Physician suicide continues to be a challenging problem in the United States. Each year, 1 in 10 doctors think about or attempt suicide, and 400 die by suicide each year. More than half of the doctors reading this know a colleague who has attempted or died by suicide.

This news organization recently sat down with three psychiatric experts to talk about the newest risk-reduction initiatives. These are part of a public health suicide prevention strategy, the preferred method for prevention, in hospitals and institutions around the country. A public health model for preventing suicide is a multifaceted approach that includes universal education, health promotion, selective and targeted prevention, and treatment and recovery. 

These physicians hope to continue creating and implementing these and other risk-reduction measures across all health care organizations.
 

Our physician experts for this discussion

Mary Moffit, PhD, is an associate professor in the department of psychiatry at Oregon Health & Science University, Portland. She directs the resident and faculty wellness program and is director of the OHSU peer support program. She helped design and developed a comprehensive wellness program that is now a national model for academic medical centers.

Christine Yu Moutier, MD, is the chief medical officer of the American Foundation for Suicide Prevention. She is the author of “Suicide Prevention,” a Cambridge University Press clinical handbook. She has been a practicing psychiatrist, professor of psychiatry, dean in the medical school at the University of California, San Diego, and medical director of the inpatient psychiatric unit at the VA Medical Center in La Jolla, Calif.

Michael F. Myers, MD, is a professor of clinical psychiatry in the department of psychiatry & behavioral sciences at the State University of New York, Brooklyn. He is recent past vice-chair of education and director of training in the department of psychiatry & behavioral sciences at the university. He is the author of several books, including “Why Physicians Die By Suicide,” “The Physician as Patient,” and “Touched by Suicide.”

The participants discussed these risk-reduction initiatives as having much potential for helping physicians at risk for suicide and suicidal ideations.
 

The importance of peer support programs

Peer support program models may differ across institutions but typically describe colleagues providing some degree of emotional first aid to peers who may be at risk.

Dr. Moffit: The Pew support program that we have in place at OHSU, similar to what’s available in many hospitals and systems nationwide, trains individual physicians across multiple specialties in a peer support model. It’s not specifically emotional first aid, although that’s integral to it. It’s also for adverse events: Having a tragic patient death, having learned that you will be named in a lawsuit, and exposure to trauma in the medical role.

Peer to peer is not where we anticipate physicians seeking someone to talk to about their marital relationship not going well. However, the peer supporter will know about resources throughout the university and the community for what is needed. We’ve got 20-30 peer supporters. We try to match them – for example, a surgeon with a surgeon, a primary care doc with a primary care doc. Physicians who use peer support aren’t tracked, and no notes are taken or documented. It takes place informally but has changed the culture and lowered a barrier. We have a waiting list of people who want to be peer supporters. 

Dr. Moutier: Peer-to-peer support is usually part of a multi-pronged program and is usually not the only effort going on. Depending on how they’re set up, the goals may be slightly different for each program. Peer-to-peer can be one of the most powerful ways to augment awareness raising and education, which is almost always a basic first step.

Dr. Myers: It doesn’t feel as threatening when people start in a peer-to-peer support group. Users may have been afraid of getting a mental health diagnosis, but with peers, many of whom are often not psychiatrists, that eases distress. Peer support can break down that sense of isolation and loneliness so that someone can take the next step.

Dr. Moutier: To be connected to family, to any community resource, frankly, is a protective factor that mitigates suicide risk. So that’s the logic model from a suicide prevention standpoint. It may be the only opportunity for someone to start disclosing what they’re experiencing, receive validation and support, and not a judgmental response. It can open up the avenue toward help-seeking.

Opt-in/opt-out support for medical residents

This initiative matches residents with a counselor as part of their orientation.

Dr. Moffit: Each resident has a meet and greet with a counselor when they arrive or in their first 6 months at their university. The resident can opt out and cancel the meeting, but they’re scheduled for it as part of their “curriculum.” Institutions like Michigan, Columbia, Montefiore, Mount Sinai, and the University of California, San Diego, have this in place. It starts something like: ‘Hello. Good afternoon. How’s it going? I’m Dr. Moffitt, and here are the services available in this program.’

