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Headache Strongly Linked to Attempted, Completed Suicide
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.
The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.
Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.
First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.
The findings were published online on February 3 in JAMA Neurology.
Common, Disabling
With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.
First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.
Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.
“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.
Not ‘Just Headaches’
In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.
“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.
At least one of his patients per week screens positive for depression, he noted.
“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”
Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”
The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.
There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.
How Long Does It Take to See a Neurologist?
a cross-sectional analysis of Medicare data showed.
Wait times were not affected by the number of available neurologists. However, those with multiple sclerosis (MS), epilepsy, Parkinson’s disease, dementia, and sleep disorders had the longest wait times.
“In general, early referral to specialists has been shown to improve outcomes and increase patient satisfaction,” study author Chun Chieh Lin, PhD, MBA, of Ohio State University, Columbus, said in a press release. “Our findings underscore the need to develop new strategies to help people with neurological conditions see neurologists faster.”
The findings were published online in Neurology.
No National Benchmark for Wait Times
For this study, researchers analyzed a large sample of fee-for-service Medicare data from 2018 to 2019. Researchers identified patients with a year or less between their last referring physician visit and a new neurologist visit.
Exclusion criteria included enrollment in health maintenance organization plans without continuous enrollment in Medicare Part A and Part B for 2 years before the index neurologist visit, missing patient data, no physician referral at all, or referral by a different neurologist.
In addition to assessing wait times, investigators examined the availability of neurologists who provided medical services to Medicare beneficiaries in the 2018 dataset across 306 hospital referral regions in the United States, based on zip codes.
Results showed that 163,313 patients (average age, 74 years; 58% women; 85% White) were referred by 84,975 physicians to 10,250 neurologists across the United States.
Overall, the average wait time from physician referral to index neurologist visit was 34 days (range, 1-365 days), with longer wait times for White patients, women, and those aged 65-69 years. Overall, 18% waited longer than 90 days for an appointment.
The most common conditions diagnosed at the index neurologist visit were chronic pain/abnormality of gait (13%), sleep disorders (11%), and peripheral neuropathy (10%).
Using a linear mixed-effects statistical model, investigators found that patients with back pain waited an average of 30 days to see a neurologist, with longer waits for other conditions. Those with MS had an average wait that was 29 days longer, patients with epilepsy waited an average of 10 days longer, and those with Parkinson’s disease waited 9 days longer (P < .0001).
The number of available neurologists (range, 10-50 neurologists per 100,000 Medicare patients) did not affect wait times. However, there were differences in wait times across states because of different policies or regulations regarding healthcare access, with wait times ranging from a median high of 49 days in Idaho to a low of 24 days in Wyoming.
Notably, when patients saw a neurologist outside of their physician’s referral area, wait times were longer by an average of 11 days.
More than 40% of patients with new neurology referrals had prior office-based visits for the same neurologic diagnosis. For these patients, the median time between diagnosis and index neurologist visit was 342 days (range, 66-753 days).
Female patients in this category waited slightly longer (median, 353 days) than male patients (median, 328 days), and Black and Hispanic patients had longer median waits than White patients (389.5 days and 397 days respectively, vs 337 days; P = .0003).
“It is important to note that there is no national benchmark for determining appropriate wait times for specialist care, making it difficult to standardize expectations for timely access to specialists,” the authors noted.
The investigators suggested that a direct communication channel between primary care physicians and neurologists such as an eConsult service may hasten access to neurology consultation without the need for a formal appointment. Telemedicine in rural areas could also shorten wait times, they added.
Study limitations included the inability to determine if patients followed through with their index neurology visits or whether the last visit with the physician was the time of referral, as this could not be determined through the claims data.
This study was funded by the American Academy of Neurology. Lin reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
a cross-sectional analysis of Medicare data showed.
Wait times were not affected by the number of available neurologists. However, those with multiple sclerosis (MS), epilepsy, Parkinson’s disease, dementia, and sleep disorders had the longest wait times.
“In general, early referral to specialists has been shown to improve outcomes and increase patient satisfaction,” study author Chun Chieh Lin, PhD, MBA, of Ohio State University, Columbus, said in a press release. “Our findings underscore the need to develop new strategies to help people with neurological conditions see neurologists faster.”
The findings were published online in Neurology.
No National Benchmark for Wait Times
For this study, researchers analyzed a large sample of fee-for-service Medicare data from 2018 to 2019. Researchers identified patients with a year or less between their last referring physician visit and a new neurologist visit.
Exclusion criteria included enrollment in health maintenance organization plans without continuous enrollment in Medicare Part A and Part B for 2 years before the index neurologist visit, missing patient data, no physician referral at all, or referral by a different neurologist.
In addition to assessing wait times, investigators examined the availability of neurologists who provided medical services to Medicare beneficiaries in the 2018 dataset across 306 hospital referral regions in the United States, based on zip codes.
Results showed that 163,313 patients (average age, 74 years; 58% women; 85% White) were referred by 84,975 physicians to 10,250 neurologists across the United States.
Overall, the average wait time from physician referral to index neurologist visit was 34 days (range, 1-365 days), with longer wait times for White patients, women, and those aged 65-69 years. Overall, 18% waited longer than 90 days for an appointment.
The most common conditions diagnosed at the index neurologist visit were chronic pain/abnormality of gait (13%), sleep disorders (11%), and peripheral neuropathy (10%).
Using a linear mixed-effects statistical model, investigators found that patients with back pain waited an average of 30 days to see a neurologist, with longer waits for other conditions. Those with MS had an average wait that was 29 days longer, patients with epilepsy waited an average of 10 days longer, and those with Parkinson’s disease waited 9 days longer (P < .0001).
The number of available neurologists (range, 10-50 neurologists per 100,000 Medicare patients) did not affect wait times. However, there were differences in wait times across states because of different policies or regulations regarding healthcare access, with wait times ranging from a median high of 49 days in Idaho to a low of 24 days in Wyoming.
Notably, when patients saw a neurologist outside of their physician’s referral area, wait times were longer by an average of 11 days.
More than 40% of patients with new neurology referrals had prior office-based visits for the same neurologic diagnosis. For these patients, the median time between diagnosis and index neurologist visit was 342 days (range, 66-753 days).
Female patients in this category waited slightly longer (median, 353 days) than male patients (median, 328 days), and Black and Hispanic patients had longer median waits than White patients (389.5 days and 397 days respectively, vs 337 days; P = .0003).
“It is important to note that there is no national benchmark for determining appropriate wait times for specialist care, making it difficult to standardize expectations for timely access to specialists,” the authors noted.
The investigators suggested that a direct communication channel between primary care physicians and neurologists such as an eConsult service may hasten access to neurology consultation without the need for a formal appointment. Telemedicine in rural areas could also shorten wait times, they added.
Study limitations included the inability to determine if patients followed through with their index neurology visits or whether the last visit with the physician was the time of referral, as this could not be determined through the claims data.
This study was funded by the American Academy of Neurology. Lin reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
a cross-sectional analysis of Medicare data showed.
