieve and keep improvements throughout the study.
“One of the biggest challenges we have, particularly with trauma and stress disorders, is keeping people in therapy” because of the difficult nature of the exposure therapy, said Dr. Morganstein, who was not involved with the research.
“The number of people assigned to each group and who ultimately completed the last follow-up gives a good idea of the utility of the intervention,” he added.
However, Dr. Morganstein noted that some of the exclusion criteria, particularly suicidality and substance abuse, affected the study’s relevance to real-world populations.
“The people in the study become less representative of those who are actually in clinical care,” he said, noting that these two conditions are often comorbid with PTSD.
The study was funded by the Department of Defense, the Defense Health Program, the Psychological Health and Traumatic Brain Injury Research Program, the Department of Veterans Affairs, the Office of Research and Development, and the Clinical Science Research & Development Service. The investigators and Dr. Morganstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Two forms of short-term exposure therapy may help reduce symptoms of posttraumatic stress disorder, new research suggests.
In addition, remission rates of around 50% were sustained in both groups up to the 6-month mark.
“With about two-thirds of study participants reporting clinically meaningful symptom improvement and more than half losing their PTSD diagnosis, this study provides important new evidence that combat-related PTSD can be effectively treated – in as little as 3 weeks,” lead investigator Alan Peterson, PhD, told this news organization.
Dr. Peterson, professor of psychiatry and behavioral sciences at the University of Texas Health Science Center, San Antonio, and director of the Consortium to Alleviate PTSD, noted that while condensed treatments may not be feasible for everyone, “results show that compressed formats adapted to the military context resulted in significant, meaningful, and lasting improvements in PTSD, disability, and functional impairments for most participants.”
The findings were published online in JAMA Network Open.
Breathing, direct exposure, education
The investigators randomly recruited 234 military personnel and veterans from two military treatment facilities and two Veterans Affairs facilities in south and central Texas.
Participants (78% men; mean age, 39 years) were active-duty service members or veterans who had deployed post Sept. 11 and met diagnostic criteria for PTSD. They could receive psychotropic medications at stable doses and were excluded if they had mania, substance abuse, psychosis, or suicidality.
The sample included 44% White participants, 26% Black participants, and 25% Hispanic participants.
The researchers randomly assigned the participants to receive either massed-PE (n = 117) or IOP-PE (n = 117).
PE, the foundation of both protocols, includes psychoeducation about trauma, diaphragmatic breathing, direct and imaginal exposure, and processing of the trauma.
The massed-PE protocol was delivered in 15 daily 90-minute sessions over 3 consecutive weeks, as was the IOP-PE. However, the IOP-PE also included eight additional multiple daily feedback sessions, homework, social support from friends or family, and three booster sessions post treatment.
The investigators conducted baseline assessments and follow-up assessments at 1 month, 3 months, and 6 months. At the 6-month follow-up, there were 57 participants left to analyze in the massed-PE group and 57 in the IOP-PE group.
Significantly decreased symptoms
As measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), PTSD symptoms decreased significantly from baseline to the 1-month follow-up in both groups (massed-PE mean change, –14.13; P < .001; IOP-PE mean change, –13.85; P < .001).
Both groups also failed to meet PTSD diagnostic criteria at 1-, 3-, and 6-month follow-ups.
At the 1-month follow-up, 62% of participants who received massed-PE and 48% of those who received IOP-PE no longer met diagnostic criteria on the CAPS-5. Diagnostic remission was maintained in more than half of the massed-PE group (52%) and the IOP-PE group (53%) at the 6-month follow-up.
Disability scores as measured by the Sheehan Disability Scale also decreased significantly in both groups (P < .001) from baseline to the 1-month follow-up mark; as did psychosocial functioning scores, as reflected by the Brief Inventory of Psychosocial Functioning (P < .001).
Dr. Peterson noted that the condensed treatment format could be an essential option to consider even in other countries, such as Ukraine, where there are concerns about PTSD in military personnel.
Study limitations included the lack of a placebo or inactive comparison group, and the lack of generalizability of the results to the entire population of U.S. service members and veterans outside of Texas.
Dr. Peterson said he plans to continue his research and that the compressed treatment formats studied “are well-suited for the evaluation of alternative modes of therapy combining cognitive-behavioral treatments with medications and medical devices.”
Generalizability limited?
Commenting on the research, Joshua Morganstein, MD, chair of the American Psychiatric Association’s committee on the psychiatric dimensions of disaster, said he was reassured to see participants achieve and keep improvements throughout the study.
“One of the biggest challenges we have, particularly with trauma and stress disorders, is keeping people in therapy” because of the difficult nature of the exposure therapy, said Dr. Morganstein, who was not involved with the research.
“The number of people assigned to each group and who ultimately completed the last follow-up gives a good idea of the utility of the intervention,” he added.
However, Dr. Morganstein noted that some of the exclusion criteria, particularly suicidality and substance abuse, affected the study’s relevance to real-world populations.
“The people in the study become less representative of those who are actually in clinical care,” he said, noting that these two conditions are often comorbid with PTSD.
The study was funded by the Department of Defense, the Defense Health Program, the Psychological Health and Traumatic Brain Injury Research Program, the Department of Veterans Affairs, the Office of Research and Development, and the Clinical Science Research & Development Service. The investigators and Dr. Morganstein have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
‘Concerning’ uptick in pediatric antipsychotic prescribing
“This study demonstrates a concerning trend in antipsychotic prescribing in children and adolescents,” study investigator Matthias Pierce, PhD, senior research fellow at the University of Manchester (England) Center for Women’s Mental Health, who jointly led the study, said in a news release.
“We do not think the changes in prescribing necessarily relate to changes in clinical need; rather, it may be more likely to reflect changes in prescribing practice by clinicians,” Dr. Pierce said.
The study was published online in The Lancet Psychiatry.
Increase in long-term use
Between 2000 and 2019, prescriptions for antipsychotics nearly doubled from 0.06% to 0.11%.
The investigators note that the U.K.’s National Institute for Health and Care Excellence has approved the use of some antipsychotics in patients younger than age 18 with schizophrenia, bipolar disorder, and severely aggressive behavior attributable to conduct disorder.
However, these data suggest antipsychotics are being prescribed for an increasingly broad range of conditions, most commonly autism, but also for attention-deficit/ hyperactivity disorder, tic disorders like Tourrette syndrome, and learning difficulties.
“Broadening use of antipsychotics in developing young people begs questions about their safety over time and demands more research on this topic,” senior author Kathryn Abel, MBBS, PhD, from the University of Manchester said in the news release.
During the study period, antipsychotic prescribing in primary care increased by an average of 3.3% per year and the rate of first prescriptions increased by 2.2% per year.
The data also suggest that more children and adolescents are taking these powerful drugs for longer periods of time. The proportion receiving antipsychotics for at least 6 months after an initial prescription rose from 41.9% in 2000 to 62.8% in 2018.
Prescribing inequities
From 2009 onwards, more than 90% of prescriptions were for atypical antipsychotics.
Over time, risperidone dominated, with more than 60% of all prescriptions, followed by aripiprazole, quetiapine, olanzapine, and haloperidol as the most prescribed antipsychotics.
Boys and older children aged 15-18 years were most likely to receive an antipsychotic. However, the increasing trends were evident in all groups.
The data also point to inequities in prescribing as a result of deprivation levels, with typical antipsychotics prescribed more frequently in more deprived areas over time.
Dr. Pierce said he hopes this study will “help clinicians to evaluate the prescribing of antipsychotics to children more fully and will encourage them to consider better access to alternatives.”
Dr. Abel noted that antipsychotic medications “continue to have a valuable role in the treatment of serious mental illness. These findings represent a descriptive account of antipsychotic prescribing to children and adolescents in the U.K. today and provide a window onto current practice.”
Findings are no surprise
Emily Simonoff, MD, professor of child and adolescent psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, offered perspective on the study in a statement from the U.K. nonprofit Science Media Centre.
“To clinicians, it will not be surprising that the authors demonstrate an increase in rates of prescriptions over that time period, as there has been a steadily emerging evidence base for the benefits of this group of medication for a range of different indications, which has been further supported by new licensing indications and recommendations from NICE,” Dr. Simonoff said.
For example, “there is good evidence for their benefits for other conditions such as irritability in autism spectrum disorder.
“However, it should also be noted that NICE recommendations for their use in many conditions is as part of a multimodal treatment plan, for example including psychological or behavioral interventions. It’s unclear from the study whether such recommendations were being followed or medication was being used on its own,” she added.
Dr. Simonoff also said it’s “reassuring” that prescribing rates remain very low in the youngest children and notes that the authors “rightly highlight the need for high-quality, longer-term studies on efficacy and, most importantly, adverse effects. This should be a research priority.”
The study had no funding. The authors report no relevant financial relationships. Dr. Simonoff is a member of the NICE guideline development group for the management of autism and has published on the efficacy of antipsychotic medication for irritability in autism.
A version of this article first appeared on Medscape.com.
“This study demonstrates a concerning trend in antipsychotic prescribing in children and adolescents,” study investigator Matthias Pierce, PhD, senior research fellow at the University of Manchester (England) Center for Women’s Mental Health, who jointly led the study, said in a news release.
“We do not think the changes in prescribing necessarily relate to changes in clinical need; rather, it may be more likely to reflect changes in prescribing practice by clinicians,” Dr. Pierce said.
The study was published online in The Lancet Psychiatry.
Increase in long-term use
Between 2000 and 2019, prescriptions for antipsychotics nearly doubled from 0.06% to 0.11%.
The investigators note that the U.K.’s National Institute for Health and Care Excellence has approved the use of some antipsychotics in patients younger than age 18 with schizophrenia, bipolar disorder, and severely aggressive behavior attributable to conduct disorder.
However, these data suggest antipsychotics are being prescribed for an increasingly broad range of conditions, most commonly autism, but also for attention-deficit/ hyperactivity disorder, tic disorders like Tourrette syndrome, and learning difficulties.
“Broadening use of antipsychotics in developing young people begs questions about their safety over time and demands more research on this topic,” senior author Kathryn Abel, MBBS, PhD, from the University of Manchester said in the news release.
During the study period, antipsychotic prescribing in primary care increased by an average of 3.3% per year and the rate of first prescriptions increased by 2.2% per year.
The data also suggest that more children and adolescents are taking these powerful drugs for longer periods of time. The proportion receiving antipsychotics for at least 6 months after an initial prescription rose from 41.9% in 2000 to 62.8% in 2018.
Prescribing inequities
From 2009 onwards, more than 90% of prescriptions were for atypical antipsychotics.
Over time, risperidone dominated, with more than 60% of all prescriptions, followed by aripiprazole, quetiapine, olanzapine, and haloperidol as the most prescribed antipsychotics.
Boys and older children aged 15-18 years were most likely to receive an antipsychotic. However, the increasing trends were evident in all groups.
The data also point to inequities in prescribing as a result of deprivation levels, with typical antipsychotics prescribed more frequently in more deprived areas over time.
Dr. Pierce said he hopes this study will “help clinicians to evaluate the prescribing of antipsychotics to children more fully and will encourage them to consider better access to alternatives.”
Dr. Abel noted that antipsychotic medications “continue to have a valuable role in the treatment of serious mental illness. These findings represent a descriptive account of antipsychotic prescribing to children and adolescents in the U.K. today and provide a window onto current practice.”
Findings are no surprise
Emily Simonoff, MD, professor of child and adolescent psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, offered perspective on the study in a statement from the U.K. nonprofit Science Media Centre.
“To clinicians, it will not be surprising that the authors demonstrate an increase in rates of prescriptions over that time period, as there has been a steadily emerging evidence base for the benefits of this group of medication for a range of different indications, which has been further supported by new licensing indications and recommendations from NICE,” Dr. Simonoff said.
For example, “there is good evidence for their benefits for other conditions such as irritability in autism spectrum disorder.
“However, it should also be noted that NICE recommendations for their use in many conditions is as part of a multimodal treatment plan, for example including psychological or behavioral interventions. It’s unclear from the study whether such recommendations were being followed or medication was being used on its own,” she added.
Dr. Simonoff also said it’s “reassuring” that prescribing rates remain very low in the youngest children and notes that the authors “rightly highlight the need for high-quality, longer-term studies on efficacy and, most importantly, adverse effects. This should be a research priority.”
The study had no funding. The authors report no relevant financial relationships. Dr. Simonoff is a member of the NICE guideline development group for the management of autism and has published on the efficacy of antipsychotic medication for irritability in autism.
A version of this article first appeared on Medscape.com.
“This study demonstrates a concerning trend in antipsychotic prescribing in children and adolescents,” study investigator Matthias Pierce, PhD, senior research fellow at the University of Manchester (England) Center for Women’s Mental Health, who jointly led the study, said in a news release.
“We do not think the changes in prescribing necessarily relate to changes in clinical need; rather, it may be more likely to reflect changes in prescribing practice by clinicians,” Dr. Pierce said.
