Clinical Psychiatry News

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

What if a walk in a green environment could reshape brains, recalibrate sense of time, and stave off mental health conditions? If the research trends are true, you might soon find yourself writing prescriptions of 20 minutes of nature per day.

Evidence for the health benefits of exposure to green spaces, like parks, open spaces, gardens, outdoor gyms, and woodland trails, has been mostly interventional and observational, but that has not stopped global recognition that these exposures are important. 

In the wake of the pandemic, the British government allocated more than £5 million to pandemic recovery efforts that specifically involved green spaces. Since then, it has committed even more funding toward an expansive social prescribing program that connects patients to “link workers” who determine personal care needs and facilitate community and volunteer-based interventions. These can include group walking and volunteering to help out in community gardens or conservation efforts. Similar green programs can be found in Japan, where shinrin-yoku (forest bathing) was recently adopted as a national health strategy, and in the United States and Canada.

“Disconnection from nature is a major part of the health problems that we have on this planet,” said William Bird, a UK-based general practitioner, green prescriber, and CEO of Intelligent Health, which is geared toward building healthy, active, and connected communities. Dr. Bird received the prestigious Member of the Order of the British Empire (MBE) in 2010 for services related to physical activity and health. 

“Our brains are designed to connect to nature ... and we haven’t lost that instinct,” he explained. “Once we are with birdsong and water flowing and greenery, cortisol levels drop, our central vagus nerve improves, our fight and flight [response] disappears, and we start to be more receptive to other people.” 
 

Shifting Time Perception and Health

Ricardo A. Correia, PhD, a biologist and researcher at the University of Helsinki in Finland, said he believed that the mechanism for at least some of these outcomes might be differences in how time is perceived. In a perspective that appeared in March in People and Nature, Dr. Correia explored how the “services” that nature provides shift time perceptions and, in turn, regulate overall well-being. 

“I reached the realization that there was some evidence for the shift in some of the dimensions that we use to make sense of time in urban vs natural environments,” he told this news organization. 

Dr. Correia explained that human time perception facilitates understanding cause and effect, so we can act in a way that allows us to survive. 

“Time perception in humans is really complex and multifaceted,” he said. “The way that we make sense of time is not directly attached to any sensory organ, but rather goes through a range of cognitive, emotional, and bodily processes, all of which vary from person to person.” 

Dr. Correia pointed to evidence showing that time perception is shorter in urban environments and longer in natural ones. This, in turn, influences attention and attention restoration. “When we live in cities, we are exposed to similar sorts of demanding environments, increased time pressures, less time for oneself and for recreational purposes,” he said. “Ever-mounting pressure on daily demands plus processes we use to make sense of time, especially attention, means that we pay a cognitive toll.”

Dr. Correia posits that it might be possible to recalibrate time perception, but only by breaking the cycle of exposure. 

“If we are always exposed to fast-paced lifestyles, we become attuned to them and get caught up in an endless loop.” This cycle can be broken, Dr. Correia explained, by increasing exposure to natural environments. This leads to positive emotions, a sense of being in the present, and a heightened sense of mindfulness, all of which help mitigate the physical and mental health outcomes commonly associated with time scarcity. 
 

Brain-Mental Health Benefits

To date, there is quite a bit of research exploring the impacts of exposure to nature on the brain. For example, data have shown that adolescents raised exclusively in rural environments have a larger hippocampus and better spatial processing than children exclusively raised in cities. Other research demonstrated that spending just an hour in the forest led to a decline in amygdala activity in adults, whereas it remained stable after walking in an urban setting, underscoring the salutogenic effects on brain regions related to stress. There is also evidence from a 10-year longitudinal study of more than 2 million Welsh adults that highlights the value of proximity to green or blue (eg, lakes and rivers) spaces and common mental health conditions, with every additional 360 meters to the nearest green or blue space associated with 10% greater odds of anxiety and depression.

Dr. Bird said there has been a massive sea change in attitudes among general practitioners, who have come around to embracing the concept of nature as medicine. This shift among peers, who teased him in the 1990s about his green walking and conservation prescriptions, portends a bandwagon of epic proportions that could benefit patients. He said that he was especially hopeful that green prescriptions will become mainstream in certain conditions, especially those like depression and anxiety that are resistant to medication.

But Dr. Bird cautions that primary care professionals need to be mindful. “Patients need to know that it’s real science, otherwise they’ll think that they’re being pawned off or dismissed,” he said. “I try to put real evidence behind it and explain that there’s no contraindication. The main thing is to start where patients are, what they’re feeling, and what they need. Some people just don’t like nature,” he said.
 

A version of this article appeared on Medscape.com.

Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight. 

Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail. 

Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior. 

In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.

Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate. 

While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:

• Slowing down eating/chewing thoroughly
• Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
• Eating only until physically satiated
• Distinguishing between true hunger and cravings
• Noticing the texture, flavors, and smell of food
• Paying attention to the effect of food on your mood
• Appreciating food

In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle. 

If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction. 

Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.

Dr. Messer has disclosed no relevant financial relationships.

Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.

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

Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight. 

Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail. 

Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior. 

In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.

Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate. 

While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:

• Slowing down eating/chewing thoroughly
• Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
• Eating only until physically satiated
• Distinguishing between true hunger and cravings
• Noticing the texture, flavors, and smell of food
• Paying attention to the effect of food on your mood
• Appreciating food

In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle. 

If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction. 

Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.

Dr. Messer has disclosed no relevant financial relationships.

Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.

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

Logan is a 62-year-old woman who has reached the pinnacle of professional success. She started a $50 million consumer products company and, after selling it, managed to develop another successful brand. She is healthy and happily married, with four adult children. And yet, despite all her achievements and stable family life, Logan was always bothered by her inability to lose weight. 

Despite peddling in beauty, she felt perpetually overweight and, frankly, unattractive. She has no family history of obesity, drinks minimal alcohol, and follows an (allegedly) healthy diet. Logan had tried “everything” to lose weight — human growth hormone injections (not prescribed by me), Ozempic-like medications, Belviq, etc. — all to no avail. 

Here’s the catch: After she finished with her busy days of meetings and spreadsheets, Logan sat down to read through countless emails and rewarded herself with all her favorite foods. Without realizing it, she often doubled her daily caloric intake in one sitting. She wasn’t hungry in these moments, rather just a little worn out and perhaps a little careless. She then proceeded to email her doctor (me) to report on this endless cycle of unwanted behavior. 

In January 2024, a novel study from Turkey examined the relationship between hedonic eating, self-condemnation, and self-esteem. Surprising to no one, the study determined that higher hedonic hunger scores were associated with lower self-esteem and an increased propensity to self-stigmatize.

Oprah could have handily predicted this conclusion. Many years ago, she described food as a fake friend: Perhaps you’ve had a long and difficult day. While you’re busy eating your feelings, the heaping plate of pasta feels like your best buddy in the world. However, the moment the plate is empty, you realize that you feel worse than before. Not only do you have to unbutton your new jeans, but you also realize that you have just lost your ability to self-regulate. 

While the positive association between hedonic eating and low self-esteem may seem self-evident, the solution is less obvious. Mindfulness is one possible approach to this issue. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” and has existed for thousands of years. Mindful eating, in particular, involves paying close attention to our food choices and how they affect our emotions, and typically includes some combination of:

• Slowing down eating/chewing thoroughly
• Eliminating distractions such as TV, computers, and phones — perhaps even eating in silence
• Eating only until physically satiated
• Distinguishing between true hunger and cravings
• Noticing the texture, flavors, and smell of food
• Paying attention to the effect of food on your mood
• Appreciating food

In our society, where processed food is so readily available and stress is so ubiquitous, eating can become a hedonic and fast-paced activity. Our brains don’t have time to process our bodies’ signals of fullness and, as a result, we often ingest many more calories than we need for a healthy lifestyle. 

If mindless eating is part of the problem, mindful eating is part of the solution. Indeed, a meta-review of 10 scientific studies showed that mindful eating is as effective as conventional weight loss programs in regard to body mass index and waist circumference. On the basis of these studies — as well as some good old-fashioned common sense — intuitive eating is an important component of sustainable weight reduction. 

Eventually, I convinced Logan to meet up with the psychologist in our group who specializes in emotional eating. Through weekly cognitive-behavioral therapy sessions, Logan was able to understand the impetus behind her self-defeating behavior and has finally been able to reverse some of her lifelong habits. Once she started practicing mindful eating, I was able to introduce Ozempic, and now Logan is happily shedding several pounds a week.

Dr. Messer has disclosed no relevant financial relationships.

Dr. Messer is clinical assistant professor, Mount Sinai School of Medicine and associate professor, Hofstra School of Medicine, both in New York City.

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

Cognitive assessments administered via a smartphone app are a reliable and valid way to detect frontotemporal dementia (FTD) in high-risk individuals, new research showed.

Cognitive tests administered remotely on the phone “showed similar findings as our gold standard in-clinic cognitive tests and brain imaging,” said study investigator Adam M. Staffaroni, PhD, with the Memory and Aging Center, University of California San Francisco.

“We also provided evidence that these assessments may be useful for detecting early symptoms of the disease at a level that is on par, or perhaps slightly better, than our gold standard in-person tests,” Dr. Staffaroni said.

The study was published online in JAMA Network Open.
 

Tough to Diagnose

Although relatively rare, FTD is the top cause of dementia in patients younger than 60 years. Patients are usually diagnosed relatively late in the disease because they are young and because their symptoms may be mistaken for psychiatric disorders.

In addition, behavioral and motor symptoms of FTD can make it hard for families to get to an academic center for in-clinic assessments, making remote assessments a huge need.

Dr. Staffaroni and colleagues with the ALLFTD Consortium partnered with software company Datacubed Health to develop the ALLFTD-mApp, which includes cognitive, motor, and speech tasks.

They assessed the reliability and validity of the app, against standard in-clinic assessments, in 350 individuals (mean age, 54 years; 58% women; mean education level, 16.5 years).

Among the 329 individuals with data on disease stage, 195 (59%) were asymptomatic or had preclinical FTD, 66 (20%) had prodromal FTD, and 68 (21%) had symptomatic FTD with a range of clinical syndromes.

The smartphone app showed “moderate to excellent” reliability within a single administration (ie, internally consistent) and across repeated assessments (ie, test-retest reliability), the researchers reported.

Validity was supported by association of smartphones tests with disease severity, criterion-standard neuropsychological tests, and brain volume, they noted.
 

Of Great Interest

They also reported that a composite of brief smartphone tests accurately distinguished dementia from cognitively unimpaired participants, screening out participants without symptoms, and detected prodromal FTD with greater sensitivity than the Montreal Cognitive Assessment.

“This tool is currently being used in several research studies. The remote aspect of this technology is important because it could allow researchers to collect data more frequently, which may give them a more accurate picture of the disease. Furthermore, researchers can be more inclusive in their study designs and include participants who otherwise might have difficulty traveling to academic centers for standard in-person visits,” said Dr. Staffaroni.

“Because the app appears sensitive to early stages of the disease, it could be also used as a screening tool, possibly alongside other remote data collection, to help identify participants that might be appropriate for a clinical trial. At this point, these technologies are not ready for clinical use and require additional research studies to understand their clinical utility,” he cautioned.

Commenting on the study, Walter Kukull, PhD, director of the National Alzheimer’s Coordinating Center at the University of Washington in Seattle, noted that “remote direct and indirect testing/telemetry are of great interest to the field and are being examined carefully in comparison to in-person means both for validity and possibly earlier recognition.”