Wait times were not affected by the number of available neurologists. However, those with multiple sclerosis (MS), epilepsy, Parkinson’s disease, dementia, and sleep disorders had the longest wait times.
“In general, early referral to specialists has been shown to improve outcomes and increase patient satisfaction,” study author Chun Chieh Lin, PhD, MBA, of Ohio State University, Columbus, said in a press release. “Our findings underscore the need to develop new strategies to help people with neurological conditions see neurologists faster.”
The findings were published online in Neurology.
No National Benchmark for Wait Times
For this study, researchers analyzed a large sample of fee-for-service Medicare data from 2018 to 2019. Researchers identified patients with a year or less between their last referring physician visit and a new neurologist visit.
Exclusion criteria included enrollment in health maintenance organization plans without continuous enrollment in Medicare Part A and Part B for 2 years before the index neurologist visit, missing patient data, no physician referral at all, or referral by a different neurologist.
In addition to assessing wait times, investigators examined the availability of neurologists who provided medical services to Medicare beneficiaries in the 2018 dataset across 306 hospital referral regions in the United States, based on zip codes.
Results showed that 163,313 patients (average age, 74 years; 58% women; 85% White) were referred by 84,975 physicians to 10,250 neurologists across the United States.
Overall, the average wait time from physician referral to index neurologist visit was 34 days (range, 1-365 days), with longer wait times for White patients, women, and those aged 65-69 years. Overall, 18% waited longer than 90 days for an appointment.
The most common conditions diagnosed at the index neurologist visit were chronic pain/abnormality of gait (13%), sleep disorders (11%), and peripheral neuropathy (10%).
Using a linear mixed-effects statistical model, investigators found that patients with back pain waited an average of 30 days to see a neurologist, with longer waits for other conditions. Those with MS had an average wait that was 29 days longer, patients with epilepsy waited an average of 10 days longer, and those with Parkinson’s disease waited 9 days longer (P < .0001).
The number of available neurologists (range, 10-50 neurologists per 100,000 Medicare patients) did not affect wait times. However, there were differences in wait times across states because of different policies or regulations regarding healthcare access, with wait times ranging from a median high of 49 days in Idaho to a low of 24 days in Wyoming.
Notably, when patients saw a neurologist outside of their physician’s referral area, wait times were longer by an average of 11 days.
More than 40% of patients with new neurology referrals had prior office-based visits for the same neurologic diagnosis. For these patients, the median time between diagnosis and index neurologist visit was 342 days (range, 66-753 days).
Female patients in this category waited slightly longer (median, 353 days) than male patients (median, 328 days), and Black and Hispanic patients had longer median waits than White patients (389.5 days and 397 days respectively, vs 337 days; P = .0003).
“It is important to note that there is no national benchmark for determining appropriate wait times for specialist care, making it difficult to standardize expectations for timely access to specialists,” the authors noted.
The investigators suggested that a direct communication channel between primary care physicians and neurologists such as an eConsult service may hasten access to neurology consultation without the need for a formal appointment. Telemedicine in rural areas could also shorten wait times, they added.
Study limitations included the inability to determine if patients followed through with their index neurology visits or whether the last visit with the physician was the time of referral, as this could not be determined through the claims data.
This study was funded by the American Academy of Neurology. Lin reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM NEUROLOGY
Carfentanil-Involved Drug Overdoses Soar From 2023 to 2024
The number of drug overdose deaths involving illegally manufactured fentanyl and fentanyl analogs (IMFs) dropped in the United States during the latter portion of 2023. But a new report from the Centers for Disease Control and Prevention (CDC) suggests that an increase in overdoses involving the potent fentanyl analog carfentanil threatens to undo that progress.
Overdose deaths from carfentanil rose by more than 700% in the past year, increasing from 29 between January and June 2023 to 238 in that same period in 2024.
Carfentanil is used as a tranquilizing agent for elephants and other large mammals and is 100 times more potent than fentanyl. Just 2 mg can be lethal to humans, and a carfentanil-related overdose can require more than three shots of naloxone to reverse.
Prior to this resurgence of carfentanil, the drug “had largely disappeared after carfentanil-involved overdose death outbreaks in 2016-2017,” study authors noted, when carfentanil overdose deaths topped 1200, other data showed.
“Educational and response efforts that can rapidly adapt to the potential for increased distribution of drugs more potent than fentanyl, such as carfentanil, are needed and might avert or mitigate new increases in overdose deaths,” the authors wrote.
The findings were published online in CDC’s Morbidity and Mortality Weekly Report.
Carfentanil May Stall Overdose Decline
IMFs such as carfentanil were first detected in the United States illegal drug supply in 2013. A little more than a decade later, IMFs have replaced heroin as the most common opioid in the United States.
The introduction of IMFs led to a sharp rise in overdose deaths, but provisional data suggest these fatalities are on the decline. A recent re-emergence of carfentanil could stall that downward trend.
To investigate further, researchers used data from the CDC’s State Unintentional Drug Overdose Reporting System to analyze detection of IMFs and carfentanil between January 2021 and June 2024.
The database houses information on drug overdoses obtained from death certificates, coroner and medical examiner reports, and postmortem toxicology reports from 49 states and the District of Columbia.
From January 2021 to December 2023, more than 251,000 people died from drug overdoses with unintentional and undetermined intent, 75% of which involved IMFs.
IMF-linked deaths peaked at 16,814 in the second quarter of 2023, then declined by nearly 16% to 14,299 deaths by the end of that year.
Investigators could only speculate on the reasons for the decline in overdoses. It is possible that drug users are mixing fentanyl with other drugs, such as xylazine, which may reduce the danger of fatal overdose. It’s also possible that overdose prevention programs are partially responsible for the decline.
“Continued and expanded implementation of these programs, including naloxone distribution and increasing access to treatments for substance use disorders, might result in sustained and continued declines in drug overdose deaths,” they wrote.
Regional Differences
When researchers analyzed the results by region, they found that IMFs were detected in 81.5% of overdose deaths in the Northeast, 75% in the Midwest, and 75% in the Southern regions during the study period. These percentages were relatively stable until summer 2023, when declines in IMF-linked overdoses were noteworthy.
Specifically, deaths caused by IMFs decreased 11% in the Northeast (8245 to 7323), 16% in the Midwest (7160 to 6008), and 10.5% in the South (13,492 to 12,077).
In the West, however, overdoses linked to IMFs increased by 66.5% between 2021 and the second quarter of 2024.
The researchers speculated that the surge in the western United States could be caused by fentanyl entering the drug markets in that region later than in other areas, “likely because of challenges of mixing fentanyl into the black tar heroin that was more common in the West,” they wrote.
The findings suggested that, despite overall declines in overdose deaths reported nationwide, “recent sharp increases in overdose deaths with carfentanil detected, although rare, highlight the ever-changing illegal drug supply and threaten progress in reducing overdose deaths.”
The report authors encouraged expanding education programs for the public about the dangers of carfentanil and other IMFs, as well as harm reduction strategies, including using fentanyl test strips or drug-checking services.