The study was published online in The Lancet Psychiatry.
Increase in long-term use
Between 2000 and 2019, prescriptions for antipsychotics nearly doubled from 0.06% to 0.11%.
The investigators note that the U.K.’s National Institute for Health and Care Excellence has approved the use of some antipsychotics in patients younger than age 18 with schizophrenia, bipolar disorder, and severely aggressive behavior attributable to conduct disorder.
However, these data suggest antipsychotics are being prescribed for an increasingly broad range of conditions, most commonly autism, but also for attention-deficit/ hyperactivity disorder, tic disorders like Tourrette syndrome, and learning difficulties.
“Broadening use of antipsychotics in developing young people begs questions about their safety over time and demands more research on this topic,” senior author Kathryn Abel, MBBS, PhD, from the University of Manchester said in the news release.
During the study period, antipsychotic prescribing in primary care increased by an average of 3.3% per year and the rate of first prescriptions increased by 2.2% per year.
The data also suggest that more children and adolescents are taking these powerful drugs for longer periods of time. The proportion receiving antipsychotics for at least 6 months after an initial prescription rose from 41.9% in 2000 to 62.8% in 2018.
Prescribing inequities
From 2009 onwards, more than 90% of prescriptions were for atypical antipsychotics.
Over time, risperidone dominated, with more than 60% of all prescriptions, followed by aripiprazole, quetiapine, olanzapine, and haloperidol as the most prescribed antipsychotics.
Boys and older children aged 15-18 years were most likely to receive an antipsychotic. However, the increasing trends were evident in all groups.
The data also point to inequities in prescribing as a result of deprivation levels, with typical antipsychotics prescribed more frequently in more deprived areas over time.
Dr. Pierce said he hopes this study will “help clinicians to evaluate the prescribing of antipsychotics to children more fully and will encourage them to consider better access to alternatives.”
Dr. Abel noted that antipsychotic medications “continue to have a valuable role in the treatment of serious mental illness. These findings represent a descriptive account of antipsychotic prescribing to children and adolescents in the U.K. today and provide a window onto current practice.”
Findings are no surprise
Emily Simonoff, MD, professor of child and adolescent psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, offered perspective on the study in a statement from the U.K. nonprofit Science Media Centre.
“To clinicians, it will not be surprising that the authors demonstrate an increase in rates of prescriptions over that time period, as there has been a steadily emerging evidence base for the benefits of this group of medication for a range of different indications, which has been further supported by new licensing indications and recommendations from NICE,” Dr. Simonoff said.
For example, “there is good evidence for their benefits for other conditions such as irritability in autism spectrum disorder.
“However, it should also be noted that NICE recommendations for their use in many conditions is as part of a multimodal treatment plan, for example including psychological or behavioral interventions. It’s unclear from the study whether such recommendations were being followed or medication was being used on its own,” she added.
Dr. Simonoff also said it’s “reassuring” that prescribing rates remain very low in the youngest children and notes that the authors “rightly highlight the need for high-quality, longer-term studies on efficacy and, most importantly, adverse effects. This should be a research priority.”
The study had no funding. The authors report no relevant financial relationships. Dr. Simonoff is a member of the NICE guideline development group for the management of autism and has published on the efficacy of antipsychotic medication for irritability in autism.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PSYCHIATRY
Kids with concussions may benefit from early return to school
The timing for return to school after a concussion has been the subject of guidelines, but data on how the timing of school returns affects later symptom burdens are limited, Christopher G. Vaughan, PhD, of Children’s National Hospital, Rockville, Md., and colleagues wrote.
Examining how the timing of return to school (RTS) affects later symptoms is needed to inform early postinjury management, they said.
In the new study published in JAMA Network Open, the researchers identified 1,630 children and teens aged 5-18 years who were treated for concussions at nine Canadian pediatric EDs. The primary outcome was symptom burden at 14 days post concussion, based on the Post-Concussion Symptom Inventory (PCSI). Early RTS was defined as missing fewer than 3 days of school post concussion.
Overall, the mean number of missed school days was 3.74 (excluding weekends). When divided by age, the mean number of missed days was 2.61 for children aged 5-7 years, 3.26 for those aged 8-12 years, and 4.71 for those aged 13-18 years.
Slightly more than half (53.7%) of the participants had an early RTS of 2 missed days or fewer. Later RTS was most common in the oldest age group, followed by the middle and younger age groups.
The researchers used a propensity score–matched analysis to determine associations. At 14 days, an early RTS was associated with reduced symptoms among 8- to 12-year-olds and 13- to 18-year-olds, though not in the youngest patients aged 5-7 years. In addition, the researchers created quantiles based on initial symptom ratings.
For the youngest age group, the association between early RTS and reduced symptoms at day 14 was higher among those with lower initial symptoms.
For the two older groups, the association was higher for those with higher initial symptoms (based on the PCSI).
The findings that earlier RTS was associated with a lower symptom burden at day 14 for those with higher levels of symptoms at baseline was surprising, but the mechanisms of the timing and effect of RTS requires more study, the researchers wrote in their discussion.
The effect of early RTS on symptoms may be in part related to factors such as “the benefits of socialization, reduced stress from not missing too much school, maintaining or returning to a normal sleep-wake schedule, and returning to light to moderate physical activity (gym class and recreational activities),” the researchers noted.
Another study related to recovery and concussion recently appeared in Neurology. In that study, the authors found that those athletes who took a longer time to recover from a sports-related concussion could still return to play with additional time off, but the methods and populations differed from the current study, which focused on RTS rather than returning to play.
The current study findings were limited by several factors including the lack of randomization for RTS timing and a lack of data on the variety of potential supports and accommodations students received, the researchers noted.
However, the results were strengthened by the large size and diverse nature of the concussions, and the roughly equal representation of boys and girls, they said.
Although randomized trials are needed to determine the best timing for RTS, the current study suggests that RTS within 2 days of a concussion is associated with improved symptoms, “and may directly or indirectly promote faster recovery,” they concluded.
Early return remains feasible for most children and teens
“Return to school can be a complicated issue for children and teens with concussions,” said Caitlyn Mooney, MD, a pediatrician and specialist in sports medicine at the University of Texas Health Science Center, San Antonio, said in an interview. Although much research has focused on diagnosis and return to sport after a concussion, there has been less focus on returning to school and learning. Various issues post concussion can make schooling difficult, and students may experience trouble with vision, concentration, sleep, headaches, and more.
Despite this knowledge, studies that specifically address recommended school protocols are limited, Dr. Mooney said. “Additionally, all concussions are different; while some students will need minimal help to return and succeed in school, others may need individualized learning plans and accommodations for school.” A return to school ideally would be a team-based approach with input from the parent, patient, physician, and educators.
“The theory of cognitive rest stems from the idea that a concussion causes metabolic dysfunction in the brain, and that increasing the metabolic demands of the brain can result in symptoms and a delayed return to school,” said Dr. Mooney.
Evidence suggests that those who start resting early after a concussion improve more quickly, “but there has been ongoing discussion over the years of what is the correct balance of cognitive rest to returning to modified activity,” she said. “This has led to the current general recommendation of rest for 24-48 hours followed by a gradual return to school as tolerated.”
Although the current study is large, it is limited by the lack of randomization, Dr. Mooney noted, therefore conclusions cannot be made that the cause of the improved symptoms is a quicker return to school.
However, the results support data from previous studies, in that both of the older age groups showed less disease burden at 14 days after an earlier return to school, she said.
“With prolonged absences, adolescents get isolated at home away from friends, and they may have increased mood symptoms. Additionally, I have found a high number of my patients who do not go to school as quickly have more sleep disturbance, which seems to increase symptoms such as difficulty concentrating or headaches,” she said. “It seems like the students do benefit from a routine schedule even if they have to have some accommodations at school, especially older students who may have more stress about missing school and falling behind on schoolwork.”
The message for pediatricians is that return to school should be individualized, Dr. Mooney said.
Although the current study does not dictate the optimal return to school, the results support those of previous studies in showing that, after 1-2 days of rest, an early return does not harm children and teens and may improve symptoms in many cases, she said. “In my experience, sometimes schools find it easier to keep the student at home rather than manage rest or special accommodations,” but the current study suggests that delaying return to school may not be the right choice for many patients.
“I hope this study empowers clinicians to advocate for these students, that the right place for them is in the classroom even with rest, extra time, or other accommodations,” said Dr. Mooney.
“Each concussion should be evaluated and treated individually; there will likely be a few who may need to stay home for a longer period of time, but this study suggests that the majority of students will suffer no ill effects from returning to the normal routine after a 2-day rest,” she noted.
The study was supported by the Canadian Institutes for Health Research. Dr. Vaughan and several coauthors disclosed being authors of the Postconcussion Symptom Inventory outside of the current study. Dr. Mooney had no financial conflicts to disclose.
The timing for return to school after a concussion has been the subject of guidelines, but data on how the timing of school returns affects later symptom burdens are limited, Christopher G. Vaughan, PhD, of Children’s National Hospital, Rockville, Md., and colleagues wrote.
Examining how the timing of return to school (RTS) affects later symptoms is needed to inform early postinjury management, they said.
In the new study published in JAMA Network Open, the researchers identified 1,630 children and teens aged 5-18 years who were treated for concussions at nine Canadian pediatric EDs. The primary outcome was symptom burden at 14 days post concussion, based on the Post-Concussion Symptom Inventory (PCSI). Early RTS was defined as missing fewer than 3 days of school post concussion.
Overall, the mean number of missed school days was 3.74 (excluding weekends). When divided by age, the mean number of missed days was 2.61 for children aged 5-7 years, 3.26 for those aged 8-12 years, and 4.71 for those aged 13-18 years.
Slightly more than half (53.7%) of the participants had an early RTS of 2 missed days or fewer. Later RTS was most common in the oldest age group, followed by the middle and younger age groups.
The researchers used a propensity score–matched analysis to determine associations. At 14 days, an early RTS was associated with reduced symptoms among 8- to 12-year-olds and 13- to 18-year-olds, though not in the youngest patients aged 5-7 years. In addition, the researchers created quantiles based on initial symptom ratings.
For the youngest age group, the association between early RTS and reduced symptoms at day 14 was higher among those with lower initial symptoms.
For the two older groups, the association was higher for those with higher initial symptoms (based on the PCSI).
The findings that earlier RTS was associated with a lower symptom burden at day 14 for those with higher levels of symptoms at baseline was surprising, but the mechanisms of the timing and effect of RTS requires more study, the researchers wrote in their discussion.
The effect of early RTS on symptoms may be in part related to factors such as “the benefits of socialization, reduced stress from not missing too much school, maintaining or returning to a normal sleep-wake schedule, and returning to light to moderate physical activity (gym class and recreational activities),” the researchers noted.
Another study related to recovery and concussion recently appeared in Neurology. In that study, the authors found that those athletes who took a longer time to recover from a sports-related concussion could still return to play with additional time off, but the methods and populations differed from the current study, which focused on RTS rather than returning to play.
The current study findings were limited by several factors including the lack of randomization for RTS timing and a lack of data on the variety of potential supports and accommodations students received, the researchers noted.
However, the results were strengthened by the large size and diverse nature of the concussions, and the roughly equal representation of boys and girls, they said.
Although randomized trials are needed to determine the best timing for RTS, the current study suggests that RTS within 2 days of a concussion is associated with improved symptoms, “and may directly or indirectly promote faster recovery,” they concluded.
Early return remains feasible for most children and teens
“Return to school can be a complicated issue for children and teens with concussions,” said Caitlyn Mooney, MD, a pediatrician and specialist in sports medicine at the University of Texas Health Science Center, San Antonio, said in an interview. Although much research has focused on diagnosis and return to sport after a concussion, there has been less focus on returning to school and learning. Various issues post concussion can make schooling difficult, and students may experience trouble with vision, concentration, sleep, headaches, and more.
Despite this knowledge, studies that specifically address recommended school protocols are limited, Dr. Mooney said. “Additionally, all concussions are different; while some students will need minimal help to return and succeed in school, others may need individualized learning plans and accommodations for school.” A return to school ideally would be a team-based approach with input from the parent, patient, physician, and educators.
“The theory of cognitive rest stems from the idea that a concussion causes metabolic dysfunction in the brain, and that increasing the metabolic demands of the brain can result in symptoms and a delayed return to school,” said Dr. Mooney.
Evidence suggests that those who start resting early after a concussion improve more quickly, “but there has been ongoing discussion over the years of what is the correct balance of cognitive rest to returning to modified activity,” she said. “This has led to the current general recommendation of rest for 24-48 hours followed by a gradual return to school as tolerated.”
Although the current study is large, it is limited by the lack of randomization, Dr. Mooney noted, therefore conclusions cannot be made that the cause of the improved symptoms is a quicker return to school.
However, the results support data from previous studies, in that both of the older age groups showed less disease burden at 14 days after an earlier return to school, she said.