This research was supported by grants from the National Institutes of Health, the Association for Frontotemporal Degeneration, the Bluefield Project to Cure FTD, the Rainwater Charitable Foundation, and the Larry L. Hillblom Foundation. Dr. Staffaroni reported being a coinventor of four ALLFTD mobile application tasks (not analyzed in the current study); receiving licensing fees from Datacubed Health and research support from the National Institute on Aging of the NIH, Bluefield Project to Cure FTD, the Alzheimer’s Association, the Larry L. Hillblom Foundation, and the Rainwater Charitable Foundation; and consulting for Alector Inc., Eli Lilly and Company Prevail Therapeutics, Passage Bio Inc, and Takeda Pharmaceuticals. Dr. Kukull participated in the ALLFTD Consortium.

A version of this article appeared on Medscape.com.

Cognitive assessments administered via a smartphone app are a reliable and valid way to detect frontotemporal dementia (FTD) in high-risk individuals, new research showed.

Cognitive tests administered remotely on the phone “showed similar findings as our gold standard in-clinic cognitive tests and brain imaging,” said study investigator Adam M. Staffaroni, PhD, with the Memory and Aging Center, University of California San Francisco.

“We also provided evidence that these assessments may be useful for detecting early symptoms of the disease at a level that is on par, or perhaps slightly better, than our gold standard in-person tests,” Dr. Staffaroni said.

The study was published online in JAMA Network Open.
 

Tough to Diagnose

Although relatively rare, FTD is the top cause of dementia in patients younger than 60 years. Patients are usually diagnosed relatively late in the disease because they are young and because their symptoms may be mistaken for psychiatric disorders.

In addition, behavioral and motor symptoms of FTD can make it hard for families to get to an academic center for in-clinic assessments, making remote assessments a huge need.

Dr. Staffaroni and colleagues with the ALLFTD Consortium partnered with software company Datacubed Health to develop the ALLFTD-mApp, which includes cognitive, motor, and speech tasks.

They assessed the reliability and validity of the app, against standard in-clinic assessments, in 350 individuals (mean age, 54 years; 58% women; mean education level, 16.5 years).

Among the 329 individuals with data on disease stage, 195 (59%) were asymptomatic or had preclinical FTD, 66 (20%) had prodromal FTD, and 68 (21%) had symptomatic FTD with a range of clinical syndromes.

The smartphone app showed “moderate to excellent” reliability within a single administration (ie, internally consistent) and across repeated assessments (ie, test-retest reliability), the researchers reported.

Validity was supported by association of smartphones tests with disease severity, criterion-standard neuropsychological tests, and brain volume, they noted.
 

Of Great Interest

They also reported that a composite of brief smartphone tests accurately distinguished dementia from cognitively unimpaired participants, screening out participants without symptoms, and detected prodromal FTD with greater sensitivity than the Montreal Cognitive Assessment.

“This tool is currently being used in several research studies. The remote aspect of this technology is important because it could allow researchers to collect data more frequently, which may give them a more accurate picture of the disease. Furthermore, researchers can be more inclusive in their study designs and include participants who otherwise might have difficulty traveling to academic centers for standard in-person visits,” said Dr. Staffaroni.

“Because the app appears sensitive to early stages of the disease, it could be also used as a screening tool, possibly alongside other remote data collection, to help identify participants that might be appropriate for a clinical trial. At this point, these technologies are not ready for clinical use and require additional research studies to understand their clinical utility,” he cautioned.

Commenting on the study, Walter Kukull, PhD, director of the National Alzheimer’s Coordinating Center at the University of Washington in Seattle, noted that “remote direct and indirect testing/telemetry are of great interest to the field and are being examined carefully in comparison to in-person means both for validity and possibly earlier recognition.”

This research was supported by grants from the National Institutes of Health, the Association for Frontotemporal Degeneration, the Bluefield Project to Cure FTD, the Rainwater Charitable Foundation, and the Larry L. Hillblom Foundation. Dr. Staffaroni reported being a coinventor of four ALLFTD mobile application tasks (not analyzed in the current study); receiving licensing fees from Datacubed Health and research support from the National Institute on Aging of the NIH, Bluefield Project to Cure FTD, the Alzheimer’s Association, the Larry L. Hillblom Foundation, and the Rainwater Charitable Foundation; and consulting for Alector Inc., Eli Lilly and Company Prevail Therapeutics, Passage Bio Inc, and Takeda Pharmaceuticals. Dr. Kukull participated in the ALLFTD Consortium.

A version of this article appeared on Medscape.com.

Cognitive assessments administered via a smartphone app are a reliable and valid way to detect frontotemporal dementia (FTD) in high-risk individuals, new research showed.

Cognitive tests administered remotely on the phone “showed similar findings as our gold standard in-clinic cognitive tests and brain imaging,” said study investigator Adam M. Staffaroni, PhD, with the Memory and Aging Center, University of California San Francisco.

“We also provided evidence that these assessments may be useful for detecting early symptoms of the disease at a level that is on par, or perhaps slightly better, than our gold standard in-person tests,” Dr. Staffaroni said.

The study was published online in JAMA Network Open.
 

Tough to Diagnose

Although relatively rare, FTD is the top cause of dementia in patients younger than 60 years. Patients are usually diagnosed relatively late in the disease because they are young and because their symptoms may be mistaken for psychiatric disorders.

In addition, behavioral and motor symptoms of FTD can make it hard for families to get to an academic center for in-clinic assessments, making remote assessments a huge need.

Dr. Staffaroni and colleagues with the ALLFTD Consortium partnered with software company Datacubed Health to develop the ALLFTD-mApp, which includes cognitive, motor, and speech tasks.

They assessed the reliability and validity of the app, against standard in-clinic assessments, in 350 individuals (mean age, 54 years; 58% women; mean education level, 16.5 years).

Among the 329 individuals with data on disease stage, 195 (59%) were asymptomatic or had preclinical FTD, 66 (20%) had prodromal FTD, and 68 (21%) had symptomatic FTD with a range of clinical syndromes.

The smartphone app showed “moderate to excellent” reliability within a single administration (ie, internally consistent) and across repeated assessments (ie, test-retest reliability), the researchers reported.

Validity was supported by association of smartphones tests with disease severity, criterion-standard neuropsychological tests, and brain volume, they noted.
 

Of Great Interest

They also reported that a composite of brief smartphone tests accurately distinguished dementia from cognitively unimpaired participants, screening out participants without symptoms, and detected prodromal FTD with greater sensitivity than the Montreal Cognitive Assessment.

“This tool is currently being used in several research studies. The remote aspect of this technology is important because it could allow researchers to collect data more frequently, which may give them a more accurate picture of the disease. Furthermore, researchers can be more inclusive in their study designs and include participants who otherwise might have difficulty traveling to academic centers for standard in-person visits,” said Dr. Staffaroni.

“Because the app appears sensitive to early stages of the disease, it could be also used as a screening tool, possibly alongside other remote data collection, to help identify participants that might be appropriate for a clinical trial. At this point, these technologies are not ready for clinical use and require additional research studies to understand their clinical utility,” he cautioned.

Commenting on the study, Walter Kukull, PhD, director of the National Alzheimer’s Coordinating Center at the University of Washington in Seattle, noted that “remote direct and indirect testing/telemetry are of great interest to the field and are being examined carefully in comparison to in-person means both for validity and possibly earlier recognition.”

This research was supported by grants from the National Institutes of Health, the Association for Frontotemporal Degeneration, the Bluefield Project to Cure FTD, the Rainwater Charitable Foundation, and the Larry L. Hillblom Foundation. Dr. Staffaroni reported being a coinventor of four ALLFTD mobile application tasks (not analyzed in the current study); receiving licensing fees from Datacubed Health and research support from the National Institute on Aging of the NIH, Bluefield Project to Cure FTD, the Alzheimer’s Association, the Larry L. Hillblom Foundation, and the Rainwater Charitable Foundation; and consulting for Alector Inc., Eli Lilly and Company Prevail Therapeutics, Passage Bio Inc, and Takeda Pharmaceuticals. Dr. Kukull participated in the ALLFTD Consortium.

A version of this article appeared on Medscape.com.

Dogs can detect stress-related compounds in the breath of people experiencing early signs of trauma, including those with posttraumatic stress disorder (PTSD), a new proof-of-concept study suggested.

The research provides evidence that some service dogs with PTSD can be trained to detect episodes of pending distress through a person’s breath and perhaps prompt the individual to use coping skills to manage the episode.

“Ours is the first study to demonstrate that at least some dogs can detect putative stress-related volatile organic compounds in human breath that are associated with PTSD symptoms,” study author Laura Kiiroja, PhD candidate, department of psychology and neuroscience, faculty of science, Dalhousie University, Halifax, Nova Scotia, Canada, told this news organization.

The study was published online on March 28, 2024, in Frontiers of Allergy.

Heightened Sense of Smell

The lifetime prevalence of PTSD is about 8% in the general population, but data show it can reach 23% in veterans. In addition, many more trauma-exposed individuals experience subthreshold symptoms.

Research is investigating the application of dogs’ sense of smell — which is up to 100,000 times more sensitive than humans’ — to detect cancers, viruses, parasites, hypoglycemia, and seizures in humans.

There is also some evidence that dogs can detect putative stress-related volatile organic compounds (VOCs) such as isoprene and monoterpenes from the human body through urine, sweat, and breath, with the greatest success achieved with breath.

The new study included 26 mostly civilian “donors” (mean age, 31 years; 18 females) who had experienced various types of trauma but had no severe mental illness. More than 50% met the criteria for PTSD.

Participants were recruited from a study examining neurocognitive mechanisms underlying the potential links between trauma and cannabis use. However, participants in the dog study abstained from using cannabis for at least 12 hours prior to the study experiments.

Breath Donors

Breath samples were collected via disposable medical-grade face masks at baseline and during ensuing experiments. In total, 40 breath sample sets were collected.

Two female companion dogs — Ivy, a red golden retriever, and Callie, a German shepherd/Belgian Malinois mix — were trained to identify target odors from the samples.

The animals were tested to determine whether they were able to discriminate between breath samples collected from these same “breath donors” during a relatively relaxed state and during induced stress testing which is known as the alternative forced choice discrimination test.

The dogs’ ability to discern trauma cues from breath samples of various individuals was tested by presenting one sample (baseline or trauma cue) at a time. The researchers used signal detection theory to evaluate the sensitivity and specificity of dogs in detecting human stress VOCs.

Investigators found the dogs had about a 90% accuracy rate across all sample sets in the discrimination experiment and 74% and 81% accuracy for Ivy and Callie, respectively, in the detection experiment.

“Our study contributed to the evidence showing that not only are dogs able to detect some physical health conditions in humans but also that some mental health conditions alter the released VOCs in a way that is detectable by dogs,” Ms. Kiiroja said.

Emotion Detectors

At baseline and during each cue exposure, donors reported their affect using the Positive and Negative Affect Schedule. Ivy’s performance correlated with the donors’ self-reported anxiety, and Callie’s performance correlated with the donors’ self-reported shame.

Based on these correlations, the researchers speculate Ivy detected VOCs that likely originated from the sympathetic-adrenomedullary axis, which involves adrenaline and noradrenaline.

VOCs detected by Callie likely originated in the hypothalamus-pituitary-adrenal axis, which involves cortisol and corticosterone. These two endocrine subsystems play a major role in reestablishing homeostasis in response to a stressor.

The results suggest some service dogs could alert to upcoming intrusion and hyperarousal symptoms even before physical signs manifest and before the person is even aware of the situation, said Ms. Kiiroja.