No study funding information was available. There were no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The number of drug overdose deaths involving illegally manufactured fentanyl and fentanyl analogs (IMFs) dropped in the United States during the latter portion of 2023. But a new report from the Centers for Disease Control and Prevention (CDC) suggests that an increase in overdoses involving the potent fentanyl analog carfentanil threatens to undo that progress.
Overdose deaths from carfentanil rose by more than 700% in the past year, increasing from 29 between January and June 2023 to 238 in that same period in 2024.
Carfentanil is used as a tranquilizing agent for elephants and other large mammals and is 100 times more potent than fentanyl. Just 2 mg can be lethal to humans, and a carfentanil-related overdose can require more than three shots of naloxone to reverse.
Prior to this resurgence of carfentanil, the drug “had largely disappeared after carfentanil-involved overdose death outbreaks in 2016-2017,” study authors noted, when carfentanil overdose deaths topped 1200, other data showed.
“Educational and response efforts that can rapidly adapt to the potential for increased distribution of drugs more potent than fentanyl, such as carfentanil, are needed and might avert or mitigate new increases in overdose deaths,” the authors wrote.
The findings were published online in CDC’s Morbidity and Mortality Weekly Report.
Carfentanil May Stall Overdose Decline
IMFs such as carfentanil were first detected in the United States illegal drug supply in 2013. A little more than a decade later, IMFs have replaced heroin as the most common opioid in the United States.
The introduction of IMFs led to a sharp rise in overdose deaths, but provisional data suggest these fatalities are on the decline. A recent re-emergence of carfentanil could stall that downward trend.
To investigate further, researchers used data from the CDC’s State Unintentional Drug Overdose Reporting System to analyze detection of IMFs and carfentanil between January 2021 and June 2024.
The database houses information on drug overdoses obtained from death certificates, coroner and medical examiner reports, and postmortem toxicology reports from 49 states and the District of Columbia.
From January 2021 to December 2023, more than 251,000 people died from drug overdoses with unintentional and undetermined intent, 75% of which involved IMFs.
IMF-linked deaths peaked at 16,814 in the second quarter of 2023, then declined by nearly 16% to 14,299 deaths by the end of that year.
Investigators could only speculate on the reasons for the decline in overdoses. It is possible that drug users are mixing fentanyl with other drugs, such as xylazine, which may reduce the danger of fatal overdose. It’s also possible that overdose prevention programs are partially responsible for the decline.
“Continued and expanded implementation of these programs, including naloxone distribution and increasing access to treatments for substance use disorders, might result in sustained and continued declines in drug overdose deaths,” they wrote.
Regional Differences
When researchers analyzed the results by region, they found that IMFs were detected in 81.5% of overdose deaths in the Northeast, 75% in the Midwest, and 75% in the Southern regions during the study period. These percentages were relatively stable until summer 2023, when declines in IMF-linked overdoses were noteworthy.
Specifically, deaths caused by IMFs decreased 11% in the Northeast (8245 to 7323), 16% in the Midwest (7160 to 6008), and 10.5% in the South (13,492 to 12,077).
In the West, however, overdoses linked to IMFs increased by 66.5% between 2021 and the second quarter of 2024.
The researchers speculated that the surge in the western United States could be caused by fentanyl entering the drug markets in that region later than in other areas, “likely because of challenges of mixing fentanyl into the black tar heroin that was more common in the West,” they wrote.
The findings suggested that, despite overall declines in overdose deaths reported nationwide, “recent sharp increases in overdose deaths with carfentanil detected, although rare, highlight the ever-changing illegal drug supply and threaten progress in reducing overdose deaths.”
The report authors encouraged expanding education programs for the public about the dangers of carfentanil and other IMFs, as well as harm reduction strategies, including using fentanyl test strips or drug-checking services.
No study funding information was available. There were no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The number of drug overdose deaths involving illegally manufactured fentanyl and fentanyl analogs (IMFs) dropped in the United States during the latter portion of 2023. But a new report from the Centers for Disease Control and Prevention (CDC) suggests that an increase in overdoses involving the potent fentanyl analog carfentanil threatens to undo that progress.
Overdose deaths from carfentanil rose by more than 700% in the past year, increasing from 29 between January and June 2023 to 238 in that same period in 2024.
Carfentanil is used as a tranquilizing agent for elephants and other large mammals and is 100 times more potent than fentanyl. Just 2 mg can be lethal to humans, and a carfentanil-related overdose can require more than three shots of naloxone to reverse.
Prior to this resurgence of carfentanil, the drug “had largely disappeared after carfentanil-involved overdose death outbreaks in 2016-2017,” study authors noted, when carfentanil overdose deaths topped 1200, other data showed.
“Educational and response efforts that can rapidly adapt to the potential for increased distribution of drugs more potent than fentanyl, such as carfentanil, are needed and might avert or mitigate new increases in overdose deaths,” the authors wrote.
The findings were published online in CDC’s Morbidity and Mortality Weekly Report.
Carfentanil May Stall Overdose Decline
IMFs such as carfentanil were first detected in the United States illegal drug supply in 2013. A little more than a decade later, IMFs have replaced heroin as the most common opioid in the United States.
The introduction of IMFs led to a sharp rise in overdose deaths, but provisional data suggest these fatalities are on the decline. A recent re-emergence of carfentanil could stall that downward trend.
To investigate further, researchers used data from the CDC’s State Unintentional Drug Overdose Reporting System to analyze detection of IMFs and carfentanil between January 2021 and June 2024.
The database houses information on drug overdoses obtained from death certificates, coroner and medical examiner reports, and postmortem toxicology reports from 49 states and the District of Columbia.
From January 2021 to December 2023, more than 251,000 people died from drug overdoses with unintentional and undetermined intent, 75% of which involved IMFs.
IMF-linked deaths peaked at 16,814 in the second quarter of 2023, then declined by nearly 16% to 14,299 deaths by the end of that year.
Investigators could only speculate on the reasons for the decline in overdoses. It is possible that drug users are mixing fentanyl with other drugs, such as xylazine, which may reduce the danger of fatal overdose. It’s also possible that overdose prevention programs are partially responsible for the decline.
“Continued and expanded implementation of these programs, including naloxone distribution and increasing access to treatments for substance use disorders, might result in sustained and continued declines in drug overdose deaths,” they wrote.
Regional Differences
When researchers analyzed the results by region, they found that IMFs were detected in 81.5% of overdose deaths in the Northeast, 75% in the Midwest, and 75% in the Southern regions during the study period. These percentages were relatively stable until summer 2023, when declines in IMF-linked overdoses were noteworthy.
Specifically, deaths caused by IMFs decreased 11% in the Northeast (8245 to 7323), 16% in the Midwest (7160 to 6008), and 10.5% in the South (13,492 to 12,077).
In the West, however, overdoses linked to IMFs increased by 66.5% between 2021 and the second quarter of 2024.
The researchers speculated that the surge in the western United States could be caused by fentanyl entering the drug markets in that region later than in other areas, “likely because of challenges of mixing fentanyl into the black tar heroin that was more common in the West,” they wrote.
The findings suggested that, despite overall declines in overdose deaths reported nationwide, “recent sharp increases in overdose deaths with carfentanil detected, although rare, highlight the ever-changing illegal drug supply and threaten progress in reducing overdose deaths.”