“With prolonged absences, adolescents get isolated at home away from friends, and they may have increased mood symptoms. Additionally, I have found a high number of my patients who do not go to school as quickly have more sleep disturbance, which seems to increase symptoms such as difficulty concentrating or headaches,” she said. “It seems like the students do benefit from a routine schedule even if they have to have some accommodations at school, especially older students who may have more stress about missing school and falling behind on schoolwork.”
The message for pediatricians is that return to school should be individualized, Dr. Mooney said.
Although the current study does not dictate the optimal return to school, the results support those of previous studies in showing that, after 1-2 days of rest, an early return does not harm children and teens and may improve symptoms in many cases, she said. “In my experience, sometimes schools find it easier to keep the student at home rather than manage rest or special accommodations,” but the current study suggests that delaying return to school may not be the right choice for many patients.
“I hope this study empowers clinicians to advocate for these students, that the right place for them is in the classroom even with rest, extra time, or other accommodations,” said Dr. Mooney.
“Each concussion should be evaluated and treated individually; there will likely be a few who may need to stay home for a longer period of time, but this study suggests that the majority of students will suffer no ill effects from returning to the normal routine after a 2-day rest,” she noted.
The study was supported by the Canadian Institutes for Health Research. Dr. Vaughan and several coauthors disclosed being authors of the Postconcussion Symptom Inventory outside of the current study. Dr. Mooney had no financial conflicts to disclose.
The timing for return to school after a concussion has been the subject of guidelines, but data on how the timing of school returns affects later symptom burdens are limited, Christopher G. Vaughan, PhD, of Children’s National Hospital, Rockville, Md., and colleagues wrote.
Examining how the timing of return to school (RTS) affects later symptoms is needed to inform early postinjury management, they said.
In the new study published in JAMA Network Open, the researchers identified 1,630 children and teens aged 5-18 years who were treated for concussions at nine Canadian pediatric EDs. The primary outcome was symptom burden at 14 days post concussion, based on the Post-Concussion Symptom Inventory (PCSI). Early RTS was defined as missing fewer than 3 days of school post concussion.
Overall, the mean number of missed school days was 3.74 (excluding weekends). When divided by age, the mean number of missed days was 2.61 for children aged 5-7 years, 3.26 for those aged 8-12 years, and 4.71 for those aged 13-18 years.
Slightly more than half (53.7%) of the participants had an early RTS of 2 missed days or fewer. Later RTS was most common in the oldest age group, followed by the middle and younger age groups.
The researchers used a propensity score–matched analysis to determine associations. At 14 days, an early RTS was associated with reduced symptoms among 8- to 12-year-olds and 13- to 18-year-olds, though not in the youngest patients aged 5-7 years. In addition, the researchers created quantiles based on initial symptom ratings.
For the youngest age group, the association between early RTS and reduced symptoms at day 14 was higher among those with lower initial symptoms.
For the two older groups, the association was higher for those with higher initial symptoms (based on the PCSI).
The findings that earlier RTS was associated with a lower symptom burden at day 14 for those with higher levels of symptoms at baseline was surprising, but the mechanisms of the timing and effect of RTS requires more study, the researchers wrote in their discussion.
The effect of early RTS on symptoms may be in part related to factors such as “the benefits of socialization, reduced stress from not missing too much school, maintaining or returning to a normal sleep-wake schedule, and returning to light to moderate physical activity (gym class and recreational activities),” the researchers noted.
Another study related to recovery and concussion recently appeared in Neurology. In that study, the authors found that those athletes who took a longer time to recover from a sports-related concussion could still return to play with additional time off, but the methods and populations differed from the current study, which focused on RTS rather than returning to play.
The current study findings were limited by several factors including the lack of randomization for RTS timing and a lack of data on the variety of potential supports and accommodations students received, the researchers noted.
However, the results were strengthened by the large size and diverse nature of the concussions, and the roughly equal representation of boys and girls, they said.
Although randomized trials are needed to determine the best timing for RTS, the current study suggests that RTS within 2 days of a concussion is associated with improved symptoms, “and may directly or indirectly promote faster recovery,” they concluded.
Early return remains feasible for most children and teens
“Return to school can be a complicated issue for children and teens with concussions,” said Caitlyn Mooney, MD, a pediatrician and specialist in sports medicine at the University of Texas Health Science Center, San Antonio, said in an interview. Although much research has focused on diagnosis and return to sport after a concussion, there has been less focus on returning to school and learning. Various issues post concussion can make schooling difficult, and students may experience trouble with vision, concentration, sleep, headaches, and more.
Despite this knowledge, studies that specifically address recommended school protocols are limited, Dr. Mooney said. “Additionally, all concussions are different; while some students will need minimal help to return and succeed in school, others may need individualized learning plans and accommodations for school.” A return to school ideally would be a team-based approach with input from the parent, patient, physician, and educators.
“The theory of cognitive rest stems from the idea that a concussion causes metabolic dysfunction in the brain, and that increasing the metabolic demands of the brain can result in symptoms and a delayed return to school,” said Dr. Mooney.
Evidence suggests that those who start resting early after a concussion improve more quickly, “but there has been ongoing discussion over the years of what is the correct balance of cognitive rest to returning to modified activity,” she said. “This has led to the current general recommendation of rest for 24-48 hours followed by a gradual return to school as tolerated.”
Although the current study is large, it is limited by the lack of randomization, Dr. Mooney noted, therefore conclusions cannot be made that the cause of the improved symptoms is a quicker return to school.
However, the results support data from previous studies, in that both of the older age groups showed less disease burden at 14 days after an earlier return to school, she said.
“With prolonged absences, adolescents get isolated at home away from friends, and they may have increased mood symptoms. Additionally, I have found a high number of my patients who do not go to school as quickly have more sleep disturbance, which seems to increase symptoms such as difficulty concentrating or headaches,” she said. “It seems like the students do benefit from a routine schedule even if they have to have some accommodations at school, especially older students who may have more stress about missing school and falling behind on schoolwork.”
The message for pediatricians is that return to school should be individualized, Dr. Mooney said.
Although the current study does not dictate the optimal return to school, the results support those of previous studies in showing that, after 1-2 days of rest, an early return does not harm children and teens and may improve symptoms in many cases, she said. “In my experience, sometimes schools find it easier to keep the student at home rather than manage rest or special accommodations,” but the current study suggests that delaying return to school may not be the right choice for many patients.
“I hope this study empowers clinicians to advocate for these students, that the right place for them is in the classroom even with rest, extra time, or other accommodations,” said Dr. Mooney.
“Each concussion should be evaluated and treated individually; there will likely be a few who may need to stay home for a longer period of time, but this study suggests that the majority of students will suffer no ill effects from returning to the normal routine after a 2-day rest,” she noted.
The study was supported by the Canadian Institutes for Health Research. Dr. Vaughan and several coauthors disclosed being authors of the Postconcussion Symptom Inventory outside of the current study. Dr. Mooney had no financial conflicts to disclose.
FROM JAMA NETWORK OPEN
Emotional eating tied to risk of diastolic dysfunction
Eating in response to stress – known as emotional eating – was significantly associated with several markers of long-term cardiovascular damage, based on data from 1,109 individuals.
“We know diet plays a huge role in cardiovascular disease, but we have focused a lot of work on what you eat, not on what makes you eat” – the current study did exactly that, Martha Gulati, MD, who wasn’t involved in the study, said in an interview.
“Emotional eaters consume food to satisfy their brains rather than their stomachs,” study investigator Nicolas Girerd, MD, of the National Institute of Health and Medical Research (INSERM) and a cardiologist at the University Hospital of Nancy (France), wrote in a press release accompanying the study.
Diet plays a role in the development of cardiovascular disease (CVD), but the impact of eating behavior on long-term cardiovascular health remains unclear, wrote Dr. Girerd and colleagues. Previous research has yielded three common psychological dimensions for eating behavior: emotional eating, restrained eating, and external eating.
Both emotional eating and restrained eating have been linked to cardiovascular disease risk, the researchers noted. “Because of previous findings, we hypothesized that [emotional and/or restrained dimensions of eating behavior] are positively associated with cardiovascular damages, as well as with CV risk factors, such as metabolic syndrome,” they wrote.
In a study published in the European Journal of Preventive Cardiology, the researchers reviewed data from 916 adults and 193 adolescents who were participants in the STANISLAS (Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux), a longitudinal familial cohort in France. Cardiovascular data were collected at four medical visits as part of a full clinical examination between 1993 and 2016, with one visit every 5-10 years. Roughly one-third (31.0%) of the adults were overweight, 7.9% were obese, and 2.7% were underweight. The median age of the adults at the second visit was 44.7 years; the median age of the adolescent group was 15.2 years.
The primary outcome of cardiovascular damage was measured at the fourth visit. Eating behavior was assessed during the second visit using the Dutch Eating Behaviour Questionnaire (DEBQ), and participants were identified as emotional eaters, restrained eaters, or external eaters.
Among the adults, emotional eating was associated with a 38% increased risk of diastolic dysfunction (odds ratio, 1.38; P = .02), over an average follow-up of 13 years, and this association was mediated by stress in 32% of cases. Emotional eating also was positively linked with a higher carotid-femoral pulse-wave velocity (cfPWV-beta), indicative of increased arterial stiffness. However, none of the three dimensions of eating behavior was associated with cardiovascular damage among the adolescents. In addition, none of the eating-behavior dimensions was tied to metabolic syndrome in the adult group (this association was not measured in the adolescents).
Energy intake had no apparent impact on any associations between eating behavior and CVD measures, Dr. Girerd said in the press release. “We might expect that emotional eaters would consume high-calorie foods, which would in turn lead to cardiovascular problems, but this was not the case. One explanation is that we measured average calorie intake and emotional eaters may binge when stressed and then eat less at other times,” and that the resulting “yo-yo” pattern might negatively affect the heart and blood vessels more than stable food intake, he said.
The study findings were limited by several factors, including the observational design that prevented conclusions of causality, the researchers noted. Other limitations included the use of a nonvalidated scale to measure stress, the lack of data on physical activity, and the use of a mainly healthy population in a limited geographic area, which may limit generalizability, they said.
More research is needed in other contexts and larger cohorts, but the results were strengthened by the large study population and the complete data on eating behaviors and detailed health information, they wrote. The results support previous studies and suggest that patients with emotional eating behavior could benefit from emotion regulation skills training, including cognitive, behavioral, psychological, and interpersonal therapies used in other areas, and from pharmacological treatments, the researchers concluded.
The current study offers a unique and important perspective on the relationship between diet and cardiovascular disease, Dr. Gulati, director of preventive cardiology at the Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, told this news organization.
“Examining eating behavior and its relationship with cardiovascular effects in healthy individuals in this prospective way is quite interesting,” said Dr. Gulati, who was not involved in the study.
The researchers examined healthy people at baseline, inquired about their eating habits, and found that emotional eaters “have evidence of cardiovascular changes when compared with the other groups of eaters, after controlling for other risk factors that are associated with cardiovascular disease when following them for 13 years,” said Dr. Gulati, who was recently named Anita Dann Friedman Endowed Chair in Women’s Cardiovascular Medicine and Research at Cedars-Sinai. “This same finding wasn’t seen in adolescents, but this is probably because they are younger, and the effects aren’t seen. That is reassuring, because it means that the more we address eating behaviors, the more likely we are to reduce their effects to the heart,” she noted.
“This study is important because usually, as cardiologists or anyone in medicine, how we assess diet is by assessment of what food people eat; we don’t usually ask about what triggers them to eat,” Dr. Gulati said. “Eating behaviors based on their triggers ultimately affect food choice and food quantity, and help us understand weight changes during a lifetime,” she said.
“I think we don’t have the data to know that an eating behavior would be able to affect cardiac function,” said Dr. Gulati, “but I think we all might hypothesize that emotional eating may be associated with abnormal diastolic function simply through eating high-density food and weight gain.”
The current study did not show a relationship between eating behavior and metabolic syndrome, in contrast with prior studies, Dr. Gulati noted. However, “the authors report that the association between eating behaviors and diastolic dysfunction was mediated through the stress level,” Dr. Gulati said. “It is important to note that this European population was healthy at baseline, and also relatively healthy 13 years later, which makes these findings even more profound.”
Dr. Gulati said that she agrees with the study authors on the need to assess diet and eating behaviors when assessing cardiovascular risk in patient. “Diet assessment as part of prevention is central, but we should ask not only ‘what do you eat,’ but also ‘what makes you eat,’ ” she said.
More research is needed in other populations, Dr. Gulati added. The current study population was healthy at baseline and follow-up. Studies are needed in cohorts in the United States and in the developing world to see how the results might differ; as well as in rural America or in “food deserts” where food choices are limited.
Another research topic is the interplay between eating behaviors and social determinants of health, in terms of their effect on cardiovascular function, Dr. Gulati said, “and it will be valuable to follow this cohort further to see how these eating behaviors and these intermediate measures translate into cardiovascular outcomes.” Future studies should also examine whether the changes in cardiac function are reversible by interventions to modify eating behavior, particularly emotional eating, she said.