“This would enable earlier distraction and reminders to use skills learned in psychotherapy; this would have a better likelihood of increasing the efficacy of these skills and preventing further escalation of the arousal,” she said.

Most breath samples likely included both early and late stress VOCs, as the breath donors wore the trauma mask for a relatively long time, the authors noted. Future studies should test dogs’ olfactory acuity on samples collected minutes after the trauma cue, they added.

Another limitation is that all donors were regular cannabis users, so the results may not generalize to others. However, the fact the dogs demonstrated their detection ability even with cannabis users makes the proof-of-concept “more stringent,” Ms. Kiiroja said.

The goal of the study was to see if some dogs are capable of detecting stress VOCs from people with trauma histories in response to trauma cues, so the small number of dogs in the study isn’t a limitation, the authors noted.

‘Wonderful Work’

Commenting on the findings, Elspeth Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, described the research as “wonderful work.” Dr. Ritchie, who was not a part of this study, has also studied PTSD supports dogs.

The study is yet another illustration of the “amazing things dogs can do ... not just for veterans but for people with mental illness.” They can be a source of comfort and help people manage their anxiety.

Training PTSD service dogs can be expensive, with some well-accredited organizations charging about $50,000 for an animal, Dr. Ritchie said. Training a dog to detect VOCs could also be costly, she added.

Although such research has increased in recent years, it’s unclear how it would be applied in practice. Identifying funding for this sort of study and designing trials would also be challenging, Dr. Ritchie added.

“The idea is good, but when you try to operationalize it, it gets tricky,” she said.

The fact that all donors in the study used cannabis is a confounding factor and raises the question of what else might confound the results, Dr. Ritchie added.

Dr. Ritchie emphasized that although ideally veterans would learn to recognize the onset of stress symptoms themselves, a dog could serve as a valuable companion in this process. “That’s precisely why this research should progress,” she said.

The authors and Dr. Ritchie reported no relevant disclosures.
 

A version of this article appeared on Medscape.com.

Dogs can detect stress-related compounds in the breath of people experiencing early signs of trauma, including those with posttraumatic stress disorder (PTSD), a new proof-of-concept study suggested.

The research provides evidence that some service dogs with PTSD can be trained to detect episodes of pending distress through a person’s breath and perhaps prompt the individual to use coping skills to manage the episode.

“Ours is the first study to demonstrate that at least some dogs can detect putative stress-related volatile organic compounds in human breath that are associated with PTSD symptoms,” study author Laura Kiiroja, PhD candidate, department of psychology and neuroscience, faculty of science, Dalhousie University, Halifax, Nova Scotia, Canada, told this news organization.

The study was published online on March 28, 2024, in Frontiers of Allergy.

Heightened Sense of Smell

The lifetime prevalence of PTSD is about 8% in the general population, but data show it can reach 23% in veterans. In addition, many more trauma-exposed individuals experience subthreshold symptoms.

Research is investigating the application of dogs’ sense of smell — which is up to 100,000 times more sensitive than humans’ — to detect cancers, viruses, parasites, hypoglycemia, and seizures in humans.

There is also some evidence that dogs can detect putative stress-related volatile organic compounds (VOCs) such as isoprene and monoterpenes from the human body through urine, sweat, and breath, with the greatest success achieved with breath.

The new study included 26 mostly civilian “donors” (mean age, 31 years; 18 females) who had experienced various types of trauma but had no severe mental illness. More than 50% met the criteria for PTSD.

Participants were recruited from a study examining neurocognitive mechanisms underlying the potential links between trauma and cannabis use. However, participants in the dog study abstained from using cannabis for at least 12 hours prior to the study experiments.

Breath Donors

Breath samples were collected via disposable medical-grade face masks at baseline and during ensuing experiments. In total, 40 breath sample sets were collected.

Two female companion dogs — Ivy, a red golden retriever, and Callie, a German shepherd/Belgian Malinois mix — were trained to identify target odors from the samples.

The animals were tested to determine whether they were able to discriminate between breath samples collected from these same “breath donors” during a relatively relaxed state and during induced stress testing which is known as the alternative forced choice discrimination test.

The dogs’ ability to discern trauma cues from breath samples of various individuals was tested by presenting one sample (baseline or trauma cue) at a time. The researchers used signal detection theory to evaluate the sensitivity and specificity of dogs in detecting human stress VOCs.

Investigators found the dogs had about a 90% accuracy rate across all sample sets in the discrimination experiment and 74% and 81% accuracy for Ivy and Callie, respectively, in the detection experiment.

“Our study contributed to the evidence showing that not only are dogs able to detect some physical health conditions in humans but also that some mental health conditions alter the released VOCs in a way that is detectable by dogs,” Ms. Kiiroja said.

Emotion Detectors

At baseline and during each cue exposure, donors reported their affect using the Positive and Negative Affect Schedule. Ivy’s performance correlated with the donors’ self-reported anxiety, and Callie’s performance correlated with the donors’ self-reported shame.

Based on these correlations, the researchers speculate Ivy detected VOCs that likely originated from the sympathetic-adrenomedullary axis, which involves adrenaline and noradrenaline.

VOCs detected by Callie likely originated in the hypothalamus-pituitary-adrenal axis, which involves cortisol and corticosterone. These two endocrine subsystems play a major role in reestablishing homeostasis in response to a stressor.

The results suggest some service dogs could alert to upcoming intrusion and hyperarousal symptoms even before physical signs manifest and before the person is even aware of the situation, said Ms. Kiiroja.

“This would enable earlier distraction and reminders to use skills learned in psychotherapy; this would have a better likelihood of increasing the efficacy of these skills and preventing further escalation of the arousal,” she said.

Most breath samples likely included both early and late stress VOCs, as the breath donors wore the trauma mask for a relatively long time, the authors noted. Future studies should test dogs’ olfactory acuity on samples collected minutes after the trauma cue, they added.

Another limitation is that all donors were regular cannabis users, so the results may not generalize to others. However, the fact the dogs demonstrated their detection ability even with cannabis users makes the proof-of-concept “more stringent,” Ms. Kiiroja said.

The goal of the study was to see if some dogs are capable of detecting stress VOCs from people with trauma histories in response to trauma cues, so the small number of dogs in the study isn’t a limitation, the authors noted.

‘Wonderful Work’

Commenting on the findings, Elspeth Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, described the research as “wonderful work.” Dr. Ritchie, who was not a part of this study, has also studied PTSD supports dogs.

The study is yet another illustration of the “amazing things dogs can do ... not just for veterans but for people with mental illness.” They can be a source of comfort and help people manage their anxiety.

Training PTSD service dogs can be expensive, with some well-accredited organizations charging about $50,000 for an animal, Dr. Ritchie said. Training a dog to detect VOCs could also be costly, she added.

Although such research has increased in recent years, it’s unclear how it would be applied in practice. Identifying funding for this sort of study and designing trials would also be challenging, Dr. Ritchie added.

“The idea is good, but when you try to operationalize it, it gets tricky,” she said.

The fact that all donors in the study used cannabis is a confounding factor and raises the question of what else might confound the results, Dr. Ritchie added.

Dr. Ritchie emphasized that although ideally veterans would learn to recognize the onset of stress symptoms themselves, a dog could serve as a valuable companion in this process. “That’s precisely why this research should progress,” she said.

The authors and Dr. Ritchie reported no relevant disclosures.
 

A version of this article appeared on Medscape.com.

Dogs can detect stress-related compounds in the breath of people experiencing early signs of trauma, including those with posttraumatic stress disorder (PTSD), a new proof-of-concept study suggested.

The research provides evidence that some service dogs with PTSD can be trained to detect episodes of pending distress through a person’s breath and perhaps prompt the individual to use coping skills to manage the episode.

“Ours is the first study to demonstrate that at least some dogs can detect putative stress-related volatile organic compounds in human breath that are associated with PTSD symptoms,” study author Laura Kiiroja, PhD candidate, department of psychology and neuroscience, faculty of science, Dalhousie University, Halifax, Nova Scotia, Canada, told this news organization.

The study was published online on March 28, 2024, in Frontiers of Allergy.

Heightened Sense of Smell

The lifetime prevalence of PTSD is about 8% in the general population, but data show it can reach 23% in veterans. In addition, many more trauma-exposed individuals experience subthreshold symptoms.

Research is investigating the application of dogs’ sense of smell — which is up to 100,000 times more sensitive than humans’ — to detect cancers, viruses, parasites, hypoglycemia, and seizures in humans.

There is also some evidence that dogs can detect putative stress-related volatile organic compounds (VOCs) such as isoprene and monoterpenes from the human body through urine, sweat, and breath, with the greatest success achieved with breath.

The new study included 26 mostly civilian “donors” (mean age, 31 years; 18 females) who had experienced various types of trauma but had no severe mental illness. More than 50% met the criteria for PTSD.

Participants were recruited from a study examining neurocognitive mechanisms underlying the potential links between trauma and cannabis use. However, participants in the dog study abstained from using cannabis for at least 12 hours prior to the study experiments.

Breath Donors

Breath samples were collected via disposable medical-grade face masks at baseline and during ensuing experiments. In total, 40 breath sample sets were collected.

Two female companion dogs — Ivy, a red golden retriever, and Callie, a German shepherd/Belgian Malinois mix — were trained to identify target odors from the samples.

The animals were tested to determine whether they were able to discriminate between breath samples collected from these same “breath donors” during a relatively relaxed state and during induced stress testing which is known as the alternative forced choice discrimination test.

The dogs’ ability to discern trauma cues from breath samples of various individuals was tested by presenting one sample (baseline or trauma cue) at a time. The researchers used signal detection theory to evaluate the sensitivity and specificity of dogs in detecting human stress VOCs.

Investigators found the dogs had about a 90% accuracy rate across all sample sets in the discrimination experiment and 74% and 81% accuracy for Ivy and Callie, respectively, in the detection experiment.

“Our study contributed to the evidence showing that not only are dogs able to detect some physical health conditions in humans but also that some mental health conditions alter the released VOCs in a way that is detectable by dogs,” Ms. Kiiroja said.

Emotion Detectors

At baseline and during each cue exposure, donors reported their affect using the Positive and Negative Affect Schedule. Ivy’s performance correlated with the donors’ self-reported anxiety, and Callie’s performance correlated with the donors’ self-reported shame.

Based on these correlations, the researchers speculate Ivy detected VOCs that likely originated from the sympathetic-adrenomedullary axis, which involves adrenaline and noradrenaline.

VOCs detected by Callie likely originated in the hypothalamus-pituitary-adrenal axis, which involves cortisol and corticosterone. These two endocrine subsystems play a major role in reestablishing homeostasis in response to a stressor.

The results suggest some service dogs could alert to upcoming intrusion and hyperarousal symptoms even before physical signs manifest and before the person is even aware of the situation, said Ms. Kiiroja.

“This would enable earlier distraction and reminders to use skills learned in psychotherapy; this would have a better likelihood of increasing the efficacy of these skills and preventing further escalation of the arousal,” she said.

Most breath samples likely included both early and late stress VOCs, as the breath donors wore the trauma mask for a relatively long time, the authors noted. Future studies should test dogs’ olfactory acuity on samples collected minutes after the trauma cue, they added.

Another limitation is that all donors were regular cannabis users, so the results may not generalize to others. However, the fact the dogs demonstrated their detection ability even with cannabis users makes the proof-of-concept “more stringent,” Ms. Kiiroja said.