The report authors encouraged expanding education programs for the public about the dangers of carfentanil and other IMFs, as well as harm reduction strategies, including using fentanyl test strips or drug-checking services.
No study funding information was available. There were no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE MMWR
Leaded Gas Exposure Tied to 151 Million Excess Cases of Mental Illness Cases
Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.
The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.
Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.
“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.
However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.
The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.
Lead Astray?
Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.
The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.
For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.
They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.
These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .
Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.
These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.
They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.
The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.
151 Million Excess Cases of Mental Illness
Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.
Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.
While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.
The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.
“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.
Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).
These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.
For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.
Assess Lead Risk
The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.
However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.
Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.
“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”
He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.
While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.
‘Legacy of Lead’
In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”
“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.
Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.
“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.
The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.
The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.
Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.
“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.
However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.
The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.
Lead Astray?
Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.
The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.
For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.
They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.
These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .
Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.
These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.
They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.
The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.
151 Million Excess Cases of Mental Illness
Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.
Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.
While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.
The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.
“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.
Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).
These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.
For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.
Assess Lead Risk
The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.
However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.
Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.
“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”
He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.
While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.
‘Legacy of Lead’
In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”
“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.
Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.
“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.
The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.
The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.
Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.
“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.
However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.
The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.
Lead Astray?
Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.
The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.
For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.
They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.
These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .
Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.
These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.
They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.
The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.
151 Million Excess Cases of Mental Illness
Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.
Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.
While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.
The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.
“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.
Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).
These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.
For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.
Assess Lead Risk
The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.
However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.
Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.
“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”
He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.
While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.
‘Legacy of Lead’
In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”
“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.
Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.
“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.
The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY
Rise in Psychotherapy Use Exposes Access Inequities
Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.
Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.
Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.
“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.
“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.
The findings were published online in JAMA Psychiatry.
Psychotherapy Uptick
Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.
Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.
To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.
The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.
The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.
Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.
Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.
Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).
After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).
A National Priority
Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).
Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).
In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).
Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.
Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.
The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.
Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.
“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.
“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.
Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.
Study funding was not disclosed. Olfson reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.
Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.
Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.
“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.
“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.
The findings were published online in JAMA Psychiatry.
Psychotherapy Uptick
Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.
Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.
To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.
The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.
The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.
Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.
Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.
Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).
After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).
A National Priority
Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).
Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).
In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).
Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.
Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.
The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.
Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.
“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.
“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.
Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.
Study funding was not disclosed. Olfson reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.
Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.
Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.
“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.
“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.
The findings were published online in JAMA Psychiatry.
Psychotherapy Uptick
Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.
Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.
To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.
The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.
The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.
Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.
Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.
Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).
After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).
A National Priority
Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).
Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).
In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).
Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.
Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.
The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.
Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.
“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.
“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.
Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.
Study funding was not disclosed. Olfson reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY
A New and Early Predictor of Dementia?
, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.
Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.
“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
The findings were published online in JAMA Neurology.
A Promising Biomarker
An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.
To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).
The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.
Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.
Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.
Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.
After adjustment for potential confounders, frailty scores were modeled using backward time scales.
Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.
When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).
Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.
In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.
Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.
In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.
The ‘Four Pillars’ of Prevention
The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.
To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.
Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.
Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.
Unclear Pathway
Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.
The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.
“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.
The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.
Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.
“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
The findings were published online in JAMA Neurology.
A Promising Biomarker
An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.
To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).
The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.
Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.
Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.
Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.
After adjustment for potential confounders, frailty scores were modeled using backward time scales.
Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.
When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).
Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.
In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.
Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.
In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.
The ‘Four Pillars’ of Prevention
The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.
To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.
Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.
Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.
Unclear Pathway
Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.
The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.
“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.
The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.
Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.
“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.
The findings were published online in JAMA Neurology.
A Promising Biomarker
An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.
To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).
The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.
Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.
Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.
Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.
After adjustment for potential confounders, frailty scores were modeled using backward time scales.
Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.
When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).
Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.
In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.
Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.
In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.
The ‘Four Pillars’ of Prevention
The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.
To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.
Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.
Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.
Unclear Pathway
Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.
The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.
“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.
The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Semaglutide a Potential Treatment Option for Opioid Use Disorder?
Semaglutide (Ozempic, Novo Nordisk) is associated with a significantly lower risk for overdose in individuals with opioid use disorder (OUD), new research shows.
The findings suggest that the drug may be a promising treatment option for OUD, adding to the growing evidence of the potential psychiatric benefits of glucagon-like peptide 1 (GLP-1) inhibitors.
“Our study provided real-world evidence suggesting that semaglutide could have benefits in preventing opioid overdose and treating opioid use disorder,” co–lead author Rong Xu, PhD, director of the Center for Artificial Intelligence in Drug Discovery at Case Western Reserve University School of Medicine, Cleveland, Ohio, said in an interview.
However, Xu cautioned that this evidence is preliminary and randomized clinical trials are required to confirm these findings.
The study published online in a research letter on September 25 in JAMA Network Open.
New Addiction Meds an Urgent Priority
Investigators analyzed electronic medical records from 33,006 patients with type 2 diabetes and OUD who were prescribed one of eight antidiabetic medications between 2017 and 2023.
Drugs included in the study were semaglutide, insulin, metformin, albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, dipeptidyl peptidase–4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, and thiazolidinediones.
Participants in the semaglutide and each comparison group were matched for certain covariates at baseline, such as socioeconomic status and OUD medications.
After 1 year, semaglutide was associated with a 42%-68% lower risk for opioid overdose than other antidiabetic medications, including other GLP-1s (range of hazard ratio [HR]: HR, 0.32; 95% CI, 0.12-0.89; to HR, 0.58; 95%CI, 0.38-0.87).
Xu noted a number of study limitations including the effect of possible confounders and sole reliance on prescription data.
However, the findings are in line with those of prior studies showing that semaglutide may be associated with lower rates of alcohol and nicotine use, she said.
Earlier this year, Xu, along with National Institute on Drug Abuse Director Nora Volkow, MD, and colleagues, published a retrospective cohort study of nearly 84,000 patients with obesity. That analysis showed that semaglutide was associated with a significantly lower risk of new alcohol use disorder diagnoses.
In a previous editorial by Xu and Volkow that summarized the research to-date on GLP-1s for nicotine, alcohol, and substance use disorders, they note that “closing the addiction treatment gap and discovering new, more effective addiction medications are urgent priorities. In this regard, investigating the potential of GLP-1 analogue medications to treat substance use disorder deserves fast and rigorous testing.”
Caution Warranted
Commenting on the study, Riccardo De Giorgi, MD, PhD, department of psychiatry, University of Oxford in England, said at this point, “we have to be very careful about how we interpret these data.”
In August, De Giorgi published a study showing that semaglutide was associated with reduced risk for several neurologic and psychiatric outcomes including dementia and nicotine misuse.
While there is enough observational evidence linking GLP-1 medications with reduced SUD risk, he noted that “now is the time to move on and conduct some randomized clinical trials, specifically testing our hypothesis in people who have psychiatric disorders.”
De Giorgi also called for mechanistic studies of semaglutide and other so that researchers could learn more about how it works to reduce cravings. “Instead of going from bench to bed, we need to go back to the bench,” he said.