Supporters of the study included the Regional University Hospital Center of Nancy, the French Ministry of Solidarity and Health, and a public grant overseen by the French National Research Agency. The researchers had no financial conflicts to disclose.
Dr. Gulati, who serves on the editorial advisory board of MDedge Cardiology, had no financial conflicts to disclose.
Eating in response to stress – known as emotional eating – was significantly associated with several markers of long-term cardiovascular damage, based on data from 1,109 individuals.
“We know diet plays a huge role in cardiovascular disease, but we have focused a lot of work on what you eat, not on what makes you eat” – the current study did exactly that, Martha Gulati, MD, who wasn’t involved in the study, said in an interview.
“Emotional eaters consume food to satisfy their brains rather than their stomachs,” study investigator Nicolas Girerd, MD, of the National Institute of Health and Medical Research (INSERM) and a cardiologist at the University Hospital of Nancy (France), wrote in a press release accompanying the study.
Diet plays a role in the development of cardiovascular disease (CVD), but the impact of eating behavior on long-term cardiovascular health remains unclear, wrote Dr. Girerd and colleagues. Previous research has yielded three common psychological dimensions for eating behavior: emotional eating, restrained eating, and external eating.
Both emotional eating and restrained eating have been linked to cardiovascular disease risk, the researchers noted. “Because of previous findings, we hypothesized that [emotional and/or restrained dimensions of eating behavior] are positively associated with cardiovascular damages, as well as with CV risk factors, such as metabolic syndrome,” they wrote.
In a study published in the European Journal of Preventive Cardiology, the researchers reviewed data from 916 adults and 193 adolescents who were participants in the STANISLAS (Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux), a longitudinal familial cohort in France. Cardiovascular data were collected at four medical visits as part of a full clinical examination between 1993 and 2016, with one visit every 5-10 years. Roughly one-third (31.0%) of the adults were overweight, 7.9% were obese, and 2.7% were underweight. The median age of the adults at the second visit was 44.7 years; the median age of the adolescent group was 15.2 years.
The primary outcome of cardiovascular damage was measured at the fourth visit. Eating behavior was assessed during the second visit using the Dutch Eating Behaviour Questionnaire (DEBQ), and participants were identified as emotional eaters, restrained eaters, or external eaters.
Among the adults, emotional eating was associated with a 38% increased risk of diastolic dysfunction (odds ratio, 1.38; P = .02), over an average follow-up of 13 years, and this association was mediated by stress in 32% of cases. Emotional eating also was positively linked with a higher carotid-femoral pulse-wave velocity (cfPWV-beta), indicative of increased arterial stiffness. However, none of the three dimensions of eating behavior was associated with cardiovascular damage among the adolescents. In addition, none of the eating-behavior dimensions was tied to metabolic syndrome in the adult group (this association was not measured in the adolescents).
Energy intake had no apparent impact on any associations between eating behavior and CVD measures, Dr. Girerd said in the press release. “We might expect that emotional eaters would consume high-calorie foods, which would in turn lead to cardiovascular problems, but this was not the case. One explanation is that we measured average calorie intake and emotional eaters may binge when stressed and then eat less at other times,” and that the resulting “yo-yo” pattern might negatively affect the heart and blood vessels more than stable food intake, he said.
The study findings were limited by several factors, including the observational design that prevented conclusions of causality, the researchers noted. Other limitations included the use of a nonvalidated scale to measure stress, the lack of data on physical activity, and the use of a mainly healthy population in a limited geographic area, which may limit generalizability, they said.
More research is needed in other contexts and larger cohorts, but the results were strengthened by the large study population and the complete data on eating behaviors and detailed health information, they wrote. The results support previous studies and suggest that patients with emotional eating behavior could benefit from emotion regulation skills training, including cognitive, behavioral, psychological, and interpersonal therapies used in other areas, and from pharmacological treatments, the researchers concluded.
The current study offers a unique and important perspective on the relationship between diet and cardiovascular disease, Dr. Gulati, director of preventive cardiology at the Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, told this news organization.
“Examining eating behavior and its relationship with cardiovascular effects in healthy individuals in this prospective way is quite interesting,” said Dr. Gulati, who was not involved in the study.
The researchers examined healthy people at baseline, inquired about their eating habits, and found that emotional eaters “have evidence of cardiovascular changes when compared with the other groups of eaters, after controlling for other risk factors that are associated with cardiovascular disease when following them for 13 years,” said Dr. Gulati, who was recently named Anita Dann Friedman Endowed Chair in Women’s Cardiovascular Medicine and Research at Cedars-Sinai. “This same finding wasn’t seen in adolescents, but this is probably because they are younger, and the effects aren’t seen. That is reassuring, because it means that the more we address eating behaviors, the more likely we are to reduce their effects to the heart,” she noted.
“This study is important because usually, as cardiologists or anyone in medicine, how we assess diet is by assessment of what food people eat; we don’t usually ask about what triggers them to eat,” Dr. Gulati said. “Eating behaviors based on their triggers ultimately affect food choice and food quantity, and help us understand weight changes during a lifetime,” she said.
“I think we don’t have the data to know that an eating behavior would be able to affect cardiac function,” said Dr. Gulati, “but I think we all might hypothesize that emotional eating may be associated with abnormal diastolic function simply through eating high-density food and weight gain.”
The current study did not show a relationship between eating behavior and metabolic syndrome, in contrast with prior studies, Dr. Gulati noted. However, “the authors report that the association between eating behaviors and diastolic dysfunction was mediated through the stress level,” Dr. Gulati said. “It is important to note that this European population was healthy at baseline, and also relatively healthy 13 years later, which makes these findings even more profound.”
Dr. Gulati said that she agrees with the study authors on the need to assess diet and eating behaviors when assessing cardiovascular risk in patient. “Diet assessment as part of prevention is central, but we should ask not only ‘what do you eat,’ but also ‘what makes you eat,’ ” she said.
More research is needed in other populations, Dr. Gulati added. The current study population was healthy at baseline and follow-up. Studies are needed in cohorts in the United States and in the developing world to see how the results might differ; as well as in rural America or in “food deserts” where food choices are limited.
Another research topic is the interplay between eating behaviors and social determinants of health, in terms of their effect on cardiovascular function, Dr. Gulati said, “and it will be valuable to follow this cohort further to see how these eating behaviors and these intermediate measures translate into cardiovascular outcomes.” Future studies should also examine whether the changes in cardiac function are reversible by interventions to modify eating behavior, particularly emotional eating, she said.
Supporters of the study included the Regional University Hospital Center of Nancy, the French Ministry of Solidarity and Health, and a public grant overseen by the French National Research Agency. The researchers had no financial conflicts to disclose.
Dr. Gulati, who serves on the editorial advisory board of MDedge Cardiology, had no financial conflicts to disclose.
Eating in response to stress – known as emotional eating – was significantly associated with several markers of long-term cardiovascular damage, based on data from 1,109 individuals.
“We know diet plays a huge role in cardiovascular disease, but we have focused a lot of work on what you eat, not on what makes you eat” – the current study did exactly that, Martha Gulati, MD, who wasn’t involved in the study, said in an interview.
“Emotional eaters consume food to satisfy their brains rather than their stomachs,” study investigator Nicolas Girerd, MD, of the National Institute of Health and Medical Research (INSERM) and a cardiologist at the University Hospital of Nancy (France), wrote in a press release accompanying the study.
Diet plays a role in the development of cardiovascular disease (CVD), but the impact of eating behavior on long-term cardiovascular health remains unclear, wrote Dr. Girerd and colleagues. Previous research has yielded three common psychological dimensions for eating behavior: emotional eating, restrained eating, and external eating.
Both emotional eating and restrained eating have been linked to cardiovascular disease risk, the researchers noted. “Because of previous findings, we hypothesized that [emotional and/or restrained dimensions of eating behavior] are positively associated with cardiovascular damages, as well as with CV risk factors, such as metabolic syndrome,” they wrote.
In a study published in the European Journal of Preventive Cardiology, the researchers reviewed data from 916 adults and 193 adolescents who were participants in the STANISLAS (Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux), a longitudinal familial cohort in France. Cardiovascular data were collected at four medical visits as part of a full clinical examination between 1993 and 2016, with one visit every 5-10 years. Roughly one-third (31.0%) of the adults were overweight, 7.9% were obese, and 2.7% were underweight. The median age of the adults at the second visit was 44.7 years; the median age of the adolescent group was 15.2 years.
The primary outcome of cardiovascular damage was measured at the fourth visit. Eating behavior was assessed during the second visit using the Dutch Eating Behaviour Questionnaire (DEBQ), and participants were identified as emotional eaters, restrained eaters, or external eaters.
Among the adults, emotional eating was associated with a 38% increased risk of diastolic dysfunction (odds ratio, 1.38; P = .02), over an average follow-up of 13 years, and this association was mediated by stress in 32% of cases. Emotional eating also was positively linked with a higher carotid-femoral pulse-wave velocity (cfPWV-beta), indicative of increased arterial stiffness. However, none of the three dimensions of eating behavior was associated with cardiovascular damage among the adolescents. In addition, none of the eating-behavior dimensions was tied to metabolic syndrome in the adult group (this association was not measured in the adolescents).
Energy intake had no apparent impact on any associations between eating behavior and CVD measures, Dr. Girerd said in the press release. “We might expect that emotional eaters would consume high-calorie foods, which would in turn lead to cardiovascular problems, but this was not the case. One explanation is that we measured average calorie intake and emotional eaters may binge when stressed and then eat less at other times,” and that the resulting “yo-yo” pattern might negatively affect the heart and blood vessels more than stable food intake, he said.
The study findings were limited by several factors, including the observational design that prevented conclusions of causality, the researchers noted. Other limitations included the use of a nonvalidated scale to measure stress, the lack of data on physical activity, and the use of a mainly healthy population in a limited geographic area, which may limit generalizability, they said.
More research is needed in other contexts and larger cohorts, but the results were strengthened by the large study population and the complete data on eating behaviors and detailed health information, they wrote. The results support previous studies and suggest that patients with emotional eating behavior could benefit from emotion regulation skills training, including cognitive, behavioral, psychological, and interpersonal therapies used in other areas, and from pharmacological treatments, the researchers concluded.
The current study offers a unique and important perspective on the relationship between diet and cardiovascular disease, Dr. Gulati, director of preventive cardiology at the Smidt Heart Institute at Cedars-Sinai Medical Center, Los Angeles, told this news organization.
“Examining eating behavior and its relationship with cardiovascular effects in healthy individuals in this prospective way is quite interesting,” said Dr. Gulati, who was not involved in the study.
The researchers examined healthy people at baseline, inquired about their eating habits, and found that emotional eaters “have evidence of cardiovascular changes when compared with the other groups of eaters, after controlling for other risk factors that are associated with cardiovascular disease when following them for 13 years,” said Dr. Gulati, who was recently named Anita Dann Friedman Endowed Chair in Women’s Cardiovascular Medicine and Research at Cedars-Sinai. “This same finding wasn’t seen in adolescents, but this is probably because they are younger, and the effects aren’t seen. That is reassuring, because it means that the more we address eating behaviors, the more likely we are to reduce their effects to the heart,” she noted.
“This study is important because usually, as cardiologists or anyone in medicine, how we assess diet is by assessment of what food people eat; we don’t usually ask about what triggers them to eat,” Dr. Gulati said. “Eating behaviors based on their triggers ultimately affect food choice and food quantity, and help us understand weight changes during a lifetime,” she said.
“I think we don’t have the data to know that an eating behavior would be able to affect cardiac function,” said Dr. Gulati, “but I think we all might hypothesize that emotional eating may be associated with abnormal diastolic function simply through eating high-density food and weight gain.”
The current study did not show a relationship between eating behavior and metabolic syndrome, in contrast with prior studies, Dr. Gulati noted. However, “the authors report that the association between eating behaviors and diastolic dysfunction was mediated through the stress level,” Dr. Gulati said. “It is important to note that this European population was healthy at baseline, and also relatively healthy 13 years later, which makes these findings even more profound.”
Dr. Gulati said that she agrees with the study authors on the need to assess diet and eating behaviors when assessing cardiovascular risk in patient. “Diet assessment as part of prevention is central, but we should ask not only ‘what do you eat,’ but also ‘what makes you eat,’ ” she said.
More research is needed in other populations, Dr. Gulati added. The current study population was healthy at baseline and follow-up. Studies are needed in cohorts in the United States and in the developing world to see how the results might differ; as well as in rural America or in “food deserts” where food choices are limited.
Another research topic is the interplay between eating behaviors and social determinants of health, in terms of their effect on cardiovascular function, Dr. Gulati said, “and it will be valuable to follow this cohort further to see how these eating behaviors and these intermediate measures translate into cardiovascular outcomes.” Future studies should also examine whether the changes in cardiac function are reversible by interventions to modify eating behavior, particularly emotional eating, she said.