Dr. Myers: It’s another excellent example of normalizing the stress in the rigors of training and making it part of the wellness initiative.

Dr. Moutier:  It’s just a normal part of orientation. Again, as a universal strategy, one thing that I was doing at UCSD with a particular group of medical students, who were at higher risk, was a postbaccalaureate program that found students from underrepresented, under-resourced backgrounds and brought them into this post-bacc year. I was directing it and mentoring these students.

So, I could afford a lot more intensive time and attention to them because it was a small group, but every one of them had regular meetings with me every 2 weeks. My approach was to help them uncover their unique strengths and vulnerabilities as they started this program. They all made it into med school.

It was a very intensive and more concierge-personalized approach. It’s like personalized medicine. What specific self-care, mentoring, and mental health care plan would each student codesign with me to stay on track?

And it would involve very holistic things, like if part of their vulnerability was that leaving their Chicano family was creating stress because their father had said: ‘You’re leaving our culture and our family by going into the profession of medicine,’ then we had specific plans around how to care for that aspect of their struggle. It was a much more informed, customized mentoring approach called the UCSD CAP (Conditional Acceptance Post-Baccalaureate Program). It could be a feature in a more specialized opt-in/opt-out program.
 

One-question survey: How full is your gas tank?

This initiative is a one-question survey emailed/texted to residents to check in on their wellness. We ask, how full is your gas tank? Select 1 to 5 (Empty to Full). If they flag low, they receive a follow-up.

Dr. Moffit: It’s certainly a metaphor that we use. It’s the idea of being depleted in combination with being extremely sleep deprived and the inability to access the usual sources of support or outlets, and how that can create a perfect storm of a level of distress that can put physicians at risk.

Dr. Moutier: It is a way to help people realize that there are things they can do proactively to keep that tank at least somewhat full enough.

Dr. Myers: Using colloquial or figurative language can get better buy-in than “Here’s a PHQ-9.” It also has a caring or intimate tone to it. Somebody could feel they’re a 1 in this rotation but a 4-5 the next. We know from a lot of the literature that when residents get a good, welcoming orientation, their satisfaction with that rotation is uniformly better than if they’re thrown to the wolves. And we know trial by fire can put trainees at risk.

A buddy to check in with

This initiative is when you’re assigned a buddy in or out of residency that you regularly check in with about how you’re doing.

Dr. Myers: Not to be cynical, but there has been some mentor/mentee research that if you’re assigned a mentor, the results are not nearly as good. And if it’s left to the individual to find a mentor, results could be marginal as well. You need a guide to say, ‘Here are some potential mentors for you, but you decide.’ We do a lot of that at (SUNY) Downstate instead of assigning a person. So, it may require some oversight. Picking a check-in buddy from a list provided rather than having one assigned may be more beneficial.

A lot of what we’re talking about are universal strategies that allow for increased interpersonal connection, which is a protective factor that normalizes help-seeking.
 

A platform or social media forum to share experiences

An online forum or platform where medical students, residents, and physicians can discuss mental health and suicide prevention. Physicians with personal experience could provide testimonials.

Dr. Myers: I’ve recently signed a book contract, and the working title is “Physicians With Lived Experience: How Their Stories Give Clinical Guidance.” When I talk with doctors who have published their personal stories in the New England Journal of Medicine, JAMA, or sometimes The Washington Post or The New York Times, many of them have said they had no idea at the beginning of their journey that they would do something like this: be transparent about their story. It’s a measure of their health, growth, and grace.

Dr. Moutier: The current president of the Academic Association of Surgeons, Carrie Cunningham, MD, MPH, used her platform at the annual AAS conference in 2022 to focus on suicide prevention. She told her own recent story of having gotten into recovery after having been near suicide and struggling with addiction. It was a groundbreaking moment for the field of surgery and produced a ripple effect. She risked everything to tell her story, which was highly emotional since it was still raw. It got everyone engaged, a real turning point for that field. Storytelling and a place for trainees to discuss suicide prevention, and physicians to recall their lived experiences can be highly beneficial.

Interactive Screening Program

The Interactive Screening Program (ISP) is used in higher education to allow physicians to take a safe, confidential screening test and receive a personalized response that can connect them to mental health services before a crisis emerges.