As previously reported, De Giorgi recently called on experts in the field to actively explore the potential of GLP-1 inhibitors for mental illness.
The study was funded by National Institute on Alcohol Abuse and Alcoholism, National Institute on Aging, the National Center for Advancing Translational Sciences, and the Intramural Research Program of the National Institutes of Health. Xu reported no relevant financial relationships. De Giorgi reported receiving funding from the National Institute for Health Research Oxford Health Biomedical Research Centre.
A version of this article first appeared on Medscape.com.
Semaglutide (Ozempic, Novo Nordisk) is associated with a significantly lower risk for overdose in individuals with opioid use disorder (OUD), new research shows.
The findings suggest that the drug may be a promising treatment option for OUD, adding to the growing evidence of the potential psychiatric benefits of glucagon-like peptide 1 (GLP-1) inhibitors.
“Our study provided real-world evidence suggesting that semaglutide could have benefits in preventing opioid overdose and treating opioid use disorder,” co–lead author Rong Xu, PhD, director of the Center for Artificial Intelligence in Drug Discovery at Case Western Reserve University School of Medicine, Cleveland, Ohio, said in an interview.
However, Xu cautioned that this evidence is preliminary and randomized clinical trials are required to confirm these findings.
The study published online in a research letter on September 25 in JAMA Network Open.
New Addiction Meds an Urgent Priority
Investigators analyzed electronic medical records from 33,006 patients with type 2 diabetes and OUD who were prescribed one of eight antidiabetic medications between 2017 and 2023.
Drugs included in the study were semaglutide, insulin, metformin, albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, dipeptidyl peptidase–4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, and thiazolidinediones.
Participants in the semaglutide and each comparison group were matched for certain covariates at baseline, such as socioeconomic status and OUD medications.
After 1 year, semaglutide was associated with a 42%-68% lower risk for opioid overdose than other antidiabetic medications, including other GLP-1s (range of hazard ratio [HR]: HR, 0.32; 95% CI, 0.12-0.89; to HR, 0.58; 95%CI, 0.38-0.87).
Xu noted a number of study limitations including the effect of possible confounders and sole reliance on prescription data.
However, the findings are in line with those of prior studies showing that semaglutide may be associated with lower rates of alcohol and nicotine use, she said.
Earlier this year, Xu, along with National Institute on Drug Abuse Director Nora Volkow, MD, and colleagues, published a retrospective cohort study of nearly 84,000 patients with obesity. That analysis showed that semaglutide was associated with a significantly lower risk of new alcohol use disorder diagnoses.
In a previous editorial by Xu and Volkow that summarized the research to-date on GLP-1s for nicotine, alcohol, and substance use disorders, they note that “closing the addiction treatment gap and discovering new, more effective addiction medications are urgent priorities. In this regard, investigating the potential of GLP-1 analogue medications to treat substance use disorder deserves fast and rigorous testing.”
Caution Warranted
Commenting on the study, Riccardo De Giorgi, MD, PhD, department of psychiatry, University of Oxford in England, said at this point, “we have to be very careful about how we interpret these data.”
In August, De Giorgi published a study showing that semaglutide was associated with reduced risk for several neurologic and psychiatric outcomes including dementia and nicotine misuse.
While there is enough observational evidence linking GLP-1 medications with reduced SUD risk, he noted that “now is the time to move on and conduct some randomized clinical trials, specifically testing our hypothesis in people who have psychiatric disorders.”
De Giorgi also called for mechanistic studies of semaglutide and other so that researchers could learn more about how it works to reduce cravings. “Instead of going from bench to bed, we need to go back to the bench,” he said.
As previously reported, De Giorgi recently called on experts in the field to actively explore the potential of GLP-1 inhibitors for mental illness.
The study was funded by National Institute on Alcohol Abuse and Alcoholism, National Institute on Aging, the National Center for Advancing Translational Sciences, and the Intramural Research Program of the National Institutes of Health. Xu reported no relevant financial relationships. De Giorgi reported receiving funding from the National Institute for Health Research Oxford Health Biomedical Research Centre.
A version of this article first appeared on Medscape.com.
Semaglutide (Ozempic, Novo Nordisk) is associated with a significantly lower risk for overdose in individuals with opioid use disorder (OUD), new research shows.
The findings suggest that the drug may be a promising treatment option for OUD, adding to the growing evidence of the potential psychiatric benefits of glucagon-like peptide 1 (GLP-1) inhibitors.
“Our study provided real-world evidence suggesting that semaglutide could have benefits in preventing opioid overdose and treating opioid use disorder,” co–lead author Rong Xu, PhD, director of the Center for Artificial Intelligence in Drug Discovery at Case Western Reserve University School of Medicine, Cleveland, Ohio, said in an interview.
However, Xu cautioned that this evidence is preliminary and randomized clinical trials are required to confirm these findings.
The study published online in a research letter on September 25 in JAMA Network Open.
New Addiction Meds an Urgent Priority
Investigators analyzed electronic medical records from 33,006 patients with type 2 diabetes and OUD who were prescribed one of eight antidiabetic medications between 2017 and 2023.
Drugs included in the study were semaglutide, insulin, metformin, albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, dipeptidyl peptidase–4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, and thiazolidinediones.
Participants in the semaglutide and each comparison group were matched for certain covariates at baseline, such as socioeconomic status and OUD medications.
After 1 year, semaglutide was associated with a 42%-68% lower risk for opioid overdose than other antidiabetic medications, including other GLP-1s (range of hazard ratio [HR]: HR, 0.32; 95% CI, 0.12-0.89; to HR, 0.58; 95%CI, 0.38-0.87).
Xu noted a number of study limitations including the effect of possible confounders and sole reliance on prescription data.
However, the findings are in line with those of prior studies showing that semaglutide may be associated with lower rates of alcohol and nicotine use, she said.
Earlier this year, Xu, along with National Institute on Drug Abuse Director Nora Volkow, MD, and colleagues, published a retrospective cohort study of nearly 84,000 patients with obesity. That analysis showed that semaglutide was associated with a significantly lower risk of new alcohol use disorder diagnoses.
In a previous editorial by Xu and Volkow that summarized the research to-date on GLP-1s for nicotine, alcohol, and substance use disorders, they note that “closing the addiction treatment gap and discovering new, more effective addiction medications are urgent priorities. In this regard, investigating the potential of GLP-1 analogue medications to treat substance use disorder deserves fast and rigorous testing.”
Caution Warranted
Commenting on the study, Riccardo De Giorgi, MD, PhD, department of psychiatry, University of Oxford in England, said at this point, “we have to be very careful about how we interpret these data.”
In August, De Giorgi published a study showing that semaglutide was associated with reduced risk for several neurologic and psychiatric outcomes including dementia and nicotine misuse.
While there is enough observational evidence linking GLP-1 medications with reduced SUD risk, he noted that “now is the time to move on and conduct some randomized clinical trials, specifically testing our hypothesis in people who have psychiatric disorders.”