Supporters of the study included the Regional University Hospital Center of Nancy, the French Ministry of Solidarity and Health, and a public grant overseen by the French National Research Agency. The researchers had no financial conflicts to disclose.
Dr. Gulati, who serves on the editorial advisory board of MDedge Cardiology, had no financial conflicts to disclose.
FROM THE EUROPEAN JOURNAL OF PREVENTIVE CARDIOLOGY
More support for MDMA-assisted psychotherapy for PTSD
The MAPP2 study is the second randomized, double-blind, placebo-controlled study to demonstrate the safety and efficacy of MDMA-assisted therapy for PTSD.
The investigators confirm results of the MAPP1 study, which were published in Nature Medicine. Patients who received MDMA-assisted psychotherapy in MAPP1 demonstrated greater improvement in PTSD symptoms, mood, and empathy, compared with participants who received psychotherapy with placebo.
The design of the MAPP2 study was similar to that of MAPP1, and its results were similar, the nonprofit Multidisciplinary Association for Psychedelic Studies (MAPS), which sponsored MAPP1 and MAPP2, said in a news release.
No specific results from MAPP2 were provided at this time. The full data from MAPP2 are expected to be published in a peer-reviewed journal later this year, and a new drug application to the U.S. Food and Drug Administration will follow.
The FDA granted breakthrough therapy designation to MDMA as an adjunct to psychotherapy for adults with PTSD in 2017.
MAPS was founded in 1986 to fund and facilitate research into the potential of psychedelic-assisted therapies; to educate the public about psychedelics for medical, social, and spiritual use; and to advocate for drug policy reform.
“When I first articulated a plan to legitimize a psychedelic-assisted therapy through FDA approval, many people said it was impossible,” Rick Doblin, PhD, founder and executive director of MAPS, said in the news release.
“Thirty-seven years later, we are on the precipice of bringing a novel therapy to the millions of Americans living with PTSD who haven’t found relief through current treatments,” said Dr. Doblin.
“The impossible became possible through the bravery of clinical trial participants, the compassion of mental health practitioners, and the generosity of thousands of donors. Today, we can imagine that MDMA-assisted therapy for PTSD may soon be available and accessible to all who could benefit,” Dr. Doblin added.
According to MAPS, phase 2 trials are being planned or conducted regarding the efficacy of MDMA-assisted therapies for substance use disorder and eating disorders, as well as couples therapy and group therapy among veterans.
Currently, no psychedelic-assisted therapy has been approved by the FDA or other regulatory authorities.
A version of this article first appeared on Medscape.com.
The MAPP2 study is the second randomized, double-blind, placebo-controlled study to demonstrate the safety and efficacy of MDMA-assisted therapy for PTSD.
The investigators confirm results of the MAPP1 study, which were published in Nature Medicine. Patients who received MDMA-assisted psychotherapy in MAPP1 demonstrated greater improvement in PTSD symptoms, mood, and empathy, compared with participants who received psychotherapy with placebo.
The design of the MAPP2 study was similar to that of MAPP1, and its results were similar, the nonprofit Multidisciplinary Association for Psychedelic Studies (MAPS), which sponsored MAPP1 and MAPP2, said in a news release.
No specific results from MAPP2 were provided at this time. The full data from MAPP2 are expected to be published in a peer-reviewed journal later this year, and a new drug application to the U.S. Food and Drug Administration will follow.
The FDA granted breakthrough therapy designation to MDMA as an adjunct to psychotherapy for adults with PTSD in 2017.
MAPS was founded in 1986 to fund and facilitate research into the potential of psychedelic-assisted therapies; to educate the public about psychedelics for medical, social, and spiritual use; and to advocate for drug policy reform.
“When I first articulated a plan to legitimize a psychedelic-assisted therapy through FDA approval, many people said it was impossible,” Rick Doblin, PhD, founder and executive director of MAPS, said in the news release.
“Thirty-seven years later, we are on the precipice of bringing a novel therapy to the millions of Americans living with PTSD who haven’t found relief through current treatments,” said Dr. Doblin.
“The impossible became possible through the bravery of clinical trial participants, the compassion of mental health practitioners, and the generosity of thousands of donors. Today, we can imagine that MDMA-assisted therapy for PTSD may soon be available and accessible to all who could benefit,” Dr. Doblin added.
According to MAPS, phase 2 trials are being planned or conducted regarding the efficacy of MDMA-assisted therapies for substance use disorder and eating disorders, as well as couples therapy and group therapy among veterans.
Currently, no psychedelic-assisted therapy has been approved by the FDA or other regulatory authorities.
A version of this article first appeared on Medscape.com.
The MAPP2 study is the second randomized, double-blind, placebo-controlled study to demonstrate the safety and efficacy of MDMA-assisted therapy for PTSD.
The investigators confirm results of the MAPP1 study, which were published in Nature Medicine. Patients who received MDMA-assisted psychotherapy in MAPP1 demonstrated greater improvement in PTSD symptoms, mood, and empathy, compared with participants who received psychotherapy with placebo.
The design of the MAPP2 study was similar to that of MAPP1, and its results were similar, the nonprofit Multidisciplinary Association for Psychedelic Studies (MAPS), which sponsored MAPP1 and MAPP2, said in a news release.
No specific results from MAPP2 were provided at this time. The full data from MAPP2 are expected to be published in a peer-reviewed journal later this year, and a new drug application to the U.S. Food and Drug Administration will follow.
The FDA granted breakthrough therapy designation to MDMA as an adjunct to psychotherapy for adults with PTSD in 2017.
MAPS was founded in 1986 to fund and facilitate research into the potential of psychedelic-assisted therapies; to educate the public about psychedelics for medical, social, and spiritual use; and to advocate for drug policy reform.
“When I first articulated a plan to legitimize a psychedelic-assisted therapy through FDA approval, many people said it was impossible,” Rick Doblin, PhD, founder and executive director of MAPS, said in the news release.
“Thirty-seven years later, we are on the precipice of bringing a novel therapy to the millions of Americans living with PTSD who haven’t found relief through current treatments,” said Dr. Doblin.
“The impossible became possible through the bravery of clinical trial participants, the compassion of mental health practitioners, and the generosity of thousands of donors. Today, we can imagine that MDMA-assisted therapy for PTSD may soon be available and accessible to all who could benefit,” Dr. Doblin added.
According to MAPS, phase 2 trials are being planned or conducted regarding the efficacy of MDMA-assisted therapies for substance use disorder and eating disorders, as well as couples therapy and group therapy among veterans.
Currently, no psychedelic-assisted therapy has been approved by the FDA or other regulatory authorities.
A version of this article first appeared on Medscape.com.
HRT may prevent Alzheimer’s in high-risk women
new research suggests.
Results from a cohort study of almost 1,200 women showed that use of HRT was associated with higher delayed memory scores and larger entorhinal and hippocampal brain volumes – areas that are affected early by Alzheimer’s disease (AD) pathology.
HRT was also found to be most effective, as seen by larger hippocampal volume, when introduced during early perimenopause.
“Clinicians are very much aware of the susceptibility of women to cognitive disturbances during menopause,” lead author Rasha Saleh, MD, senior research associate, University of East Anglia (England), said in an interview.
“Identifying the at-risk APOE4 women and early HRT introduction can be of benefit. Confirming our findings in a clinical trial would be the next step forward,” Dr. Saleh said.
The findings were published online in Alzheimer’s Research and Therapy.
Personalized approaches
Dr. Saleh noted that estrogen receptors are localized in various areas of the brain, including cognition-related areas. Estrogen regulates such things as neuroinflammatory status, glucose utilization, and lipid metabolism.
“The decline of estrogen during menopause can lead to disturbance in these functions, which can accelerate AD-related pathology,” she said.
HRT during the menopausal transition and afterward is “being considered as a strategy to mitigate cognitive decline,” the investigators wrote. Early observational studies have suggested that oral estrogen “may be protective against dementia,” but results of clinical trials have been inconsistent, and some have even shown “harmful effects.”
The current researchers were “interested in the personalized approaches in the prevention of AD,” Dr. Saleh said. Preclinical and pilot data from her group have shown that women with APOE4 have “better cognitive test scores with nutritional and hormonal interventions.”
This led Dr. Saleh to hypothesize that HRT would be of more cognitive benefit for those with versus without APOE4, particularly when introduced early during the menopausal transition.
To investigate this hypothesis, the researchers analyzed baseline data from participants in the European Prevention of Alzheimer’s Dementia (EPAD) cohort. This project was initiated in 2015 with the aim of developing longitudinal models over the entire course of AD prior to dementia clinical diagnosis.
Participants were recruited from 10 European countries. All were required to be at least 50 years old, to have not been diagnosed with dementia at baseline, and to have no medical or psychiatric illness that could potentially exclude them from further research.
The current study included 1,178 women (mean age, 65.1 years), who were divided by genotype into non-APOE4 and APOE4 groups. HRT treatment for current or previous users included estrogen alone or estrogen plus progestogens via oral or transdermal administration routes, and at different doses.
The four tests used to assess cognition were the Mini-Mental State Examination dot counting to evaluate verbal working memory, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score, the Four Mountain Test, and the supermarket trolley virtual reality test.
Brain MRI data were collected. The researchers focused on the medial temporal lobe as the “main brain region regulating cognition and memory processing.” This lobe includes the hippocampus, the parahippocampus, the entorhinal cortex, and the amygdala.
‘Critical window’
The researchers found a “trend” toward an APOE-HRT interaction (P-interaction = .097) for the total RBANS score. In particular, it was significant for the RBANS delayed memory index, where scores were consistently higher for women with APOE4 who had received HRT, compared with all other groups (P-interaction = .009).
Within-genotype group comparisons showed that HRT users had a higher RBANS total scale score and delayed memory index (P = .045 and P = .002, respectively), but only among APOE4 carriers. Effect size analyses showed a large effect of HRT use on the Four Mountain Test score and the supermarket trolley virtual reality test score (Cohen’s d = 0.988 and 1.2, respectively).
“This large effect was found only in APOE4 carriers,” the investigators noted.
Similarly, a moderate to large effect of HRT on the left entorhinal volume was observed in APOE4 carriers (Cohen’s d = 0.63).
In members of the APOE4 group who received HRT, the left entorhinal and left and right amygdala volumes were larger, compared with both no-APOE4 and non-HRT users (P-interaction = .002, .003, and .005, respectively). Similar trends were observed for the right entorhinal volume (P = .074).
In addition, among HRT users, the left entorhinal volume was larger (P = .03); the right and left anterior cingulate gyrus volumes were smaller (P = .003 and .062, respectively); and the left superior frontal gyrus volume was larger (P = .009) in comparison with women who did not receive HRT, independently of their APOE genotype.
Early use of HRT among APOE4 carriers was associated with larger right and left hippocampal volume (P = .035 and P = .028, respectively) – an association not found in non-APOE4 carriers. The association was also not significant when participants were not stratified by APOE genotype.
“The key important point here is the timing, or the ‘critical window,’ when HRT can be of most benefit,” Dr. Saleh said. “This is most beneficial when introduced early, before the neuropathology becomes irreversible.”
Study limitations include its cross-sectional design, which precludes the establishment of a causal relationship, and the fact that information regarding the type and dose of estrogen was not available for all participants.
HRT is not without risk, Dr. Saleh noted. She recommended that clinicians “carry out various screening tests to make sure that a woman is eligible for HRT and not at risk of hypercoagulability, for instance.”
Risk-benefit ratio
In a comment, Howard Fillit, MD, cofounder and chief science officer at the Alzheimer’s Drug Discovery Foundation, called the study “exactly the kind of work that needs to be done.”
Dr. Fillit, who was not involved with the current research, is a clinical professor of geriatric medicine, palliative care medicine, and neuroscience at Mount Sinai Hospital, New York.
He compared the process with that of osteoporosis. “We know that if women are treated [with HRT] at the time of the menopause, you can prevent the rapid bone loss that occurs with rapid estrogen loss. But if you wait 5, 10 years out, once the bone loss has occurred, the HRT doesn’t really have any impact on osteoporosis risk because the horse is already out of the barn,” he said.
Although HRT carries risks, “they can clearly be managed; and if it’s proven that estrogen or hormone replacement around the time of the menopause can be protective [against AD], the risk-benefit ratio of HRT could be in favor of treatment,” Dr. Fillit added.
The study was conducted as part of the Medical Research Council NuBrain Consortium. The investigators and Dr. Fillit reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
Results from a cohort study of almost 1,200 women showed that use of HRT was associated with higher delayed memory scores and larger entorhinal and hippocampal brain volumes – areas that are affected early by Alzheimer’s disease (AD) pathology.
HRT was also found to be most effective, as seen by larger hippocampal volume, when introduced during early perimenopause.