The goal of the study was to see if some dogs are capable of detecting stress VOCs from people with trauma histories in response to trauma cues, so the small number of dogs in the study isn’t a limitation, the authors noted.

‘Wonderful Work’

Commenting on the findings, Elspeth Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, described the research as “wonderful work.” Dr. Ritchie, who was not a part of this study, has also studied PTSD supports dogs.

The study is yet another illustration of the “amazing things dogs can do ... not just for veterans but for people with mental illness.” They can be a source of comfort and help people manage their anxiety.

Training PTSD service dogs can be expensive, with some well-accredited organizations charging about $50,000 for an animal, Dr. Ritchie said. Training a dog to detect VOCs could also be costly, she added.

Although such research has increased in recent years, it’s unclear how it would be applied in practice. Identifying funding for this sort of study and designing trials would also be challenging, Dr. Ritchie added.

“The idea is good, but when you try to operationalize it, it gets tricky,” she said.

The fact that all donors in the study used cannabis is a confounding factor and raises the question of what else might confound the results, Dr. Ritchie added.

Dr. Ritchie emphasized that although ideally veterans would learn to recognize the onset of stress symptoms themselves, a dog could serve as a valuable companion in this process. “That’s precisely why this research should progress,” she said.

The authors and Dr. Ritchie reported no relevant disclosures.
 

A version of this article appeared on Medscape.com.

This case is a little out of the ordinary, but we would love to find out how readers would handle it.

Diana is a 51-year-old woman with a history of depression, obesity, hypertension, type 2 diabetes, and coronary artery disease. She has come in for a routine visit for her chronic illnesses. She seems very distant and has a flat affect during the initial interview. When you ask about any recent stressful events, she begins crying and explains that her daughter was just deported, leaving behind a child and boyfriend.

Their country of origin suffers from chronic instability and violence. Diana’s father was murdered there, and Diana was the victim of sexual assault. “I escaped when I was 18, and I tried to never look back. Until now.” Diana is very worried about her daughter’s return to that country. “I don’t want her to have to endure what I have endured.”

You spend some time discussing the patient’s mental health burden and identify a counselor and online resources that might help. You wonder if Diana’s adverse childhood experiences (ACEs) might have contributed to some of her physical illnesses.

ACEs and Adult Health

The effects of trauma run long and deep. ACEs have been associated with higher risks for multiple chronic conditions, even among adults aged 60 years or older. Therefore, clinicians should consider a patient’s history of ACEs as part of their evaluation of risk for chronic illness.

One of the most pronounced and straightforward links is that between ACEs and depression. In the Southern Community Cohort Study of more than 38,200 US adults, the highest odds ratio between ACEs and chronic disease was for depression. Persons who reported more than three ACEs had about a twofold increase in the risk for depression compared with persons without ACEs. There was a monotonic increase in the risk for depression and other chronic illnesses as the burden of ACEs increased.

In another study from the United Kingdom, each additional ACE was associated with a significant 11% increase in the risk for incident diabetes during adulthood. Researchers found that both depression symptoms and cardiometabolic dysfunction mediated the effects of ACEs in promoting higher rates of diabetes.

Depression and diabetes are significant risk factors for coronary artery disease, so it is not surprising that ACEs are also associated with a higher risk for coronary events. A review by Godoy and colleagues described how ACEs promote neuroendocrine, autonomic, and inflammatory dysfunction, which in turn leads to higher rates of traditional cardiovascular risk factors such as diabetes and obesity. Ultimately, the presence of four or more ACEs is associated with more than a twofold higher risk for cardiovascular disease compared with no ACEs.

Many of the pathologic processes that promote cardiovascular disease also increase the risk for dementia. Could the reach of ACEs span decades to promote a higher risk for dementia among older adults? A study by Yuan and colleagues of 7222 Chinese adults suggests that the answer is yes. This study divided the cohort into persons with a history of no ACEs, household dysfunction during childhood, or mistreatment during childhood. Child mistreatment was associated with higher rates of diabetes, depression, and cardiovascular disease, as well as an odds ratio of 1.37 (95% CI, 1.12 to 1.68) for cognitive impairment.

The magnitude of the effects ACEs can have on well-being is reinforced by epidemiologic data surrounding ACEs. According to the US Centers for Disease Control and Prevention (CDC), 64% of US adults report at least one ACE and 17% experienced at least four ACEs. Risk factors for ACEs include being female, American Indian or Alaska Native, or unemployed.

How do we reduce the impact of ACEs? Prevention is key. The CDC estimates that nearly 2 million cases of adult heart disease and more than 20 million cases of adult depression could be avoided if ACEs were eliminated.

But what is the best means to pragmatically reduce ACEs in our current practice models? How do we discover a history of ACEs in patients, and what are the best practices in managing persons with a positive history? We will cover these critical subjects in a future article, but for now, please provide your own comments and pearls regarding the prevention and management of ACEs.

Dr. Vega, health sciences clinical professor, family medicine, University of California, Irvine, disclosed ties with GlaxoSmithKline and Johnson and Johnson. Ms. Hurtado, MD candidate, University of California, Irvine School of Medicine, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This case is a little out of the ordinary, but we would love to find out how readers would handle it.

Diana is a 51-year-old woman with a history of depression, obesity, hypertension, type 2 diabetes, and coronary artery disease. She has come in for a routine visit for her chronic illnesses. She seems very distant and has a flat affect during the initial interview. When you ask about any recent stressful events, she begins crying and explains that her daughter was just deported, leaving behind a child and boyfriend.

Their country of origin suffers from chronic instability and violence. Diana’s father was murdered there, and Diana was the victim of sexual assault. “I escaped when I was 18, and I tried to never look back. Until now.” Diana is very worried about her daughter’s return to that country. “I don’t want her to have to endure what I have endured.”

You spend some time discussing the patient’s mental health burden and identify a counselor and online resources that might help. You wonder if Diana’s adverse childhood experiences (ACEs) might have contributed to some of her physical illnesses.

ACEs and Adult Health

The effects of trauma run long and deep. ACEs have been associated with higher risks for multiple chronic conditions, even among adults aged 60 years or older. Therefore, clinicians should consider a patient’s history of ACEs as part of their evaluation of risk for chronic illness.

One of the most pronounced and straightforward links is that between ACEs and depression. In the Southern Community Cohort Study of more than 38,200 US adults, the highest odds ratio between ACEs and chronic disease was for depression. Persons who reported more than three ACEs had about a twofold increase in the risk for depression compared with persons without ACEs. There was a monotonic increase in the risk for depression and other chronic illnesses as the burden of ACEs increased.

In another study from the United Kingdom, each additional ACE was associated with a significant 11% increase in the risk for incident diabetes during adulthood. Researchers found that both depression symptoms and cardiometabolic dysfunction mediated the effects of ACEs in promoting higher rates of diabetes.

Depression and diabetes are significant risk factors for coronary artery disease, so it is not surprising that ACEs are also associated with a higher risk for coronary events. A review by Godoy and colleagues described how ACEs promote neuroendocrine, autonomic, and inflammatory dysfunction, which in turn leads to higher rates of traditional cardiovascular risk factors such as diabetes and obesity. Ultimately, the presence of four or more ACEs is associated with more than a twofold higher risk for cardiovascular disease compared with no ACEs.

Many of the pathologic processes that promote cardiovascular disease also increase the risk for dementia. Could the reach of ACEs span decades to promote a higher risk for dementia among older adults? A study by Yuan and colleagues of 7222 Chinese adults suggests that the answer is yes. This study divided the cohort into persons with a history of no ACEs, household dysfunction during childhood, or mistreatment during childhood. Child mistreatment was associated with higher rates of diabetes, depression, and cardiovascular disease, as well as an odds ratio of 1.37 (95% CI, 1.12 to 1.68) for cognitive impairment.

The magnitude of the effects ACEs can have on well-being is reinforced by epidemiologic data surrounding ACEs. According to the US Centers for Disease Control and Prevention (CDC), 64% of US adults report at least one ACE and 17% experienced at least four ACEs. Risk factors for ACEs include being female, American Indian or Alaska Native, or unemployed.

How do we reduce the impact of ACEs? Prevention is key. The CDC estimates that nearly 2 million cases of adult heart disease and more than 20 million cases of adult depression could be avoided if ACEs were eliminated.

But what is the best means to pragmatically reduce ACEs in our current practice models? How do we discover a history of ACEs in patients, and what are the best practices in managing persons with a positive history? We will cover these critical subjects in a future article, but for now, please provide your own comments and pearls regarding the prevention and management of ACEs.

Dr. Vega, health sciences clinical professor, family medicine, University of California, Irvine, disclosed ties with GlaxoSmithKline and Johnson and Johnson. Ms. Hurtado, MD candidate, University of California, Irvine School of Medicine, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This case is a little out of the ordinary, but we would love to find out how readers would handle it.

Diana is a 51-year-old woman with a history of depression, obesity, hypertension, type 2 diabetes, and coronary artery disease. She has come in for a routine visit for her chronic illnesses. She seems very distant and has a flat affect during the initial interview. When you ask about any recent stressful events, she begins crying and explains that her daughter was just deported, leaving behind a child and boyfriend.

Their country of origin suffers from chronic instability and violence. Diana’s father was murdered there, and Diana was the victim of sexual assault. “I escaped when I was 18, and I tried to never look back. Until now.” Diana is very worried about her daughter’s return to that country. “I don’t want her to have to endure what I have endured.”

You spend some time discussing the patient’s mental health burden and identify a counselor and online resources that might help. You wonder if Diana’s adverse childhood experiences (ACEs) might have contributed to some of her physical illnesses.

ACEs and Adult Health

The effects of trauma run long and deep. ACEs have been associated with higher risks for multiple chronic conditions, even among adults aged 60 years or older. Therefore, clinicians should consider a patient’s history of ACEs as part of their evaluation of risk for chronic illness.

One of the most pronounced and straightforward links is that between ACEs and depression. In the Southern Community Cohort Study of more than 38,200 US adults, the highest odds ratio between ACEs and chronic disease was for depression. Persons who reported more than three ACEs had about a twofold increase in the risk for depression compared with persons without ACEs. There was a monotonic increase in the risk for depression and other chronic illnesses as the burden of ACEs increased.

In another study from the United Kingdom, each additional ACE was associated with a significant 11% increase in the risk for incident diabetes during adulthood. Researchers found that both depression symptoms and cardiometabolic dysfunction mediated the effects of ACEs in promoting higher rates of diabetes.

Depression and diabetes are significant risk factors for coronary artery disease, so it is not surprising that ACEs are also associated with a higher risk for coronary events. A review by Godoy and colleagues described how ACEs promote neuroendocrine, autonomic, and inflammatory dysfunction, which in turn leads to higher rates of traditional cardiovascular risk factors such as diabetes and obesity. Ultimately, the presence of four or more ACEs is associated with more than a twofold higher risk for cardiovascular disease compared with no ACEs.

Many of the pathologic processes that promote cardiovascular disease also increase the risk for dementia. Could the reach of ACEs span decades to promote a higher risk for dementia among older adults? A study by Yuan and colleagues of 7222 Chinese adults suggests that the answer is yes. This study divided the cohort into persons with a history of no ACEs, household dysfunction during childhood, or mistreatment during childhood. Child mistreatment was associated with higher rates of diabetes, depression, and cardiovascular disease, as well as an odds ratio of 1.37 (95% CI, 1.12 to 1.68) for cognitive impairment.