De Giorgi also called for mechanistic studies of semaglutide and other so that researchers could learn more about how it works to reduce cravings. “Instead of going from bench to bed, we need to go back to the bench,” he said.
As previously reported, De Giorgi recently called on experts in the field to actively explore the potential of GLP-1 inhibitors for mental illness.
The study was funded by National Institute on Alcohol Abuse and Alcoholism, National Institute on Aging, the National Center for Advancing Translational Sciences, and the Intramural Research Program of the National Institutes of Health. Xu reported no relevant financial relationships. De Giorgi reported receiving funding from the National Institute for Health Research Oxford Health Biomedical Research Centre.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Is It Time for Universal Suicide Screening?
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
Brain Structure Differs in Youth With Conduct Disorder
Youth with conduct disorder (CD) have extensive brain structure differences, new research showed.
“We know very little about this disorder even though it can carry a high burden for families and societies,” co–lead author Yidian Gao, PhD, of the University of Birmingham, Birmingham, England, said in a press release.
“The sample included in our study is 10-20 times larger than previous studies and contains data on children from North America, Europe, and Asia. It provides the most compelling evidence to date that CD is associated with widespread structural brain differences,” he added.
The findings were published online in The Lancet Psychiatry.
An Understudied Disorder
In the largest study of its kind, researchers at the Universities of Bath and Birmingham, both in England, collaborated with research teams across Europe, North America, and Asia, as part of the Enhancing NeuroImaging Genetics through Meta-Analysis–Antisocial Behavior Working Group to learn more about one of the “least researched psychiatric disorders,” they wrote.
The investigators used MRI to examine the brain structure of 1185 children with a clinical diagnosis of CD and 1253 typically developing children from 17-21 across 15 international study cohorts.
After adjusting for total intracranial volume investigators found that youth with CD (29% women; mean age, 13.7 years) had lower total surface area and lower regional surface area in 26 of the 34 cortical regions, spanning all four lobes of the brain, compared with their typically developing counterparts (35.6% women; mean age, 13.5 years).
Youth with CD also showed greater cortical thickness in the caudal anterior cingulate cortex (P = .0001) and lower cortical thickness in the banks of the superior temporal sulcus vs those without CD (P = .0010).
In addition, the CD group also had lower volume in the thalamus (P = .0009), amygdala (P = .0014), hippocampus (P = .0031), and nucleus accumbens (P = .0052).
Most findings remained significant after adjusting for intelligence quotient, psychiatric comorbidities, and psychotropic medication use. Of note, group difference in cortical thickness, 22 of 27 differences in surface area. In addition, three of four subcortical differences remained robust after adjusting for co-occurring attention-deficit/hyperactivity disorder, the most frequent comorbidity.
When the investigators divided individuals with CD into two subgroups — those with high vs low levels of callous-unemotional traits — they found limited overall differences. However, those with high callous-unemotional traits had lower surface area in the superior temporal and superior frontal gyri vs those with low callous-unemotional traits and the typically developing group.
Investigators also found that individuals with childhood-onset CD had greater cortical thickness in the caudal anterior cingulate cortex compared with those with adolescent-onset CD.
Study limitations include comparison of different cohorts with differing protocols that could affect the validity of the findings. In addition, subgroup samples were small and had lower statistical power.
“Our finding of robust brain alterations in conduct disorder — similar to those in more widely recognized and widely treated disorders such as ADHD — emphasize the need for a greater focus on conduct disorder in research, treatment, and public policy,” the authors noted.
Seven study authors reported conflicts of interest with various pharmaceutical companies and other organizations.
A version of this article first appeared on Medscape.com.
Youth with conduct disorder (CD) have extensive brain structure differences, new research showed.
“We know very little about this disorder even though it can carry a high burden for families and societies,” co–lead author Yidian Gao, PhD, of the University of Birmingham, Birmingham, England, said in a press release.
“The sample included in our study is 10-20 times larger than previous studies and contains data on children from North America, Europe, and Asia. It provides the most compelling evidence to date that CD is associated with widespread structural brain differences,” he added.
The findings were published online in The Lancet Psychiatry.
An Understudied Disorder
In the largest study of its kind, researchers at the Universities of Bath and Birmingham, both in England, collaborated with research teams across Europe, North America, and Asia, as part of the Enhancing NeuroImaging Genetics through Meta-Analysis–Antisocial Behavior Working Group to learn more about one of the “least researched psychiatric disorders,” they wrote.
The investigators used MRI to examine the brain structure of 1185 children with a clinical diagnosis of CD and 1253 typically developing children from 17-21 across 15 international study cohorts.
After adjusting for total intracranial volume investigators found that youth with CD (29% women; mean age, 13.7 years) had lower total surface area and lower regional surface area in 26 of the 34 cortical regions, spanning all four lobes of the brain, compared with their typically developing counterparts (35.6% women; mean age, 13.5 years).
Youth with CD also showed greater cortical thickness in the caudal anterior cingulate cortex (P = .0001) and lower cortical thickness in the banks of the superior temporal sulcus vs those without CD (P = .0010).
In addition, the CD group also had lower volume in the thalamus (P = .0009), amygdala (P = .0014), hippocampus (P = .0031), and nucleus accumbens (P = .0052).
Most findings remained significant after adjusting for intelligence quotient, psychiatric comorbidities, and psychotropic medication use. Of note, group difference in cortical thickness, 22 of 27 differences in surface area. In addition, three of four subcortical differences remained robust after adjusting for co-occurring attention-deficit/hyperactivity disorder, the most frequent comorbidity.
When the investigators divided individuals with CD into two subgroups — those with high vs low levels of callous-unemotional traits — they found limited overall differences. However, those with high callous-unemotional traits had lower surface area in the superior temporal and superior frontal gyri vs those with low callous-unemotional traits and the typically developing group.
Investigators also found that individuals with childhood-onset CD had greater cortical thickness in the caudal anterior cingulate cortex compared with those with adolescent-onset CD.
Study limitations include comparison of different cohorts with differing protocols that could affect the validity of the findings. In addition, subgroup samples were small and had lower statistical power.
“Our finding of robust brain alterations in conduct disorder — similar to those in more widely recognized and widely treated disorders such as ADHD — emphasize the need for a greater focus on conduct disorder in research, treatment, and public policy,” the authors noted.
Seven study authors reported conflicts of interest with various pharmaceutical companies and other organizations.
A version of this article first appeared on Medscape.com.
Youth with conduct disorder (CD) have extensive brain structure differences, new research showed.
“We know very little about this disorder even though it can carry a high burden for families and societies,” co–lead author Yidian Gao, PhD, of the University of Birmingham, Birmingham, England, said in a press release.
“The sample included in our study is 10-20 times larger than previous studies and contains data on children from North America, Europe, and Asia. It provides the most compelling evidence to date that CD is associated with widespread structural brain differences,” he added.
The findings were published online in The Lancet Psychiatry.
An Understudied Disorder
In the largest study of its kind, researchers at the Universities of Bath and Birmingham, both in England, collaborated with research teams across Europe, North America, and Asia, as part of the Enhancing NeuroImaging Genetics through Meta-Analysis–Antisocial Behavior Working Group to learn more about one of the “least researched psychiatric disorders,” they wrote.