“Clinicians are very much aware of the susceptibility of women to cognitive disturbances during menopause,” lead author Rasha Saleh, MD, senior research associate, University of East Anglia (England), said in an interview.
“Identifying the at-risk APOE4 women and early HRT introduction can be of benefit. Confirming our findings in a clinical trial would be the next step forward,” Dr. Saleh said.
The findings were published online in Alzheimer’s Research and Therapy.
Personalized approaches
Dr. Saleh noted that estrogen receptors are localized in various areas of the brain, including cognition-related areas. Estrogen regulates such things as neuroinflammatory status, glucose utilization, and lipid metabolism.
“The decline of estrogen during menopause can lead to disturbance in these functions, which can accelerate AD-related pathology,” she said.
HRT during the menopausal transition and afterward is “being considered as a strategy to mitigate cognitive decline,” the investigators wrote. Early observational studies have suggested that oral estrogen “may be protective against dementia,” but results of clinical trials have been inconsistent, and some have even shown “harmful effects.”
The current researchers were “interested in the personalized approaches in the prevention of AD,” Dr. Saleh said. Preclinical and pilot data from her group have shown that women with APOE4 have “better cognitive test scores with nutritional and hormonal interventions.”
This led Dr. Saleh to hypothesize that HRT would be of more cognitive benefit for those with versus without APOE4, particularly when introduced early during the menopausal transition.
To investigate this hypothesis, the researchers analyzed baseline data from participants in the European Prevention of Alzheimer’s Dementia (EPAD) cohort. This project was initiated in 2015 with the aim of developing longitudinal models over the entire course of AD prior to dementia clinical diagnosis.
Participants were recruited from 10 European countries. All were required to be at least 50 years old, to have not been diagnosed with dementia at baseline, and to have no medical or psychiatric illness that could potentially exclude them from further research.
The current study included 1,178 women (mean age, 65.1 years), who were divided by genotype into non-APOE4 and APOE4 groups. HRT treatment for current or previous users included estrogen alone or estrogen plus progestogens via oral or transdermal administration routes, and at different doses.
The four tests used to assess cognition were the Mini-Mental State Examination dot counting to evaluate verbal working memory, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score, the Four Mountain Test, and the supermarket trolley virtual reality test.
Brain MRI data were collected. The researchers focused on the medial temporal lobe as the “main brain region regulating cognition and memory processing.” This lobe includes the hippocampus, the parahippocampus, the entorhinal cortex, and the amygdala.
‘Critical window’
The researchers found a “trend” toward an APOE-HRT interaction (P-interaction = .097) for the total RBANS score. In particular, it was significant for the RBANS delayed memory index, where scores were consistently higher for women with APOE4 who had received HRT, compared with all other groups (P-interaction = .009).
Within-genotype group comparisons showed that HRT users had a higher RBANS total scale score and delayed memory index (P = .045 and P = .002, respectively), but only among APOE4 carriers. Effect size analyses showed a large effect of HRT use on the Four Mountain Test score and the supermarket trolley virtual reality test score (Cohen’s d = 0.988 and 1.2, respectively).
“This large effect was found only in APOE4 carriers,” the investigators noted.
Similarly, a moderate to large effect of HRT on the left entorhinal volume was observed in APOE4 carriers (Cohen’s d = 0.63).
In members of the APOE4 group who received HRT, the left entorhinal and left and right amygdala volumes were larger, compared with both no-APOE4 and non-HRT users (P-interaction = .002, .003, and .005, respectively). Similar trends were observed for the right entorhinal volume (P = .074).
In addition, among HRT users, the left entorhinal volume was larger (P = .03); the right and left anterior cingulate gyrus volumes were smaller (P = .003 and .062, respectively); and the left superior frontal gyrus volume was larger (P = .009) in comparison with women who did not receive HRT, independently of their APOE genotype.
Early use of HRT among APOE4 carriers was associated with larger right and left hippocampal volume (P = .035 and P = .028, respectively) – an association not found in non-APOE4 carriers. The association was also not significant when participants were not stratified by APOE genotype.
“The key important point here is the timing, or the ‘critical window,’ when HRT can be of most benefit,” Dr. Saleh said. “This is most beneficial when introduced early, before the neuropathology becomes irreversible.”
Study limitations include its cross-sectional design, which precludes the establishment of a causal relationship, and the fact that information regarding the type and dose of estrogen was not available for all participants.
HRT is not without risk, Dr. Saleh noted. She recommended that clinicians “carry out various screening tests to make sure that a woman is eligible for HRT and not at risk of hypercoagulability, for instance.”
Risk-benefit ratio
In a comment, Howard Fillit, MD, cofounder and chief science officer at the Alzheimer’s Drug Discovery Foundation, called the study “exactly the kind of work that needs to be done.”
Dr. Fillit, who was not involved with the current research, is a clinical professor of geriatric medicine, palliative care medicine, and neuroscience at Mount Sinai Hospital, New York.
He compared the process with that of osteoporosis. “We know that if women are treated [with HRT] at the time of the menopause, you can prevent the rapid bone loss that occurs with rapid estrogen loss. But if you wait 5, 10 years out, once the bone loss has occurred, the HRT doesn’t really have any impact on osteoporosis risk because the horse is already out of the barn,” he said.
Although HRT carries risks, “they can clearly be managed; and if it’s proven that estrogen or hormone replacement around the time of the menopause can be protective [against AD], the risk-benefit ratio of HRT could be in favor of treatment,” Dr. Fillit added.
The study was conducted as part of the Medical Research Council NuBrain Consortium. The investigators and Dr. Fillit reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
Results from a cohort study of almost 1,200 women showed that use of HRT was associated with higher delayed memory scores and larger entorhinal and hippocampal brain volumes – areas that are affected early by Alzheimer’s disease (AD) pathology.
HRT was also found to be most effective, as seen by larger hippocampal volume, when introduced during early perimenopause.
“Clinicians are very much aware of the susceptibility of women to cognitive disturbances during menopause,” lead author Rasha Saleh, MD, senior research associate, University of East Anglia (England), said in an interview.
“Identifying the at-risk APOE4 women and early HRT introduction can be of benefit. Confirming our findings in a clinical trial would be the next step forward,” Dr. Saleh said.
The findings were published online in Alzheimer’s Research and Therapy.
Personalized approaches
Dr. Saleh noted that estrogen receptors are localized in various areas of the brain, including cognition-related areas. Estrogen regulates such things as neuroinflammatory status, glucose utilization, and lipid metabolism.
“The decline of estrogen during menopause can lead to disturbance in these functions, which can accelerate AD-related pathology,” she said.
HRT during the menopausal transition and afterward is “being considered as a strategy to mitigate cognitive decline,” the investigators wrote. Early observational studies have suggested that oral estrogen “may be protective against dementia,” but results of clinical trials have been inconsistent, and some have even shown “harmful effects.”
The current researchers were “interested in the personalized approaches in the prevention of AD,” Dr. Saleh said. Preclinical and pilot data from her group have shown that women with APOE4 have “better cognitive test scores with nutritional and hormonal interventions.”
This led Dr. Saleh to hypothesize that HRT would be of more cognitive benefit for those with versus without APOE4, particularly when introduced early during the menopausal transition.
To investigate this hypothesis, the researchers analyzed baseline data from participants in the European Prevention of Alzheimer’s Dementia (EPAD) cohort. This project was initiated in 2015 with the aim of developing longitudinal models over the entire course of AD prior to dementia clinical diagnosis.
Participants were recruited from 10 European countries. All were required to be at least 50 years old, to have not been diagnosed with dementia at baseline, and to have no medical or psychiatric illness that could potentially exclude them from further research.
The current study included 1,178 women (mean age, 65.1 years), who were divided by genotype into non-APOE4 and APOE4 groups. HRT treatment for current or previous users included estrogen alone or estrogen plus progestogens via oral or transdermal administration routes, and at different doses.
The four tests used to assess cognition were the Mini-Mental State Examination dot counting to evaluate verbal working memory, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score, the Four Mountain Test, and the supermarket trolley virtual reality test.
Brain MRI data were collected. The researchers focused on the medial temporal lobe as the “main brain region regulating cognition and memory processing.” This lobe includes the hippocampus, the parahippocampus, the entorhinal cortex, and the amygdala.
‘Critical window’
The researchers found a “trend” toward an APOE-HRT interaction (P-interaction = .097) for the total RBANS score. In particular, it was significant for the RBANS delayed memory index, where scores were consistently higher for women with APOE4 who had received HRT, compared with all other groups (P-interaction = .009).
Within-genotype group comparisons showed that HRT users had a higher RBANS total scale score and delayed memory index (P = .045 and P = .002, respectively), but only among APOE4 carriers. Effect size analyses showed a large effect of HRT use on the Four Mountain Test score and the supermarket trolley virtual reality test score (Cohen’s d = 0.988 and 1.2, respectively).
“This large effect was found only in APOE4 carriers,” the investigators noted.
Similarly, a moderate to large effect of HRT on the left entorhinal volume was observed in APOE4 carriers (Cohen’s d = 0.63).
In members of the APOE4 group who received HRT, the left entorhinal and left and right amygdala volumes were larger, compared with both no-APOE4 and non-HRT users (P-interaction = .002, .003, and .005, respectively). Similar trends were observed for the right entorhinal volume (P = .074).
In addition, among HRT users, the left entorhinal volume was larger (P = .03); the right and left anterior cingulate gyrus volumes were smaller (P = .003 and .062, respectively); and the left superior frontal gyrus volume was larger (P = .009) in comparison with women who did not receive HRT, independently of their APOE genotype.
Early use of HRT among APOE4 carriers was associated with larger right and left hippocampal volume (P = .035 and P = .028, respectively) – an association not found in non-APOE4 carriers. The association was also not significant when participants were not stratified by APOE genotype.
“The key important point here is the timing, or the ‘critical window,’ when HRT can be of most benefit,” Dr. Saleh said. “This is most beneficial when introduced early, before the neuropathology becomes irreversible.”
Study limitations include its cross-sectional design, which precludes the establishment of a causal relationship, and the fact that information regarding the type and dose of estrogen was not available for all participants.
HRT is not without risk, Dr. Saleh noted. She recommended that clinicians “carry out various screening tests to make sure that a woman is eligible for HRT and not at risk of hypercoagulability, for instance.”
Risk-benefit ratio
In a comment, Howard Fillit, MD, cofounder and chief science officer at the Alzheimer’s Drug Discovery Foundation, called the study “exactly the kind of work that needs to be done.”
Dr. Fillit, who was not involved with the current research, is a clinical professor of geriatric medicine, palliative care medicine, and neuroscience at Mount Sinai Hospital, New York.
He compared the process with that of osteoporosis. “We know that if women are treated [with HRT] at the time of the menopause, you can prevent the rapid bone loss that occurs with rapid estrogen loss. But if you wait 5, 10 years out, once the bone loss has occurred, the HRT doesn’t really have any impact on osteoporosis risk because the horse is already out of the barn,” he said.
Although HRT carries risks, “they can clearly be managed; and if it’s proven that estrogen or hormone replacement around the time of the menopause can be protective [against AD], the risk-benefit ratio of HRT could be in favor of treatment,” Dr. Fillit added.
The study was conducted as part of the Medical Research Council NuBrain Consortium. The investigators and Dr. Fillit reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM ALZHEIMER’S RESEARCH AND THERAPY
The Respect for Marriage Act: How this law supports the health and well-being of LGBTQ+ youth
Childhood and adolescence are periods of life with rapid growth and development in which the psychosocial factors of one’s environment can have a profound effect on health. There is increasing evidence that adverse childhood experiences (ACEs) can have significant negative effects on long-term health with effects persisting into subsequent generations.1 Youth themselves, however, often do not have the voice, ability, or political power to advocate for safe and more supportive environments that are essential to their well-being. Thus, advocacy has been central to the profession of pediatrics since its inception, where providers can partner with their patients, families, and communities to push for changes in the environments in which youth live and grow.2
LGBTQ+ youth are known to be at increased risk for ACEs because of the stress that comes from being part of a minority group and the discrimination they experience by their families, communities, and society at large. These factors within their environments have been shown to be associated with increased rates of anxiety, depression, substance use, sexually transmitted infections, and homelessness.3 As with other health outcomes that have been linked to the social determinants of health, these disparities are not inevitable and could be greatly improved upon through advocacy and changes in the environments of LGBTQ+ youth.
Marriage equality (the recognition that same-sex couples have the same legal right to marry as opposite-sex couples) has been shown to be not only a political issue, but one that affects health. The debates surrounding marriage equality have contributed to minority stress by questioning the validity of same-sex relationships and assigning them less value relative to opposite-sex relationships.4 In 1996, the U.S. Congress passed the Defense of Marriage Act (DOMA), which federally defined marriage as being legally recognized only between opposite-sex couples.