The magnitude of the effects ACEs can have on well-being is reinforced by epidemiologic data surrounding ACEs. According to the US Centers for Disease Control and Prevention (CDC), 64% of US adults report at least one ACE and 17% experienced at least four ACEs. Risk factors for ACEs include being female, American Indian or Alaska Native, or unemployed.

How do we reduce the impact of ACEs? Prevention is key. The CDC estimates that nearly 2 million cases of adult heart disease and more than 20 million cases of adult depression could be avoided if ACEs were eliminated.

But what is the best means to pragmatically reduce ACEs in our current practice models? How do we discover a history of ACEs in patients, and what are the best practices in managing persons with a positive history? We will cover these critical subjects in a future article, but for now, please provide your own comments and pearls regarding the prevention and management of ACEs.

Dr. Vega, health sciences clinical professor, family medicine, University of California, Irvine, disclosed ties with GlaxoSmithKline and Johnson and Johnson. Ms. Hurtado, MD candidate, University of California, Irvine School of Medicine, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

SAN DIEGO — In the clinical opinion of Jenny E. Murase, MD, caring for patients with delusional infestation — the conviction that one is infested by animate or inanimate pathogens without medical or microbiological evidence of a true infestation — puts a dermatologist’s communication skills to the ultimate test.

“The fact that delusional infestation is a fixed, false belief [means] we will never agree with patients on the etiology by definition,” Dr. Murase, a dermatologist with the Palo Alto Foundation Medical Group, Mountain View, California, said at the annual meeting of the American Academy of Dermatology. “But somehow, we must come to some kind of an agreement on how to approach this therapeutically.”

Patients with delusional infestation (DI) often describe a cutaneous sensation of itching or crawling, biting, stinging — a pins and needles sensation. “Formication is when there’s a crawling sensation on the surface of the skin,” she said. “That’s something we can agree on — the fact that there is a shared understanding that they’re experiencing some kind of sensation in their skin.”

First described in 1894, several different terms have been used to describe DI in the past, including acarophobia, delusions of parasitosis, Ekbom syndrome, and Morgellons disease. The current term used for DI includes other animate or inanimate pathogens besides parasites.

The average dermatologist manages two to three patients with DI every 5 years, “so it’s not uncommon,” said Dr. Murase, who also holds a faculty position in the department of dermatology at the University of California, San Francisco. Females are about 2.5 times more likely to be affected compared with males, she said, and 8%-12% of patients with DI have a friend or relative who shares the symptom, and they often accompany them to the office visit. “Initially, you’re trying to determine if this a primary condition where it’s only the cutaneous condition the patient is experiencing, or if there is a secondary condition like an underlying psychiatric disorder or medical condition or drug use that contributes to the sensation,” she said.

According to a descriptive study of 115 patients with DI, 50% had at least one drug detected in hair samples, and nearly 60% had evidence of some cognitive impairment that could not be explained by deficits in IQ. Another study of 147 patients with DI seen at the Mayo Clinic between 2001 and 2007 found that 81% had a prior psychiatric condition and 26% had a shared psychotic disorder.
 

Phased Approach to Treatment

Dr. Murase discussed her phased approach to caring for patients with DI, based on a review article that she and colleagues published in the International Journal of Dermatology. Phase 1 involves preparing for the visit by asking staff to refer to patients with DI as VIPs and allowing them to talk freely about the sensation they’re experiencing. “The goal is to improve the patient’s condition, not to convince the patient that he or she is delusional,” Dr. Murase explained. “Many patients can’t distinguish between when they’re talking to the doctor and when they’re talking to a nurse or a nurse practitioner; they like to feel that they’re being heard and listened to.”

She also recommends scheduling patients with DI for the end of the day and arranging frequent follow-up visits. “Making them feel valued is the bottom line,” she emphasized. “Remember: They’re less likely to respect socially defined boundaries like time constraints, so you do have to set boundaries, and don’t take what they may say to you personally. You’re not going to be able to care for that individual unless you do that. They may appear defiant, frustrated, and angry, but the fact that they showed up in your office means that you can help that person.”

Phase 2 of care for these patients consists of building a therapeutic rapport by greeting them with a smile and positive attitude and using welcoming body language such as sitting side-by-side during the office visit as opposed to face-to-face, “so it’s a less aggressive approach,” she said. Next, ask about their goal with a question such as, “Is it more important for you to find the bug/virus or to improve your condition?”

During the visit, “you’re continually shifting from etiology — which they are desperate to understand — to a shared desire for treatment,” Dr. Murase said. “No one knows what causes DI and remember, in medicine we treat patients when the exact etiology is unknown. So, we’re not doing anything that differently. Focus on the effect that the symptoms are having on their life. Say something like, ‘it must be so miserable to be living this way. I really want to help you.’ ”

Phase 3 of care for patients with DI involves performing a thorough history and physical exam. The initial office visit should include a full body exam to rule out any underlying dermatologic condition that may be causing the sensation they’re complaining about. She cited a retrospective study of 108 patients who presented to the Mayo Clinic with DI as the main reason for their office visit. Of the 80 patients who had a biopsy, 61% had chronic dermatitis; 48% had excoriation, ulceration, or erosion; and 31% had nonspecific dermal inflammation.

Whether to perform a biopsy or not is controversial, Dr. Murase added, because it’s probably not going to change the clinical impression or diagnosis. “If you agree to do the biopsy, get a verbal contract with the patient,” she advised. “You might say, ‘We’re going to do this. You’re going to choose the site, we’re going to do a biopsy, but we are going to be in agreement here that, if we can’t find the etiology, that you will still be open to going on therapy.’ This is important because it establishes a therapeutic alliance.”

Since patients with DI often bring in their own specimens, she also recommends providing them with microscope glass slides without cover slips and asking them to use clear tape, not tape that is opaque or matted, to cover the specimen.

To rule out other illnesses and conditions that could be triggering the perceived DI, she said lab tests to consider include a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, calcium, hemoglobin A1c, vitamin B12, urinalysis, toxicology screen, HIV/hepatitis C, and rapid plasma reagin.
 

Starting Treatment

Phase 4 of care for patients with DI involves initiating therapy, which includes demonstrating empathy by reflecting on the detrimental effects of the patient’s reported sensations on their quality of life. “Emphasize that you are not questioning their experience, and that you don’t doubt that they feel things on their skin,” Dr. Murase said. “Recommend medications on an empirical or ‘trial and error’ pragmatic basis. I often tell patients, ‘I will never give up on you if you will never give up on me.’”

For treating patients with DI, her first-generation antipsychotic of choice is pimozide. She starts at a dose of 0.5 mg, building up to 2-3 mg once a day. Haloperidol is another option: 0.5 mg to start, building up to 1-5 mg every night at bedtime. “This requires monitoring for bone suppression via CBC and hypermetabolic complications via fasting lipids and HbA1c,” she said. “There is also an increased risk of prolonged QT with pimozide and risk of extrapyramidal symptoms and tardive dyskinesia.”

Second-generation antipsychotics to consider include risperidone (0.5 mg to start, building up to 102 mg at bedtime); olanzapine (2.5 mg to start, building up to 5-10 mg at bedtime); aripiprazole (2-5 mg to start, building up to 10-15 mg a day), and quetiapine (12.5 mg to start, building up to 200 mg at bedtime).

For all medical therapy she recommends starting patients with a low dose, increasing by 0.5 mg every 2-3 weeks, and let them be “stable and comfortable” for 3-4 months, and then taper down the dose by 0.5 mg every 2-4 weeks or more slowly. In the medical chart, Dr. Murase recommends avoiding use of the terms “psychosis” and “delusions.” Instead, “formication” (tactile hallucination of insects crawling on or within the skin) or “cutaneous dysesthesia” are better terms if patients access their records, she said.

Dr. Murase reported having no relevant disclosures.

SAN DIEGO — In the clinical opinion of Jenny E. Murase, MD, caring for patients with delusional infestation — the conviction that one is infested by animate or inanimate pathogens without medical or microbiological evidence of a true infestation — puts a dermatologist’s communication skills to the ultimate test.

“The fact that delusional infestation is a fixed, false belief [means] we will never agree with patients on the etiology by definition,” Dr. Murase, a dermatologist with the Palo Alto Foundation Medical Group, Mountain View, California, said at the annual meeting of the American Academy of Dermatology. “But somehow, we must come to some kind of an agreement on how to approach this therapeutically.”

Patients with delusional infestation (DI) often describe a cutaneous sensation of itching or crawling, biting, stinging — a pins and needles sensation. “Formication is when there’s a crawling sensation on the surface of the skin,” she said. “That’s something we can agree on — the fact that there is a shared understanding that they’re experiencing some kind of sensation in their skin.”

First described in 1894, several different terms have been used to describe DI in the past, including acarophobia, delusions of parasitosis, Ekbom syndrome, and Morgellons disease. The current term used for DI includes other animate or inanimate pathogens besides parasites.

The average dermatologist manages two to three patients with DI every 5 years, “so it’s not uncommon,” said Dr. Murase, who also holds a faculty position in the department of dermatology at the University of California, San Francisco. Females are about 2.5 times more likely to be affected compared with males, she said, and 8%-12% of patients with DI have a friend or relative who shares the symptom, and they often accompany them to the office visit. “Initially, you’re trying to determine if this a primary condition where it’s only the cutaneous condition the patient is experiencing, or if there is a secondary condition like an underlying psychiatric disorder or medical condition or drug use that contributes to the sensation,” she said.

According to a descriptive study of 115 patients with DI, 50% had at least one drug detected in hair samples, and nearly 60% had evidence of some cognitive impairment that could not be explained by deficits in IQ. Another study of 147 patients with DI seen at the Mayo Clinic between 2001 and 2007 found that 81% had a prior psychiatric condition and 26% had a shared psychotic disorder.
 

Phased Approach to Treatment

Dr. Murase discussed her phased approach to caring for patients with DI, based on a review article that she and colleagues published in the International Journal of Dermatology. Phase 1 involves preparing for the visit by asking staff to refer to patients with DI as VIPs and allowing them to talk freely about the sensation they’re experiencing. “The goal is to improve the patient’s condition, not to convince the patient that he or she is delusional,” Dr. Murase explained. “Many patients can’t distinguish between when they’re talking to the doctor and when they’re talking to a nurse or a nurse practitioner; they like to feel that they’re being heard and listened to.”

She also recommends scheduling patients with DI for the end of the day and arranging frequent follow-up visits. “Making them feel valued is the bottom line,” she emphasized. “Remember: They’re less likely to respect socially defined boundaries like time constraints, so you do have to set boundaries, and don’t take what they may say to you personally. You’re not going to be able to care for that individual unless you do that. They may appear defiant, frustrated, and angry, but the fact that they showed up in your office means that you can help that person.”

Phase 2 of care for these patients consists of building a therapeutic rapport by greeting them with a smile and positive attitude and using welcoming body language such as sitting side-by-side during the office visit as opposed to face-to-face, “so it’s a less aggressive approach,” she said. Next, ask about their goal with a question such as, “Is it more important for you to find the bug/virus or to improve your condition?”

During the visit, “you’re continually shifting from etiology — which they are desperate to understand — to a shared desire for treatment,” Dr. Murase said. “No one knows what causes DI and remember, in medicine we treat patients when the exact etiology is unknown. So, we’re not doing anything that differently. Focus on the effect that the symptoms are having on their life. Say something like, ‘it must be so miserable to be living this way. I really want to help you.’ ”

Phase 3 of care for patients with DI involves performing a thorough history and physical exam. The initial office visit should include a full body exam to rule out any underlying dermatologic condition that may be causing the sensation they’re complaining about. She cited a retrospective study of 108 patients who presented to the Mayo Clinic with DI as the main reason for their office visit. Of the 80 patients who had a biopsy, 61% had chronic dermatitis; 48% had excoriation, ulceration, or erosion; and 31% had nonspecific dermal inflammation.