The investigators used MRI to examine the brain structure of 1185 children with a clinical diagnosis of CD and 1253 typically developing children from 17-21 across 15 international study cohorts.
After adjusting for total intracranial volume investigators found that youth with CD (29% women; mean age, 13.7 years) had lower total surface area and lower regional surface area in 26 of the 34 cortical regions, spanning all four lobes of the brain, compared with their typically developing counterparts (35.6% women; mean age, 13.5 years).
Youth with CD also showed greater cortical thickness in the caudal anterior cingulate cortex (P = .0001) and lower cortical thickness in the banks of the superior temporal sulcus vs those without CD (P = .0010).
In addition, the CD group also had lower volume in the thalamus (P = .0009), amygdala (P = .0014), hippocampus (P = .0031), and nucleus accumbens (P = .0052).
Most findings remained significant after adjusting for intelligence quotient, psychiatric comorbidities, and psychotropic medication use. Of note, group difference in cortical thickness, 22 of 27 differences in surface area. In addition, three of four subcortical differences remained robust after adjusting for co-occurring attention-deficit/hyperactivity disorder, the most frequent comorbidity.
When the investigators divided individuals with CD into two subgroups — those with high vs low levels of callous-unemotional traits — they found limited overall differences. However, those with high callous-unemotional traits had lower surface area in the superior temporal and superior frontal gyri vs those with low callous-unemotional traits and the typically developing group.
Investigators also found that individuals with childhood-onset CD had greater cortical thickness in the caudal anterior cingulate cortex compared with those with adolescent-onset CD.
Study limitations include comparison of different cohorts with differing protocols that could affect the validity of the findings. In addition, subgroup samples were small and had lower statistical power.
“Our finding of robust brain alterations in conduct disorder — similar to those in more widely recognized and widely treated disorders such as ADHD — emphasize the need for a greater focus on conduct disorder in research, treatment, and public policy,” the authors noted.
Seven study authors reported conflicts of interest with various pharmaceutical companies and other organizations.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PSYCHIATRY
Moderate Exercise in Midlife Linked to Lower Risk for ALS
Moderate exercise in midlife is associated with a reduced risk for amyotrophic lateral sclerosis (ALS) later in life, but this benefit appears to be limited to men, findings from a large prospective study showed.
Men who reported moderate levels of physical activity had a 29% lower risk for ALS, whereas those with high levels of physical activity had a 41% lower risk for the disease.
The findings were published online in Neurology.
Conflicting Findings
Several famous athletes have died of ALS, including the baseball player Lou Gehrig (for whom the disease is named), football players Dwight Clark, Steve Gleason, and Kevin Turner, and the boxer Ezzard Charles. This has led some scientists to speculate that intense physical activity may play a role in the development of the disease.
Anders M. Vaage, MD, noted there have been conflicting findings in previous studies on the topic, with results showing both increased and reduced ALS risks with increasing levels of physical activity.
In one study, researchers followed more than 212,000 Swedish cross-country skiers and more than 500,000 Swedish individuals in the general population for 20 years and found that strenuous cross-country skiing was associated with a higher risk for ALS but only among the best skiers; recreational skiers appeared to have a reduced risk.
“Our study does not necessarily contradict previous studies with findings of an increased ALS risk with extreme or intense levels of physical activity in athletes, as this study reflects more moderate levels of physical activity and fitness in the total population,” said Dr. Vaage.
To further explore the association, the researchers followed 373,700 individuals who participated in a cardiovascular health survey for an average of 27 years. When the survey began, most participants were 40-42 years old.
Participants were followed until the date of ALS diagnosis, ALS death, death from other causes, emigration, or the end of study in August 2021.
Participants answered questions about physical activity levels, smoking status, and other issues relating to cardiovascular health, and participants’ resting heart rate was measured and divided into quartiles of 31-65 beats per minute (BPM), 66-74 BPM, 75-81 BPM, or 82-100 BPM.
Participants self-reported their physical activity over the past year, classifying it into one of four categories: Sedentary, at least 4 hours per week of walking or cycling, at least 4 hours per week of recreational sports or heavy gardening, or regular participation in intense training or sports competitions several times per week.
Only a few participants reported the highest level of physical activity, so researchers combined the third and fourth categories into a single high-activity group.
Of the total study cohort, 504 participants developed ALS. Of those who developed the disease, 59% were men.
Researchers found that of the 41,898 male participants with the highest level of physical activity, 63 developed ALS. In comparison, of the 76,769 male participants who reported an intermediate level of physical activity, 131 developed ALS. Among the 29,468 male participants who reported the lowest level of physical activity, 68 developed ALS.
No Link in Women?
After adjusting for smoking, body mass index, and other risk factors, investigators found that men with moderate physical activity levels had a 29% lower risk for ALS compared with those with low physical activity levels, whereas those with the highest activity levels had a 41% lower risk.
In addition, men in the lowest of the four categories of resting heart rate had a 32% reduced risk for ALS compared with men with a higher resting heart rate.
Investigators are unclear why there was a lack of association between physical activity and resting heart rate and ALS risk in women.
“There are known sex differences in ALS, which includes a sex ratio with male preponderance, and there are also sex differences in response to physical exercise. Perhaps underlying mechanisms herein can explain the difference observed between males and females in the study,” Dr. Vaage said. He noted that future research should explore this difference.
Study limitations included the absence of data on physical trauma and head trauma, which have been linked with increased ALS risk. In addition, there were no data on genotype.
In an accompanying editorial, Pamela Shaw, MD, and Johnathan Cooper-Knock, BMBCh, PhD, of the University of Sheffield, Sheffield, England, described the research as a “valuable contribution to the field and potentially provides some reassurance that mild/moderate levels of physical activity in middle age do not increase the risk for ALS but may instead have a beneficial protective effect.”
Future research on exercise in ALS, they add, should consider sex differences, capture the most extreme physical activity levels, and identify any genetic factors that may mediate the association between intense exercise and ALS.
No targeted funding was reported. Dr. Vaage reported receiving funding from ALS Laboratory Group Norway.
A version of this article first appeared on Medscape.com.
Moderate exercise in midlife is associated with a reduced risk for amyotrophic lateral sclerosis (ALS) later in life, but this benefit appears to be limited to men, findings from a large prospective study showed.
Men who reported moderate levels of physical activity had a 29% lower risk for ALS, whereas those with high levels of physical activity had a 41% lower risk for the disease.
The findings were published online in Neurology.
Conflicting Findings
Several famous athletes have died of ALS, including the baseball player Lou Gehrig (for whom the disease is named), football players Dwight Clark, Steve Gleason, and Kevin Turner, and the boxer Ezzard Charles. This has led some scientists to speculate that intense physical activity may play a role in the development of the disease.
Anders M. Vaage, MD, noted there have been conflicting findings in previous studies on the topic, with results showing both increased and reduced ALS risks with increasing levels of physical activity.
In one study, researchers followed more than 212,000 Swedish cross-country skiers and more than 500,000 Swedish individuals in the general population for 20 years and found that strenuous cross-country skiing was associated with a higher risk for ALS but only among the best skiers; recreational skiers appeared to have a reduced risk.