Individual states then continued the marriage equality debate by passing individual state laws either allowing or prohibiting same-sex marriage. During this time, it was shown that, in states where same-sex marriage was legally prohibited, LGBTQ+ adults reported significantly higher rates of generalized anxiety disorder, alcohol use disorder, any mood disorder, and psychiatric comorbidity when compared with states without a legal ban on same-sex marriage.5
Using data from the Youth Risk Behavior Surveillance System, it was shown that state policies recognizing same-sex marriage were associated with a 7% relative reduction in suicide attempts reported by adolescent sexual minority students compared with before these policies.6 It was also shown that children with same-sex parents were overall less likely to have private health insurance, but this disparity was improved in states that legally recognized same-sex marriage and allowed second-parent adoptions.7
In 2013, the U.S. Supreme Court ruled that DOMA was unconstitutional, requiring the federal government to legally recognize same-sex marriages for the purposes of federal benefits. In 2015, the U.S. Supreme Court further ruled that same-sex couples are guaranteed the fundamental right to marry, requiring that all states issue marriage licenses to same-sex couples. These rulings were associated with a decrease in reported levels of stigma over time and increased reported levels of family support, particularly for those in same-sex relationships.8
The Respect for Marriage Act (RFMA) was passed by the U.S. Congress and signed into law by President Biden on Dec. 13, 2022. This law officially repeals DOMA and requires all states and the federal government to recognize same-sex marriages performed in any U.S. state or territory.9
If the U.S. Supreme Court were to overturn the 2015 marriage equality decision, individual state laws ensuring or banning same-sex marriage would again be in effect. However, the RFMA ensures that all states continue to recognize same-sex marriages performed in any U.S. state or territory (even if that state itself bans same-sex marriage). While we do not yet have any studies or data regarding the effect of the RFMA on public health, we can expect positive effects by drawing on the previous evidence on the effect of marriage equality and its effect on the health and well-being of LGBTQ+ individuals. By establishing marriage equality in the United States, our government institutions are affirming the relationships and identities of those in same-sex relationships, with the potential effect of helping to destigmatize the LGBTQ+ community.
Since 2002, the American Academy of Pediatrics has recommended that pediatricians “support the right of every child and family to the financial, psychological, and legal security that results from having legally recognized parents who are committed to each other and to the welfare of their children,” acknowledging that “legislative initiatives assuring legal status equivalent to marriage for gay and lesbian partners … can also attend to providing security and permanence for the children of those partnerships.”10 While changes in legal marriage equality are likely to have a positive effect on those within the LGBTQ+ community, it should also be understood that this will not solve all of the psychosocial effects and resultant health disparities that these children face.
A recent scoping review highlights that, as the result of marriage equality progress, sexual minority adults have reported increased social acceptance and reduced stigma across individual, community, and societal levels, but that sexual minority stigma continues to persist across all levels.11
As pediatricians, we can continue to support LGBTQ+ patients and parents by providing care in a safe and affirming environment in which families understand and embrace the healthy development of gender identity and sexuality in an open and destigmatized manner. Delivering care using this approach in and of itself can be seen as advocacy to promote health and well-being within minoritized populations. Pediatricians are also encouraged to become engaged in local and national advocacy initiatives to have a broader effect in the fight for health equity in minority populations, including LGBTQ+ families and youth.
Pediatricians should work with their patients, families, and communities to advocate for structural change needed to address the social determinants of health for optimal growth and development.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of pediatrics at University of Southern California, Los Angeles.
Resources
Bright Futures – Promoting Healthy Development of Sexuality and Gender Identity (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/BF_HealthySexualityGenderIdentity_Tipsheet.pdf
Bright Futures – Implementing Social Determinants of Health Into Health Supervision Visits (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/Bright%20Futures/BF_IntegrateSDoH_Tipsheet.pdf?_ga=2.214227031.1330574154.1673910248-58875083.1673910248
American Academy of Pediatrics – Advocacy Website: https://www.aap.org/en/advocacy/
References
1. Hughes K et al. Lancet Public Health. 2017;2(8):e356-66.
2. Camero K and Javier JR. Pediatr Clin N Am. 2023;70:43-51.
3. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021;48:179-89.
4. Buffie WC. Am J Public Health. 2011;101(6):986-90.
5. Hatzenbuehler ML et al. Am J Public Health. 2010;100:452-9.
6. Raifman J et al. JAMA Pediatr. 2017;171(4):350-6.
7. Gonzales G and Blewett LA. Pediatrics. 2013;132(4):703-11.
8. Ogolsky BG et al. J Fam Psychol. 2019;33(4):422-32.
9. Library of Congress. H.R.8404 – 117th Congress (2021-2022): Respect for Marriage Act. 2022 Dec 13. www.congress.gov/bill/117th-congress/house-bill/8404/text.
10. Perrin EC and Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2002;109(2):341-4.
11. Drabble LA et al. PLoS ONE. 2021;16(5):e0249125.
Childhood and adolescence are periods of life with rapid growth and development in which the psychosocial factors of one’s environment can have a profound effect on health. There is increasing evidence that adverse childhood experiences (ACEs) can have significant negative effects on long-term health with effects persisting into subsequent generations.1 Youth themselves, however, often do not have the voice, ability, or political power to advocate for safe and more supportive environments that are essential to their well-being. Thus, advocacy has been central to the profession of pediatrics since its inception, where providers can partner with their patients, families, and communities to push for changes in the environments in which youth live and grow.2
LGBTQ+ youth are known to be at increased risk for ACEs because of the stress that comes from being part of a minority group and the discrimination they experience by their families, communities, and society at large. These factors within their environments have been shown to be associated with increased rates of anxiety, depression, substance use, sexually transmitted infections, and homelessness.3 As with other health outcomes that have been linked to the social determinants of health, these disparities are not inevitable and could be greatly improved upon through advocacy and changes in the environments of LGBTQ+ youth.
Marriage equality (the recognition that same-sex couples have the same legal right to marry as opposite-sex couples) has been shown to be not only a political issue, but one that affects health. The debates surrounding marriage equality have contributed to minority stress by questioning the validity of same-sex relationships and assigning them less value relative to opposite-sex relationships.4 In 1996, the U.S. Congress passed the Defense of Marriage Act (DOMA), which federally defined marriage as being legally recognized only between opposite-sex couples.
Individual states then continued the marriage equality debate by passing individual state laws either allowing or prohibiting same-sex marriage. During this time, it was shown that, in states where same-sex marriage was legally prohibited, LGBTQ+ adults reported significantly higher rates of generalized anxiety disorder, alcohol use disorder, any mood disorder, and psychiatric comorbidity when compared with states without a legal ban on same-sex marriage.5
Using data from the Youth Risk Behavior Surveillance System, it was shown that state policies recognizing same-sex marriage were associated with a 7% relative reduction in suicide attempts reported by adolescent sexual minority students compared with before these policies.6 It was also shown that children with same-sex parents were overall less likely to have private health insurance, but this disparity was improved in states that legally recognized same-sex marriage and allowed second-parent adoptions.7
In 2013, the U.S. Supreme Court ruled that DOMA was unconstitutional, requiring the federal government to legally recognize same-sex marriages for the purposes of federal benefits. In 2015, the U.S. Supreme Court further ruled that same-sex couples are guaranteed the fundamental right to marry, requiring that all states issue marriage licenses to same-sex couples. These rulings were associated with a decrease in reported levels of stigma over time and increased reported levels of family support, particularly for those in same-sex relationships.8
The Respect for Marriage Act (RFMA) was passed by the U.S. Congress and signed into law by President Biden on Dec. 13, 2022. This law officially repeals DOMA and requires all states and the federal government to recognize same-sex marriages performed in any U.S. state or territory.9
If the U.S. Supreme Court were to overturn the 2015 marriage equality decision, individual state laws ensuring or banning same-sex marriage would again be in effect. However, the RFMA ensures that all states continue to recognize same-sex marriages performed in any U.S. state or territory (even if that state itself bans same-sex marriage). While we do not yet have any studies or data regarding the effect of the RFMA on public health, we can expect positive effects by drawing on the previous evidence on the effect of marriage equality and its effect on the health and well-being of LGBTQ+ individuals. By establishing marriage equality in the United States, our government institutions are affirming the relationships and identities of those in same-sex relationships, with the potential effect of helping to destigmatize the LGBTQ+ community.
Since 2002, the American Academy of Pediatrics has recommended that pediatricians “support the right of every child and family to the financial, psychological, and legal security that results from having legally recognized parents who are committed to each other and to the welfare of their children,” acknowledging that “legislative initiatives assuring legal status equivalent to marriage for gay and lesbian partners … can also attend to providing security and permanence for the children of those partnerships.”10 While changes in legal marriage equality are likely to have a positive effect on those within the LGBTQ+ community, it should also be understood that this will not solve all of the psychosocial effects and resultant health disparities that these children face.
A recent scoping review highlights that, as the result of marriage equality progress, sexual minority adults have reported increased social acceptance and reduced stigma across individual, community, and societal levels, but that sexual minority stigma continues to persist across all levels.11
As pediatricians, we can continue to support LGBTQ+ patients and parents by providing care in a safe and affirming environment in which families understand and embrace the healthy development of gender identity and sexuality in an open and destigmatized manner. Delivering care using this approach in and of itself can be seen as advocacy to promote health and well-being within minoritized populations. Pediatricians are also encouraged to become engaged in local and national advocacy initiatives to have a broader effect in the fight for health equity in minority populations, including LGBTQ+ families and youth.
Pediatricians should work with their patients, families, and communities to advocate for structural change needed to address the social determinants of health for optimal growth and development.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of pediatrics at University of Southern California, Los Angeles.
Resources
Bright Futures – Promoting Healthy Development of Sexuality and Gender Identity (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/BF_HealthySexualityGenderIdentity_Tipsheet.pdf
Bright Futures – Implementing Social Determinants of Health Into Health Supervision Visits (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/Bright%20Futures/BF_IntegrateSDoH_Tipsheet.pdf?_ga=2.214227031.1330574154.1673910248-58875083.1673910248
American Academy of Pediatrics – Advocacy Website: https://www.aap.org/en/advocacy/
References
1. Hughes K et al. Lancet Public Health. 2017;2(8):e356-66.
2. Camero K and Javier JR. Pediatr Clin N Am. 2023;70:43-51.
3. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021;48:179-89.
4. Buffie WC. Am J Public Health. 2011;101(6):986-90.
5. Hatzenbuehler ML et al. Am J Public Health. 2010;100:452-9.
6. Raifman J et al. JAMA Pediatr. 2017;171(4):350-6.
7. Gonzales G and Blewett LA. Pediatrics. 2013;132(4):703-11.
8. Ogolsky BG et al. J Fam Psychol. 2019;33(4):422-32.
9. Library of Congress. H.R.8404 – 117th Congress (2021-2022): Respect for Marriage Act. 2022 Dec 13. www.congress.gov/bill/117th-congress/house-bill/8404/text.
10. Perrin EC and Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2002;109(2):341-4.
11. Drabble LA et al. PLoS ONE. 2021;16(5):e0249125.
Childhood and adolescence are periods of life with rapid growth and development in which the psychosocial factors of one’s environment can have a profound effect on health. There is increasing evidence that adverse childhood experiences (ACEs) can have significant negative effects on long-term health with effects persisting into subsequent generations.1 Youth themselves, however, often do not have the voice, ability, or political power to advocate for safe and more supportive environments that are essential to their well-being. Thus, advocacy has been central to the profession of pediatrics since its inception, where providers can partner with their patients, families, and communities to push for changes in the environments in which youth live and grow.2
LGBTQ+ youth are known to be at increased risk for ACEs because of the stress that comes from being part of a minority group and the discrimination they experience by their families, communities, and society at large. These factors within their environments have been shown to be associated with increased rates of anxiety, depression, substance use, sexually transmitted infections, and homelessness.3 As with other health outcomes that have been linked to the social determinants of health, these disparities are not inevitable and could be greatly improved upon through advocacy and changes in the environments of LGBTQ+ youth.
Marriage equality (the recognition that same-sex couples have the same legal right to marry as opposite-sex couples) has been shown to be not only a political issue, but one that affects health. The debates surrounding marriage equality have contributed to minority stress by questioning the validity of same-sex relationships and assigning them less value relative to opposite-sex relationships.4 In 1996, the U.S. Congress passed the Defense of Marriage Act (DOMA), which federally defined marriage as being legally recognized only between opposite-sex couples.