Whether to perform a biopsy or not is controversial, Dr. Murase added, because it’s probably not going to change the clinical impression or diagnosis. “If you agree to do the biopsy, get a verbal contract with the patient,” she advised. “You might say, ‘We’re going to do this. You’re going to choose the site, we’re going to do a biopsy, but we are going to be in agreement here that, if we can’t find the etiology, that you will still be open to going on therapy.’ This is important because it establishes a therapeutic alliance.”

Since patients with DI often bring in their own specimens, she also recommends providing them with microscope glass slides without cover slips and asking them to use clear tape, not tape that is opaque or matted, to cover the specimen.

To rule out other illnesses and conditions that could be triggering the perceived DI, she said lab tests to consider include a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, calcium, hemoglobin A1c, vitamin B12, urinalysis, toxicology screen, HIV/hepatitis C, and rapid plasma reagin.
 

Starting Treatment

Phase 4 of care for patients with DI involves initiating therapy, which includes demonstrating empathy by reflecting on the detrimental effects of the patient’s reported sensations on their quality of life. “Emphasize that you are not questioning their experience, and that you don’t doubt that they feel things on their skin,” Dr. Murase said. “Recommend medications on an empirical or ‘trial and error’ pragmatic basis. I often tell patients, ‘I will never give up on you if you will never give up on me.’”

For treating patients with DI, her first-generation antipsychotic of choice is pimozide. She starts at a dose of 0.5 mg, building up to 2-3 mg once a day. Haloperidol is another option: 0.5 mg to start, building up to 1-5 mg every night at bedtime. “This requires monitoring for bone suppression via CBC and hypermetabolic complications via fasting lipids and HbA1c,” she said. “There is also an increased risk of prolonged QT with pimozide and risk of extrapyramidal symptoms and tardive dyskinesia.”

Second-generation antipsychotics to consider include risperidone (0.5 mg to start, building up to 102 mg at bedtime); olanzapine (2.5 mg to start, building up to 5-10 mg at bedtime); aripiprazole (2-5 mg to start, building up to 10-15 mg a day), and quetiapine (12.5 mg to start, building up to 200 mg at bedtime).

For all medical therapy she recommends starting patients with a low dose, increasing by 0.5 mg every 2-3 weeks, and let them be “stable and comfortable” for 3-4 months, and then taper down the dose by 0.5 mg every 2-4 weeks or more slowly. In the medical chart, Dr. Murase recommends avoiding use of the terms “psychosis” and “delusions.” Instead, “formication” (tactile hallucination of insects crawling on or within the skin) or “cutaneous dysesthesia” are better terms if patients access their records, she said.

Dr. Murase reported having no relevant disclosures.

SAN DIEGO — In the clinical opinion of Jenny E. Murase, MD, caring for patients with delusional infestation — the conviction that one is infested by animate or inanimate pathogens without medical or microbiological evidence of a true infestation — puts a dermatologist’s communication skills to the ultimate test.

“The fact that delusional infestation is a fixed, false belief [means] we will never agree with patients on the etiology by definition,” Dr. Murase, a dermatologist with the Palo Alto Foundation Medical Group, Mountain View, California, said at the annual meeting of the American Academy of Dermatology. “But somehow, we must come to some kind of an agreement on how to approach this therapeutically.”

Patients with delusional infestation (DI) often describe a cutaneous sensation of itching or crawling, biting, stinging — a pins and needles sensation. “Formication is when there’s a crawling sensation on the surface of the skin,” she said. “That’s something we can agree on — the fact that there is a shared understanding that they’re experiencing some kind of sensation in their skin.”

First described in 1894, several different terms have been used to describe DI in the past, including acarophobia, delusions of parasitosis, Ekbom syndrome, and Morgellons disease. The current term used for DI includes other animate or inanimate pathogens besides parasites.

The average dermatologist manages two to three patients with DI every 5 years, “so it’s not uncommon,” said Dr. Murase, who also holds a faculty position in the department of dermatology at the University of California, San Francisco. Females are about 2.5 times more likely to be affected compared with males, she said, and 8%-12% of patients with DI have a friend or relative who shares the symptom, and they often accompany them to the office visit. “Initially, you’re trying to determine if this a primary condition where it’s only the cutaneous condition the patient is experiencing, or if there is a secondary condition like an underlying psychiatric disorder or medical condition or drug use that contributes to the sensation,” she said.

According to a descriptive study of 115 patients with DI, 50% had at least one drug detected in hair samples, and nearly 60% had evidence of some cognitive impairment that could not be explained by deficits in IQ. Another study of 147 patients with DI seen at the Mayo Clinic between 2001 and 2007 found that 81% had a prior psychiatric condition and 26% had a shared psychotic disorder.
 

Phased Approach to Treatment

Dr. Murase discussed her phased approach to caring for patients with DI, based on a review article that she and colleagues published in the International Journal of Dermatology. Phase 1 involves preparing for the visit by asking staff to refer to patients with DI as VIPs and allowing them to talk freely about the sensation they’re experiencing. “The goal is to improve the patient’s condition, not to convince the patient that he or she is delusional,” Dr. Murase explained. “Many patients can’t distinguish between when they’re talking to the doctor and when they’re talking to a nurse or a nurse practitioner; they like to feel that they’re being heard and listened to.”

She also recommends scheduling patients with DI for the end of the day and arranging frequent follow-up visits. “Making them feel valued is the bottom line,” she emphasized. “Remember: They’re less likely to respect socially defined boundaries like time constraints, so you do have to set boundaries, and don’t take what they may say to you personally. You’re not going to be able to care for that individual unless you do that. They may appear defiant, frustrated, and angry, but the fact that they showed up in your office means that you can help that person.”

Phase 2 of care for these patients consists of building a therapeutic rapport by greeting them with a smile and positive attitude and using welcoming body language such as sitting side-by-side during the office visit as opposed to face-to-face, “so it’s a less aggressive approach,” she said. Next, ask about their goal with a question such as, “Is it more important for you to find the bug/virus or to improve your condition?”

During the visit, “you’re continually shifting from etiology — which they are desperate to understand — to a shared desire for treatment,” Dr. Murase said. “No one knows what causes DI and remember, in medicine we treat patients when the exact etiology is unknown. So, we’re not doing anything that differently. Focus on the effect that the symptoms are having on their life. Say something like, ‘it must be so miserable to be living this way. I really want to help you.’ ”

Phase 3 of care for patients with DI involves performing a thorough history and physical exam. The initial office visit should include a full body exam to rule out any underlying dermatologic condition that may be causing the sensation they’re complaining about. She cited a retrospective study of 108 patients who presented to the Mayo Clinic with DI as the main reason for their office visit. Of the 80 patients who had a biopsy, 61% had chronic dermatitis; 48% had excoriation, ulceration, or erosion; and 31% had nonspecific dermal inflammation.

Whether to perform a biopsy or not is controversial, Dr. Murase added, because it’s probably not going to change the clinical impression or diagnosis. “If you agree to do the biopsy, get a verbal contract with the patient,” she advised. “You might say, ‘We’re going to do this. You’re going to choose the site, we’re going to do a biopsy, but we are going to be in agreement here that, if we can’t find the etiology, that you will still be open to going on therapy.’ This is important because it establishes a therapeutic alliance.”

Since patients with DI often bring in their own specimens, she also recommends providing them with microscope glass slides without cover slips and asking them to use clear tape, not tape that is opaque or matted, to cover the specimen.

To rule out other illnesses and conditions that could be triggering the perceived DI, she said lab tests to consider include a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, calcium, hemoglobin A1c, vitamin B12, urinalysis, toxicology screen, HIV/hepatitis C, and rapid plasma reagin.
 

Starting Treatment

Phase 4 of care for patients with DI involves initiating therapy, which includes demonstrating empathy by reflecting on the detrimental effects of the patient’s reported sensations on their quality of life. “Emphasize that you are not questioning their experience, and that you don’t doubt that they feel things on their skin,” Dr. Murase said. “Recommend medications on an empirical or ‘trial and error’ pragmatic basis. I often tell patients, ‘I will never give up on you if you will never give up on me.’”

For treating patients with DI, her first-generation antipsychotic of choice is pimozide. She starts at a dose of 0.5 mg, building up to 2-3 mg once a day. Haloperidol is another option: 0.5 mg to start, building up to 1-5 mg every night at bedtime. “This requires monitoring for bone suppression via CBC and hypermetabolic complications via fasting lipids and HbA1c,” she said. “There is also an increased risk of prolonged QT with pimozide and risk of extrapyramidal symptoms and tardive dyskinesia.”

Second-generation antipsychotics to consider include risperidone (0.5 mg to start, building up to 102 mg at bedtime); olanzapine (2.5 mg to start, building up to 5-10 mg at bedtime); aripiprazole (2-5 mg to start, building up to 10-15 mg a day), and quetiapine (12.5 mg to start, building up to 200 mg at bedtime).

For all medical therapy she recommends starting patients with a low dose, increasing by 0.5 mg every 2-3 weeks, and let them be “stable and comfortable” for 3-4 months, and then taper down the dose by 0.5 mg every 2-4 weeks or more slowly. In the medical chart, Dr. Murase recommends avoiding use of the terms “psychosis” and “delusions.” Instead, “formication” (tactile hallucination of insects crawling on or within the skin) or “cutaneous dysesthesia” are better terms if patients access their records, she said.

Dr. Murase reported having no relevant disclosures.

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.

A review of the federal Open Payments database found that the pharmaceutical and medical device industry paid physicians $12.1 billion over nearly a decade.

Almost two thirds of eligible physicians — 826,313 doctors — received a payment from a drug or device maker from 2013 to 2022, according to a study published online in JAMA on March 28. Overall, the median payment was $48 per physician.

Orthopedists received the largest amount of payments in aggregate, $1.3 billion, followed by neurologists and psychiatrists at $1.2 billion and cardiologists at $1.29 billion.

Geriatric and nuclear medicine specialists and trauma and pediatric surgeons received the least amount of money in aggregate, and the mean amount paid to a pediatric surgeon in the top 0.1% was just $338,183 over the 9-year study period.

Excluding 2013 (the database was established in August that year), the total value of payments was highest in 2019 at $1.6 billion, up from $1.34 billion in 2014. It was lowest in 2020, the peak year of the COVID-19 pandemic, but dipped to $864 billion that year and rebounded to $1.28 billion in 2022, wrote the authors.

The Open Payments database, administered by the Centers for Medicare & Medicaid Services, requires drug and device makers and group purchasing organizations to report payments made to physicians, including for consulting services, speaking fees, food and beverages, travel and lodging, education, gifts, grants, and honoraria.

The database was created to shed light on these payments, which have been linked in multiple studies to more prescribing of a particular drug or more use of a particular device.

The JAMA review appeared to show that with the exception of the pandemic year, the relationships have more or less stayed the same since Open Payments began.

“There’s been no sea change, no massive shift in how these interactions are happening,” said Deborah C. Marshall, MD, assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai in New York City, who has studied industry payments.

“There’s no suggestion that anything is really changing other than that’s there is transparency,” said Robert Steinbrook, MD, director of the Health Research Group at Public Citizen.

Still, Dr. Steinbrook told this news organization, “it’s better to know this than to not know this.”