“Our study does not necessarily contradict previous studies with findings of an increased ALS risk with extreme or intense levels of physical activity in athletes, as this study reflects more moderate levels of physical activity and fitness in the total population,” said Dr. Vaage.
To further explore the association, the researchers followed 373,700 individuals who participated in a cardiovascular health survey for an average of 27 years. When the survey began, most participants were 40-42 years old.
Participants were followed until the date of ALS diagnosis, ALS death, death from other causes, emigration, or the end of study in August 2021.
Participants answered questions about physical activity levels, smoking status, and other issues relating to cardiovascular health, and participants’ resting heart rate was measured and divided into quartiles of 31-65 beats per minute (BPM), 66-74 BPM, 75-81 BPM, or 82-100 BPM.
Participants self-reported their physical activity over the past year, classifying it into one of four categories: Sedentary, at least 4 hours per week of walking or cycling, at least 4 hours per week of recreational sports or heavy gardening, or regular participation in intense training or sports competitions several times per week.
Only a few participants reported the highest level of physical activity, so researchers combined the third and fourth categories into a single high-activity group.
Of the total study cohort, 504 participants developed ALS. Of those who developed the disease, 59% were men.
Researchers found that of the 41,898 male participants with the highest level of physical activity, 63 developed ALS. In comparison, of the 76,769 male participants who reported an intermediate level of physical activity, 131 developed ALS. Among the 29,468 male participants who reported the lowest level of physical activity, 68 developed ALS.
No Link in Women?
After adjusting for smoking, body mass index, and other risk factors, investigators found that men with moderate physical activity levels had a 29% lower risk for ALS compared with those with low physical activity levels, whereas those with the highest activity levels had a 41% lower risk.
In addition, men in the lowest of the four categories of resting heart rate had a 32% reduced risk for ALS compared with men with a higher resting heart rate.
Investigators are unclear why there was a lack of association between physical activity and resting heart rate and ALS risk in women.
“There are known sex differences in ALS, which includes a sex ratio with male preponderance, and there are also sex differences in response to physical exercise. Perhaps underlying mechanisms herein can explain the difference observed between males and females in the study,” Dr. Vaage said. He noted that future research should explore this difference.
Study limitations included the absence of data on physical trauma and head trauma, which have been linked with increased ALS risk. In addition, there were no data on genotype.
In an accompanying editorial, Pamela Shaw, MD, and Johnathan Cooper-Knock, BMBCh, PhD, of the University of Sheffield, Sheffield, England, described the research as a “valuable contribution to the field and potentially provides some reassurance that mild/moderate levels of physical activity in middle age do not increase the risk for ALS but may instead have a beneficial protective effect.”
Future research on exercise in ALS, they add, should consider sex differences, capture the most extreme physical activity levels, and identify any genetic factors that may mediate the association between intense exercise and ALS.
No targeted funding was reported. Dr. Vaage reported receiving funding from ALS Laboratory Group Norway.
A version of this article first appeared on Medscape.com.
Moderate exercise in midlife is associated with a reduced risk for amyotrophic lateral sclerosis (ALS) later in life, but this benefit appears to be limited to men, findings from a large prospective study showed.
Men who reported moderate levels of physical activity had a 29% lower risk for ALS, whereas those with high levels of physical activity had a 41% lower risk for the disease.
The findings were published online in Neurology.
Conflicting Findings
Several famous athletes have died of ALS, including the baseball player Lou Gehrig (for whom the disease is named), football players Dwight Clark, Steve Gleason, and Kevin Turner, and the boxer Ezzard Charles. This has led some scientists to speculate that intense physical activity may play a role in the development of the disease.
Anders M. Vaage, MD, noted there have been conflicting findings in previous studies on the topic, with results showing both increased and reduced ALS risks with increasing levels of physical activity.
In one study, researchers followed more than 212,000 Swedish cross-country skiers and more than 500,000 Swedish individuals in the general population for 20 years and found that strenuous cross-country skiing was associated with a higher risk for ALS but only among the best skiers; recreational skiers appeared to have a reduced risk.
“Our study does not necessarily contradict previous studies with findings of an increased ALS risk with extreme or intense levels of physical activity in athletes, as this study reflects more moderate levels of physical activity and fitness in the total population,” said Dr. Vaage.
To further explore the association, the researchers followed 373,700 individuals who participated in a cardiovascular health survey for an average of 27 years. When the survey began, most participants were 40-42 years old.
Participants were followed until the date of ALS diagnosis, ALS death, death from other causes, emigration, or the end of study in August 2021.
Participants answered questions about physical activity levels, smoking status, and other issues relating to cardiovascular health, and participants’ resting heart rate was measured and divided into quartiles of 31-65 beats per minute (BPM), 66-74 BPM, 75-81 BPM, or 82-100 BPM.
Participants self-reported their physical activity over the past year, classifying it into one of four categories: Sedentary, at least 4 hours per week of walking or cycling, at least 4 hours per week of recreational sports or heavy gardening, or regular participation in intense training or sports competitions several times per week.
Only a few participants reported the highest level of physical activity, so researchers combined the third and fourth categories into a single high-activity group.
Of the total study cohort, 504 participants developed ALS. Of those who developed the disease, 59% were men.
Researchers found that of the 41,898 male participants with the highest level of physical activity, 63 developed ALS. In comparison, of the 76,769 male participants who reported an intermediate level of physical activity, 131 developed ALS. Among the 29,468 male participants who reported the lowest level of physical activity, 68 developed ALS.
No Link in Women?
After adjusting for smoking, body mass index, and other risk factors, investigators found that men with moderate physical activity levels had a 29% lower risk for ALS compared with those with low physical activity levels, whereas those with the highest activity levels had a 41% lower risk.
In addition, men in the lowest of the four categories of resting heart rate had a 32% reduced risk for ALS compared with men with a higher resting heart rate.
Investigators are unclear why there was a lack of association between physical activity and resting heart rate and ALS risk in women.
“There are known sex differences in ALS, which includes a sex ratio with male preponderance, and there are also sex differences in response to physical exercise. Perhaps underlying mechanisms herein can explain the difference observed between males and females in the study,” Dr. Vaage said. He noted that future research should explore this difference.
Study limitations included the absence of data on physical trauma and head trauma, which have been linked with increased ALS risk. In addition, there were no data on genotype.
In an accompanying editorial, Pamela Shaw, MD, and Johnathan Cooper-Knock, BMBCh, PhD, of the University of Sheffield, Sheffield, England, described the research as a “valuable contribution to the field and potentially provides some reassurance that mild/moderate levels of physical activity in middle age do not increase the risk for ALS but may instead have a beneficial protective effect.”
Future research on exercise in ALS, they add, should consider sex differences, capture the most extreme physical activity levels, and identify any genetic factors that may mediate the association between intense exercise and ALS.
No targeted funding was reported. Dr. Vaage reported receiving funding from ALS Laboratory Group Norway.
A version of this article first appeared on Medscape.com.
FROM NEUROLOGY