Individual states then continued the marriage equality debate by passing individual state laws either allowing or prohibiting same-sex marriage. During this time, it was shown that, in states where same-sex marriage was legally prohibited, LGBTQ+ adults reported significantly higher rates of generalized anxiety disorder, alcohol use disorder, any mood disorder, and psychiatric comorbidity when compared with states without a legal ban on same-sex marriage.5
Using data from the Youth Risk Behavior Surveillance System, it was shown that state policies recognizing same-sex marriage were associated with a 7% relative reduction in suicide attempts reported by adolescent sexual minority students compared with before these policies.6 It was also shown that children with same-sex parents were overall less likely to have private health insurance, but this disparity was improved in states that legally recognized same-sex marriage and allowed second-parent adoptions.7
In 2013, the U.S. Supreme Court ruled that DOMA was unconstitutional, requiring the federal government to legally recognize same-sex marriages for the purposes of federal benefits. In 2015, the U.S. Supreme Court further ruled that same-sex couples are guaranteed the fundamental right to marry, requiring that all states issue marriage licenses to same-sex couples. These rulings were associated with a decrease in reported levels of stigma over time and increased reported levels of family support, particularly for those in same-sex relationships.8
The Respect for Marriage Act (RFMA) was passed by the U.S. Congress and signed into law by President Biden on Dec. 13, 2022. This law officially repeals DOMA and requires all states and the federal government to recognize same-sex marriages performed in any U.S. state or territory.9
If the U.S. Supreme Court were to overturn the 2015 marriage equality decision, individual state laws ensuring or banning same-sex marriage would again be in effect. However, the RFMA ensures that all states continue to recognize same-sex marriages performed in any U.S. state or territory (even if that state itself bans same-sex marriage). While we do not yet have any studies or data regarding the effect of the RFMA on public health, we can expect positive effects by drawing on the previous evidence on the effect of marriage equality and its effect on the health and well-being of LGBTQ+ individuals. By establishing marriage equality in the United States, our government institutions are affirming the relationships and identities of those in same-sex relationships, with the potential effect of helping to destigmatize the LGBTQ+ community.
Since 2002, the American Academy of Pediatrics has recommended that pediatricians “support the right of every child and family to the financial, psychological, and legal security that results from having legally recognized parents who are committed to each other and to the welfare of their children,” acknowledging that “legislative initiatives assuring legal status equivalent to marriage for gay and lesbian partners … can also attend to providing security and permanence for the children of those partnerships.”10 While changes in legal marriage equality are likely to have a positive effect on those within the LGBTQ+ community, it should also be understood that this will not solve all of the psychosocial effects and resultant health disparities that these children face.
A recent scoping review highlights that, as the result of marriage equality progress, sexual minority adults have reported increased social acceptance and reduced stigma across individual, community, and societal levels, but that sexual minority stigma continues to persist across all levels.11
As pediatricians, we can continue to support LGBTQ+ patients and parents by providing care in a safe and affirming environment in which families understand and embrace the healthy development of gender identity and sexuality in an open and destigmatized manner. Delivering care using this approach in and of itself can be seen as advocacy to promote health and well-being within minoritized populations. Pediatricians are also encouraged to become engaged in local and national advocacy initiatives to have a broader effect in the fight for health equity in minority populations, including LGBTQ+ families and youth.
Pediatricians should work with their patients, families, and communities to advocate for structural change needed to address the social determinants of health for optimal growth and development.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of pediatrics at University of Southern California, Los Angeles.
Resources
Bright Futures – Promoting Healthy Development of Sexuality and Gender Identity (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/BF_HealthySexualityGenderIdentity_Tipsheet.pdf
Bright Futures – Implementing Social Determinants of Health Into Health Supervision Visits (Implementation Tip Sheet): https://downloads.aap.org/AAP/PDF/Bright%20Futures/BF_IntegrateSDoH_Tipsheet.pdf?_ga=2.214227031.1330574154.1673910248-58875083.1673910248
American Academy of Pediatrics – Advocacy Website: https://www.aap.org/en/advocacy/
References
1. Hughes K et al. Lancet Public Health. 2017;2(8):e356-66.
2. Camero K and Javier JR. Pediatr Clin N Am. 2023;70:43-51.
3. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021;48:179-89.
4. Buffie WC. Am J Public Health. 2011;101(6):986-90.
5. Hatzenbuehler ML et al. Am J Public Health. 2010;100:452-9.
6. Raifman J et al. JAMA Pediatr. 2017;171(4):350-6.
7. Gonzales G and Blewett LA. Pediatrics. 2013;132(4):703-11.
8. Ogolsky BG et al. J Fam Psychol. 2019;33(4):422-32.
9. Library of Congress. H.R.8404 – 117th Congress (2021-2022): Respect for Marriage Act. 2022 Dec 13. www.congress.gov/bill/117th-congress/house-bill/8404/text.
10. Perrin EC and Committee on Psychosocial Aspects of Child and Family Health. Pediatrics. 2002;109(2):341-4.
11. Drabble LA et al. PLoS ONE. 2021;16(5):e0249125.
Can 6 minutes of intense cycling put the brakes on Alzheimer’s?
new research suggests.
In a small study of healthy adults, 6 minutes of high-intensity cycling increased circulating levels of brain-derived neurotrophic factor (BDNF) to a significantly greater extent than prolonged light cycling or fasting.
However, the data do not suggest that 6 minutes of high-intensity exercise “wards off dementia,” cautioned lead investigator Travis Gibbons, MSc, PhD candidate in environmental physiology at the University of Otago (New Zealand), Dunedin, and now postdoctoral fellow at the University of British Columbia – Okanagan, Kelowna.
“Like all science, this is just a small piece that supports a potential mechanistic role for how exercise might improve brain health,” Dr. Gibbons told this news organization.
The findings were published online in the Journal of Physiology.
Targeting BDNF
Both intermittent fasting and exercise have previously been shown to have potent neuroprotective effects; and an acute upregulation of BDNF appears to be a common mechanistic link.
To tease apart the influence of fasting and exercise on BDNF production, Dr. Gibbons and colleagues studied 12 aerobically fit, healthy men (n = 6) and women (n = 6) aged 20-40 years.
In a study that employed a repeated-measures crossover design, they assessed circulating BDNF levels after a 20-hour fast, prolonged (90-min) light cycling, short (6-min) high-intensity cycling, and combined fasting and exercise.
Six minutes of high-intensity exercise appeared to be the most efficient way to increase BDNF.
Fasting for 20 hours led to a ninefold increase in ketone body delivery to the brain but had no effect on any metric of BDNF in peripheral circulation at rest or during exercise.
Six minutes of high-intensity exercise increased every metric of circulating BDNF four to five times more than prolonged low-intensity exercise.
In addition, the increase in plasma-derived BDNF correlated with a sixfold increase in circulating lactate irrespective of feeding or fasting state.
Lactate delivery?
“My leading theory is that, during and following intense exercise, lactate produced by muscles is delivered and consumed by the brain,” Dr. Gibbons noted.
“It takes high-intensity exercise to provoke this ‘cerebral substrate switch’ from glucose to lactate. Critically, this cerebral substrate switch has been shown to contribute to the early processes that upregulate BDNF production in the brain,” he said.
However, “Whether this translates to ‘warding off dementia’ is not clear,” Dr. Gibbons added.
The study also suggests that increases in plasma volume and platelet concentration appear to play a role in concentrating BDNF in the circulation during exercise.
The investigators note that BDNF and other neurotrophic-based pharmaceutical therapies have shown “great promise” in slowing and even arresting neurodegenerative processes in animals, but attempts to harness the protective power of BDNF in human neurodegeneration have thus far failed.
“Whether episodically upregulating BDNF production with intense exercise is an effective strategy to curb age-related cognitive decline in humans is unknown, but animal models indicate that it is and that BDNF plays a primary role,” the researchers write.
Funding for the study was provided by the Healthcare Otago Charitable Trust. The investigators have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
In a small study of healthy adults, 6 minutes of high-intensity cycling increased circulating levels of brain-derived neurotrophic factor (BDNF) to a significantly greater extent than prolonged light cycling or fasting.
However, the data do not suggest that 6 minutes of high-intensity exercise “wards off dementia,” cautioned lead investigator Travis Gibbons, MSc, PhD candidate in environmental physiology at the University of Otago (New Zealand), Dunedin, and now postdoctoral fellow at the University of British Columbia – Okanagan, Kelowna.
“Like all science, this is just a small piece that supports a potential mechanistic role for how exercise might improve brain health,” Dr. Gibbons told this news organization.
The findings were published online in the Journal of Physiology.
Targeting BDNF
Both intermittent fasting and exercise have previously been shown to have potent neuroprotective effects; and an acute upregulation of BDNF appears to be a common mechanistic link.
To tease apart the influence of fasting and exercise on BDNF production, Dr. Gibbons and colleagues studied 12 aerobically fit, healthy men (n = 6) and women (n = 6) aged 20-40 years.
In a study that employed a repeated-measures crossover design, they assessed circulating BDNF levels after a 20-hour fast, prolonged (90-min) light cycling, short (6-min) high-intensity cycling, and combined fasting and exercise.
Six minutes of high-intensity exercise appeared to be the most efficient way to increase BDNF.
Fasting for 20 hours led to a ninefold increase in ketone body delivery to the brain but had no effect on any metric of BDNF in peripheral circulation at rest or during exercise.
Six minutes of high-intensity exercise increased every metric of circulating BDNF four to five times more than prolonged low-intensity exercise.
In addition, the increase in plasma-derived BDNF correlated with a sixfold increase in circulating lactate irrespective of feeding or fasting state.
Lactate delivery?
“My leading theory is that, during and following intense exercise, lactate produced by muscles is delivered and consumed by the brain,” Dr. Gibbons noted.
“It takes high-intensity exercise to provoke this ‘cerebral substrate switch’ from glucose to lactate. Critically, this cerebral substrate switch has been shown to contribute to the early processes that upregulate BDNF production in the brain,” he said.
However, “Whether this translates to ‘warding off dementia’ is not clear,” Dr. Gibbons added.
The study also suggests that increases in plasma volume and platelet concentration appear to play a role in concentrating BDNF in the circulation during exercise.
The investigators note that BDNF and other neurotrophic-based pharmaceutical therapies have shown “great promise” in slowing and even arresting neurodegenerative processes in animals, but attempts to harness the protective power of BDNF in human neurodegeneration have thus far failed.
“Whether episodically upregulating BDNF production with intense exercise is an effective strategy to curb age-related cognitive decline in humans is unknown, but animal models indicate that it is and that BDNF plays a primary role,” the researchers write.
Funding for the study was provided by the Healthcare Otago Charitable Trust. The investigators have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new research suggests.
In a small study of healthy adults, 6 minutes of high-intensity cycling increased circulating levels of brain-derived neurotrophic factor (BDNF) to a significantly greater extent than prolonged light cycling or fasting.
However, the data do not suggest that 6 minutes of high-intensity exercise “wards off dementia,” cautioned lead investigator Travis Gibbons, MSc, PhD candidate in environmental physiology at the University of Otago (New Zealand), Dunedin, and now postdoctoral fellow at the University of British Columbia – Okanagan, Kelowna.
“Like all science, this is just a small piece that supports a potential mechanistic role for how exercise might improve brain health,” Dr. Gibbons told this news organization.
The findings were published online in the Journal of Physiology.
Targeting BDNF
Both intermittent fasting and exercise have previously been shown to have potent neuroprotective effects; and an acute upregulation of BDNF appears to be a common mechanistic link.
To tease apart the influence of fasting and exercise on BDNF production, Dr. Gibbons and colleagues studied 12 aerobically fit, healthy men (n = 6) and women (n = 6) aged 20-40 years.
In a study that employed a repeated-measures crossover design, they assessed circulating BDNF levels after a 20-hour fast, prolonged (90-min) light cycling, short (6-min) high-intensity cycling, and combined fasting and exercise.
Six minutes of high-intensity exercise appeared to be the most efficient way to increase BDNF.
Fasting for 20 hours led to a ninefold increase in ketone body delivery to the brain but had no effect on any metric of BDNF in peripheral circulation at rest or during exercise.
Six minutes of high-intensity exercise increased every metric of circulating BDNF four to five times more than prolonged low-intensity exercise.
In addition, the increase in plasma-derived BDNF correlated with a sixfold increase in circulating lactate irrespective of feeding or fasting state.
Lactate delivery?
“My leading theory is that, during and following intense exercise, lactate produced by muscles is delivered and consumed by the brain,” Dr. Gibbons noted.
“It takes high-intensity exercise to provoke this ‘cerebral substrate switch’ from glucose to lactate. Critically, this cerebral substrate switch has been shown to contribute to the early processes that upregulate BDNF production in the brain,” he said.
However, “Whether this translates to ‘warding off dementia’ is not clear,” Dr. Gibbons added.
The study also suggests that increases in plasma volume and platelet concentration appear to play a role in concentrating BDNF in the circulation during exercise.
The investigators note that BDNF and other neurotrophic-based pharmaceutical therapies have shown “great promise” in slowing and even arresting neurodegenerative processes in animals, but attempts to harness the protective power of BDNF in human neurodegeneration have thus far failed.
“Whether episodically upregulating BDNF production with intense exercise is an effective strategy to curb age-related cognitive decline in humans is unknown, but animal models indicate that it is and that BDNF plays a primary role,” the researchers write.
Funding for the study was provided by the Healthcare Otago Charitable Trust. The investigators have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF PHYSIOLOGY