The unchanging nature of industry-physician relationships “suggests that to reduce the volume and magnitude of payments, more would need to be done,” he said.

“Really, this should be banned. Doctors should not be allowed to get gifts from pharmaceutical companies,” said Adriane Fugh-Berman, MD, professor of pharmacology and physiology at Georgetown University, and director of PharmedOut, a Georgetown-based project that advances evidence-based prescribing and educates healthcare professionals about pharmaceutical marketing practices.

“The interactions wouldn’t be happening unless there was a purpose for them,” said Dr. Marshall. The relationships are “built with intention,” Dr. Marshall told this news organization.
 

Top Earners Range From $195,000 to $4.8 Million

Payments to the median physician over the study period ranged from $0 to $2339, but the mean payment to top earners — those in the top 0.1% — ranged from $194,933 for hospitalists to $4.8 million for orthopedic specialists.

Overall, the median payment was $48 per physician.

But small dollar amounts should not be discounted — even if it’s just a $25-catered lunch — said Aaron Mitchell, MD, a medical oncologist and assistant attending physician at Memorial Sloan Kettering Cancer Center in New York City who has studied industry-physician relationships. “The influence is not just in the dollar value,” Dr. Mitchell told this news organization. “It’s about the time listening to and the time in personal contact with industry representatives that these dollars are a marker for,” he said.

“There’s no such thing as a free lunch,” agreed Dr. Marshall. It’s “pretty well established” that lower-value payments do have influence, which is why academic institutions have established policies that limit gifts and meals and other payments from industry, she said.

Dr. Fugh-Berman said, “the size of the gift doesn’t really matter,” adding that research she conducted had shown that “accepting a meal increased not only the expense of the prescriptions that Medicare physicians wrote but also the number of prescriptions.”
 

Payments Mostly for High-Dollar Products

The top 25 drugs and devices that were related to industry payments tended to be high-cost brand-name products.

The top drug was Janssen’s Xarelto, an anticoagulant first approved in 2011 that costs about $600 a month, according to GoodRx. The drug has had annual sales of $4-$6 billion.

Xarelto was followed by Eliquis, another anticoagulant; Humira, used for a variety of autoimmune conditions including plaque psoriasis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis; Invokana, Jardiance, and Farxiga, all for type 2 diabetes.

The top medical devices included the da Vinci Surgical System, Mako SmartRobotics, CoreValve Evolut, Natrelle Implants, and Impella, a heart pump that received a US Food and Drug Administration (FDA) warning that it was associated with a heightened risk for death.
 

Industry Influence May Lead to Higher Cost, Poor Quality Care

Multiple studies have shown that payments to physicians tend to lead to increased prescribing and, often, higher costs for Medicare, a health system, or patients.

“I’m sure there are still a lot of physicians out there who think they’re getting away with something, that they can take meals, or they can take consulting fees and not be influenced, but there’s overwhelming data showing that it always influences you,” said Dr. Fugh-Berman.

One study in 2020 that used the Open Payments database found that physicians increase prescribing of the drugs for which they receive payment in the months just after the payment. The authors also showed that physicians who are paid prescribe lower-quality drugs following the payment, “although the magnitude is small and unlikely to be clinically significant.”

Dr. Marshall said that more studies are needed to determine whether quality of care is being affected when a physician prescribes a drug after an industry payment.

For now, there seems to be little appetite among physicians to give up the payments, said Dr. Marshall and others.

Physicians in some specialties see the payments as “an implicit statement about their value,” said Dr. Marshall.

In oncology, having received a lot of payments “gets worn more as a badge of honor,” said Dr. Mitchell.

The clinicians believe that “by collaborating with industry we are providing scientific expertise to help develop the next generation of technology and cures,” Dr. Mitchell said, adding that they see the payments “as a mark of their impact.”

Among the JAMA study authors, Joseph S. Ross, MD, reported that he is a deputy editor of JAMA but was not involved in decisions regarding acceptance of the manuscript or its review. Dr. Ross also reported receiving grants from the FDA, Johnson and Johnson, the Medical Devices Innovation Consortium, the Agency for Healthcare Research and Quality, and the National Heart, Lung, and Blood Institute. He was an expert witness in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen that was settled in 2022. Dr. Steinbrook, Dr. Marshall, and Dr. Mitchell reported no relevant financial relationships. Dr. Fugh-Berman reported being an expert witness for plaintiffs in complaints about drug and device marketing practices.

A version of this article appeared on Medscape.com.

A review of the federal Open Payments database found that the pharmaceutical and medical device industry paid physicians $12.1 billion over nearly a decade.

Almost two thirds of eligible physicians — 826,313 doctors — received a payment from a drug or device maker from 2013 to 2022, according to a study published online in JAMA on March 28. Overall, the median payment was $48 per physician.

Orthopedists received the largest amount of payments in aggregate, $1.3 billion, followed by neurologists and psychiatrists at $1.2 billion and cardiologists at $1.29 billion.

Geriatric and nuclear medicine specialists and trauma and pediatric surgeons received the least amount of money in aggregate, and the mean amount paid to a pediatric surgeon in the top 0.1% was just $338,183 over the 9-year study period.

Excluding 2013 (the database was established in August that year), the total value of payments was highest in 2019 at $1.6 billion, up from $1.34 billion in 2014. It was lowest in 2020, the peak year of the COVID-19 pandemic, but dipped to $864 billion that year and rebounded to $1.28 billion in 2022, wrote the authors.

The Open Payments database, administered by the Centers for Medicare & Medicaid Services, requires drug and device makers and group purchasing organizations to report payments made to physicians, including for consulting services, speaking fees, food and beverages, travel and lodging, education, gifts, grants, and honoraria.

The database was created to shed light on these payments, which have been linked in multiple studies to more prescribing of a particular drug or more use of a particular device.

The JAMA review appeared to show that with the exception of the pandemic year, the relationships have more or less stayed the same since Open Payments began.

“There’s been no sea change, no massive shift in how these interactions are happening,” said Deborah C. Marshall, MD, assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai in New York City, who has studied industry payments.

“There’s no suggestion that anything is really changing other than that’s there is transparency,” said Robert Steinbrook, MD, director of the Health Research Group at Public Citizen.

Still, Dr. Steinbrook told this news organization, “it’s better to know this than to not know this.”

The unchanging nature of industry-physician relationships “suggests that to reduce the volume and magnitude of payments, more would need to be done,” he said.

“Really, this should be banned. Doctors should not be allowed to get gifts from pharmaceutical companies,” said Adriane Fugh-Berman, MD, professor of pharmacology and physiology at Georgetown University, and director of PharmedOut, a Georgetown-based project that advances evidence-based prescribing and educates healthcare professionals about pharmaceutical marketing practices.

“The interactions wouldn’t be happening unless there was a purpose for them,” said Dr. Marshall. The relationships are “built with intention,” Dr. Marshall told this news organization.
 

Top Earners Range From $195,000 to $4.8 Million

Payments to the median physician over the study period ranged from $0 to $2339, but the mean payment to top earners — those in the top 0.1% — ranged from $194,933 for hospitalists to $4.8 million for orthopedic specialists.

Overall, the median payment was $48 per physician.

But small dollar amounts should not be discounted — even if it’s just a $25-catered lunch — said Aaron Mitchell, MD, a medical oncologist and assistant attending physician at Memorial Sloan Kettering Cancer Center in New York City who has studied industry-physician relationships. “The influence is not just in the dollar value,” Dr. Mitchell told this news organization. “It’s about the time listening to and the time in personal contact with industry representatives that these dollars are a marker for,” he said.

“There’s no such thing as a free lunch,” agreed Dr. Marshall. It’s “pretty well established” that lower-value payments do have influence, which is why academic institutions have established policies that limit gifts and meals and other payments from industry, she said.

Dr. Fugh-Berman said, “the size of the gift doesn’t really matter,” adding that research she conducted had shown that “accepting a meal increased not only the expense of the prescriptions that Medicare physicians wrote but also the number of prescriptions.”
 

Payments Mostly for High-Dollar Products

The top 25 drugs and devices that were related to industry payments tended to be high-cost brand-name products.

The top drug was Janssen’s Xarelto, an anticoagulant first approved in 2011 that costs about $600 a month, according to GoodRx. The drug has had annual sales of $4-$6 billion.

Xarelto was followed by Eliquis, another anticoagulant; Humira, used for a variety of autoimmune conditions including plaque psoriasis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis; Invokana, Jardiance, and Farxiga, all for type 2 diabetes.

The top medical devices included the da Vinci Surgical System, Mako SmartRobotics, CoreValve Evolut, Natrelle Implants, and Impella, a heart pump that received a US Food and Drug Administration (FDA) warning that it was associated with a heightened risk for death.
 

Industry Influence May Lead to Higher Cost, Poor Quality Care

Multiple studies have shown that payments to physicians tend to lead to increased prescribing and, often, higher costs for Medicare, a health system, or patients.

“I’m sure there are still a lot of physicians out there who think they’re getting away with something, that they can take meals, or they can take consulting fees and not be influenced, but there’s overwhelming data showing that it always influences you,” said Dr. Fugh-Berman.

One study in 2020 that used the Open Payments database found that physicians increase prescribing of the drugs for which they receive payment in the months just after the payment. The authors also showed that physicians who are paid prescribe lower-quality drugs following the payment, “although the magnitude is small and unlikely to be clinically significant.”

Dr. Marshall said that more studies are needed to determine whether quality of care is being affected when a physician prescribes a drug after an industry payment.

For now, there seems to be little appetite among physicians to give up the payments, said Dr. Marshall and others.

Physicians in some specialties see the payments as “an implicit statement about their value,” said Dr. Marshall.

In oncology, having received a lot of payments “gets worn more as a badge of honor,” said Dr. Mitchell.

The clinicians believe that “by collaborating with industry we are providing scientific expertise to help develop the next generation of technology and cures,” Dr. Mitchell said, adding that they see the payments “as a mark of their impact.”

Among the JAMA study authors, Joseph S. Ross, MD, reported that he is a deputy editor of JAMA but was not involved in decisions regarding acceptance of the manuscript or its review. Dr. Ross also reported receiving grants from the FDA, Johnson and Johnson, the Medical Devices Innovation Consortium, the Agency for Healthcare Research and Quality, and the National Heart, Lung, and Blood Institute. He was an expert witness in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen that was settled in 2022. Dr. Steinbrook, Dr. Marshall, and Dr. Mitchell reported no relevant financial relationships. Dr. Fugh-Berman reported being an expert witness for plaintiffs in complaints about drug and device marketing practices.

A version of this article appeared on Medscape.com.

A review of the federal Open Payments database found that the pharmaceutical and medical device industry paid physicians $12.1 billion over nearly a decade.

Almost two thirds of eligible physicians — 826,313 doctors — received a payment from a drug or device maker from 2013 to 2022, according to a study published online in JAMA on March 28. Overall, the median payment was $48 per physician.

Orthopedists received the largest amount of payments in aggregate, $1.3 billion, followed by neurologists and psychiatrists at $1.2 billion and cardiologists at $1.29 billion.

Geriatric and nuclear medicine specialists and trauma and pediatric surgeons received the least amount of money in aggregate, and the mean amount paid to a pediatric surgeon in the top 0.1% was just $338,183 over the 9-year study period.

Excluding 2013 (the database was established in August that year), the total value of payments was highest in 2019 at $1.6 billion, up from $1.34 billion in 2014. It was lowest in 2020, the peak year of the COVID-19 pandemic, but dipped to $864 billion that year and rebounded to $1.28 billion in 2022, wrote the authors.

The Open Payments database, administered by the Centers for Medicare & Medicaid Services, requires drug and device makers and group purchasing organizations to report payments made to physicians, including for consulting services, speaking fees, food and beverages, travel and lodging, education, gifts, grants, and honoraria.

The database was created to shed light on these payments, which have been linked in multiple studies to more prescribing of a particular drug or more use of a particular device.

The JAMA review appeared to show that with the exception of the pandemic year, the relationships have more or less stayed the same since Open Payments began.

“There’s been no sea change, no massive shift in how these interactions are happening,” said Deborah C. Marshall, MD, assistant professor in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai in New York City, who has studied industry payments.

“There’s no suggestion that anything is really changing other than that’s there is transparency,” said Robert Steinbrook, MD, director of the Health Research Group at Public Citizen.

Still, Dr. Steinbrook told this news organization, “it’s better to know this than to not know this.”

The unchanging nature of industry-physician relationships “suggests that to reduce the volume and magnitude of payments, more would need to be done,” he said.

“Really, this should be banned. Doctors should not be allowed to get gifts from pharmaceutical companies,” said Adriane Fugh-Berman, MD, professor of pharmacology and physiology at Georgetown University, and director of PharmedOut, a Georgetown-based project that advances evidence-based prescribing and educates healthcare professionals about pharmaceutical marketing practices.

“The interactions wouldn’t be happening unless there was a purpose for them,” said Dr. Marshall. The relationships are “built with intention,” Dr. Marshall told this news organization.
 

Top Earners Range From $195,000 to $4.8 Million

Payments to the median physician over the study period ranged from $0 to $2339, but the mean payment to top earners — those in the top 0.1% — ranged from $194,933 for hospitalists to $4.8 million for orthopedic specialists.

Overall, the median payment was $48 per physician.

But small dollar amounts should not be discounted — even if it’s just a $25-catered lunch — said Aaron Mitchell, MD, a medical oncologist and assistant attending physician at Memorial Sloan Kettering Cancer Center in New York City who has studied industry-physician relationships. “The influence is not just in the dollar value,” Dr. Mitchell told this news organization. “It’s about the time listening to and the time in personal contact with industry representatives that these dollars are a marker for,” he said.

“There’s no such thing as a free lunch,” agreed Dr. Marshall. It’s “pretty well established” that lower-value payments do have influence, which is why academic institutions have established policies that limit gifts and meals and other payments from industry, she said.

Dr. Fugh-Berman said, “the size of the gift doesn’t really matter,” adding that research she conducted had shown that “accepting a meal increased not only the expense of the prescriptions that Medicare physicians wrote but also the number of prescriptions.”
 

Payments Mostly for High-Dollar Products

The top 25 drugs and devices that were related to industry payments tended to be high-cost brand-name products.

The top drug was Janssen’s Xarelto, an anticoagulant first approved in 2011 that costs about $600 a month, according to GoodRx. The drug has had annual sales of $4-$6 billion.

Xarelto was followed by Eliquis, another anticoagulant; Humira, used for a variety of autoimmune conditions including plaque psoriasis, rheumatoid arthritis, Crohn’s disease, and ulcerative colitis; Invokana, Jardiance, and Farxiga, all for type 2 diabetes.

The top medical devices included the da Vinci Surgical System, Mako SmartRobotics, CoreValve Evolut, Natrelle Implants, and Impella, a heart pump that received a US Food and Drug Administration (FDA) warning that it was associated with a heightened risk for death.
 

Industry Influence May Lead to Higher Cost, Poor Quality Care

Multiple studies have shown that payments to physicians tend to lead to increased prescribing and, often, higher costs for Medicare, a health system, or patients.

“I’m sure there are still a lot of physicians out there who think they’re getting away with something, that they can take meals, or they can take consulting fees and not be influenced, but there’s overwhelming data showing that it always influences you,” said Dr. Fugh-Berman.

One study in 2020 that used the Open Payments database found that physicians increase prescribing of the drugs for which they receive payment in the months just after the payment. The authors also showed that physicians who are paid prescribe lower-quality drugs following the payment, “although the magnitude is small and unlikely to be clinically significant.”

Dr. Marshall said that more studies are needed to determine whether quality of care is being affected when a physician prescribes a drug after an industry payment.

For now, there seems to be little appetite among physicians to give up the payments, said Dr. Marshall and others.

Physicians in some specialties see the payments as “an implicit statement about their value,” said Dr. Marshall.

In oncology, having received a lot of payments “gets worn more as a badge of honor,” said Dr. Mitchell.

The clinicians believe that “by collaborating with industry we are providing scientific expertise to help develop the next generation of technology and cures,” Dr. Mitchell said, adding that they see the payments “as a mark of their impact.”

Among the JAMA study authors, Joseph S. Ross, MD, reported that he is a deputy editor of JAMA but was not involved in decisions regarding acceptance of the manuscript or its review. Dr. Ross also reported receiving grants from the FDA, Johnson and Johnson, the Medical Devices Innovation Consortium, the Agency for Healthcare Research and Quality, and the National Heart, Lung, and Blood Institute. He was an expert witness in a qui tam suit alleging violations of the False Claims Act and Anti-Kickback Statute against Biogen that was settled in 2022. Dr. Steinbrook, Dr. Marshall, and Dr. Mitchell reported no relevant financial relationships. Dr. Fugh-Berman reported being an expert witness for plaintiffs in complaints about drug and device marketing practices.

A version of this article appeared on Medscape.com.

TOPLINE:

One session of a telehealth intervention combining mindfulness and compassion significantly lowered self-perceived stress and symptoms of depression and anxiety compared with a waitlist control group, results of a new trial showed. 

METHODOLOGY:

• The randomized clinical trial (RCT) included 91 participants aged 18-70 years recruited from the community and the University of Texas at Austin and followed from 2020 to 2021.
• To be included in the trial, participants had to be sheltering at home during the pandemic and endorse loneliness as one of the top issues affecting them.
• Participants were randomized to one of three groups that received single-session online interventions. These included mindfulness-only (MO), mindfulness and compassion (MC), and a waitlist control (WL) group.
• During the compassion component, participants were instructed to focus on a person, place, object, or spiritual figure that evoked feelings of warmth, love, and kindness in them. The primary outcome was self-reported loneliness and secondary outcomes were self-reported stress, depression, and anxiety.

TAKEAWAY:

• At 1-week follow-up, the MC group led to reductions in perceived stress (b = −3.75), anxiety (b = −3.79), and depression (b = −3.01) but not loneliness compared with control individuals.
• Compared with the MO group alone, the MC group had no meaningful differences in perceived depression (b = −1.08) or anxiety (b = −1.50), and the same was true at the 2-week follow-up.
• Researchers speculated that the lack of difference between outcomes in the two mindfulness groups probably meant that the MC group may have only been effective in reducing self-perceived symptoms of stress, anxiety, and depression compared with the control group.

IN PRACTICE:

“This brief single session mindfulness intervention offers an approach that can be easily adopted in a range of contexts. It is important for future research to evaluate this approach with larger samples and to examine whether changes in symptoms are maintained over longer periods of time,” the researchers wrote. 

SOURCE:

Mikael Rubin, PhD, of Palo Alto University in Palo Alto, California, led the study, which was published online in PLOS ONE.

LIMITATIONS:

The study was limited by its small sample size and short follow-up period.

DISCLOSURES:

There was no funding listed for the study nor were there any reported disclosures. 

A version of this article appeared on Medscape.com.

TOPLINE:

One session of a telehealth intervention combining mindfulness and compassion significantly lowered self-perceived stress and symptoms of depression and anxiety compared with a waitlist control group, results of a new trial showed. 

METHODOLOGY:

• The randomized clinical trial (RCT) included 91 participants aged 18-70 years recruited from the community and the University of Texas at Austin and followed from 2020 to 2021.
• To be included in the trial, participants had to be sheltering at home during the pandemic and endorse loneliness as one of the top issues affecting them.
• Participants were randomized to one of three groups that received single-session online interventions. These included mindfulness-only (MO), mindfulness and compassion (MC), and a waitlist control (WL) group.
• During the compassion component, participants were instructed to focus on a person, place, object, or spiritual figure that evoked feelings of warmth, love, and kindness in them. The primary outcome was self-reported loneliness and secondary outcomes were self-reported stress, depression, and anxiety.

TAKEAWAY:

• At 1-week follow-up, the MC group led to reductions in perceived stress (b = −3.75), anxiety (b = −3.79), and depression (b = −3.01) but not loneliness compared with control individuals.
• Compared with the MO group alone, the MC group had no meaningful differences in perceived depression (b = −1.08) or anxiety (b = −1.50), and the same was true at the 2-week follow-up.
• Researchers speculated that the lack of difference between outcomes in the two mindfulness groups probably meant that the MC group may have only been effective in reducing self-perceived symptoms of stress, anxiety, and depression compared with the control group.

IN PRACTICE:

“This brief single session mindfulness intervention offers an approach that can be easily adopted in a range of contexts. It is important for future research to evaluate this approach with larger samples and to examine whether changes in symptoms are maintained over longer periods of time,” the researchers wrote. 

SOURCE:

Mikael Rubin, PhD, of Palo Alto University in Palo Alto, California, led the study, which was published online in PLOS ONE.

LIMITATIONS:

The study was limited by its small sample size and short follow-up period.

DISCLOSURES:

There was no funding listed for the study nor were there any reported disclosures. 

A version of this article appeared on Medscape.com.

TOPLINE:

One session of a telehealth intervention combining mindfulness and compassion significantly lowered self-perceived stress and symptoms of depression and anxiety compared with a waitlist control group, results of a new trial showed. 

METHODOLOGY:

• The randomized clinical trial (RCT) included 91 participants aged 18-70 years recruited from the community and the University of Texas at Austin and followed from 2020 to 2021.
• To be included in the trial, participants had to be sheltering at home during the pandemic and endorse loneliness as one of the top issues affecting them.
• Participants were randomized to one of three groups that received single-session online interventions. These included mindfulness-only (MO), mindfulness and compassion (MC), and a waitlist control (WL) group.
• During the compassion component, participants were instructed to focus on a person, place, object, or spiritual figure that evoked feelings of warmth, love, and kindness in them. The primary outcome was self-reported loneliness and secondary outcomes were self-reported stress, depression, and anxiety.

TAKEAWAY:

• At 1-week follow-up, the MC group led to reductions in perceived stress (b = −3.75), anxiety (b = −3.79), and depression (b = −3.01) but not loneliness compared with control individuals.
• Compared with the MO group alone, the MC group had no meaningful differences in perceived depression (b = −1.08) or anxiety (b = −1.50), and the same was true at the 2-week follow-up.
• Researchers speculated that the lack of difference between outcomes in the two mindfulness groups probably meant that the MC group may have only been effective in reducing self-perceived symptoms of stress, anxiety, and depression compared with the control group.

IN PRACTICE:

“This brief single session mindfulness intervention offers an approach that can be easily adopted in a range of contexts. It is important for future research to evaluate this approach with larger samples and to examine whether changes in symptoms are maintained over longer periods of time,” the researchers wrote. 

SOURCE:

Mikael Rubin, PhD, of Palo Alto University in Palo Alto, California, led the study, which was published online in PLOS ONE.

LIMITATIONS:

The study was limited by its small sample size and short follow-up period.

DISCLOSURES:

There was no funding listed for the study nor were there any reported disclosures. 

A version of this article appeared on Medscape.com.