Dr. Moutier: ISP is a tool within a public health model that can afford anonymity to the user so they can safely have their needs addressed. It’s a way for high-risk individuals to sync up with treatment and support. It’s sometimes used in the universal approach because it can be offered to everyone within the health system community of physicians and staff.

It can produce a ripple effect of normalizing that we all have mental health to take care of. Its intended value is in identifying those with a higher risk for suicide, but it doesn’t stop at identifying those at risk. It helps physicians move past a stage of suffering in silence.

Our data show that 86% of a very high-risk group (currently having suicidal ideation, a recent attempt, or other high-risk factors for suicide) aren’t in any form of treatment and have not disclosed their situation to anyone. A fairly high percentage of those going through ISP request a referral to treatment. It’s a unique, very niche tool, and because users remain anonymous, that affords safety around confidentiality.

It’s usually part of a multipronged approach with education, stigma reduction, storytelling, peer support, and other modalities. In my experience with the UCSD HEAR (Healer Assessment Education and Recovery) program, which is still going strong in about its 15th year, the program went from seeing 13 physicians die by suicide in the years leading up to its launch and in the 15 years since it’s been going, one suicide. We all believe that the ISP is the heart of prevention.

Even though all of the universal strategies are important, they probably wouldn’t be sufficient by themselves because the risk [for suicide] is dynamic, and you have to catch people when they are suffering and ready to seek treatment. Suicide prevention is challenging and must be strategic, multifaceted, and sustained over time.
 

The importance of confidentiality for physicians

In the past, physicians may have been hesitant to seek treatment when struggling with mental health, substance use disorder and suicidal ideations because they heard stories from doctors who said they had to disclose mental health treatment to medical and state licensing boards.

Dr. Myers: There is so much dated stuff out there, and it gets propagated by people who have had a bad experience. I’m not challenging the authenticity of that, but I feel like those are in the minority. The vast majority of people are seeking help. The Federation of State Physician Health Programs is working with state boards to update and get rid of antiquated questions, and they’re working with credentialing groups.

When I was in practice and my patient was petrified of having to come into the hospital [because of confidentiality] I would just be their physician and say: “Look, I know that this is a worry for you [licensing and credentialing issues] but trust me, I’m going to help you get well; that’s my job. And I’m going to help you sort all that out afterward.” It was part of my work as their physician that if they were going to have to jump through hurdles to get their license reinstated, etc., I could help. 

The Dr. Lorna Breen Heroes’ Foundation is also doing so much good work in this area, especially with their toolkits to audit, change, remove, and communicate the changes about intrusive language in licensing applications and credentialing. (Dr. Breen was a New York City ED physician who died by suicide in April 2020 during the early days and height of the COVID-19 pandemic. Her father was quoted as saying: “She was in the trenches. She was a hero.”)

Dr. Moutier: We’re seeing hundreds of physicians get therapy and psychiatric treatment annually. And the advocacy effort is incredibly important, and I think we are witnessing a swifter pace to eliminate those inappropriate and illegal questions about mental health and mental health treatment for physicians and nurses.

Dr. Moffit: We have lowered barriers, not only in individual institutions but also with programming. We have also worked with the Federation of State Medical Boards and The Lorna Breen Foundation to change the legislation. The Foundation has audited and changed 20 state medical boards to remove intrusive language from licensing applications.

Support for colleagues working to help each other

Dr. Myers: One final note for those physicians who need to take time out for medical leave: In my clinical experience, I find that they felt lonely as they were getting well. I can’t tell you how much it made a difference for those who received a phone call, a card, or an email from their colleagues at work. It doesn’t take long for a vibrant, active physician to feel out of the loop when ill.

We know from suicide literature that when somebody’s discharged from the hospital or the emergency department, caring communications, brief expressions of care and concern by email, letter, card, text message, etc., can make all the difference to their recovery. Reaching out to those struggling and those in recovery can help your fellow physician.

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

Physician suicide continues to be a challenging problem in the United States. Each year, 1 in 10 doctors think about or attempt suicide, and 400 die by suicide each year. More than half of the doctors reading this know a colleague who has attempted or died by suicide.

This news organization recently sat down with three psychiatric experts to talk about the newest risk-reduction initiatives. These are part of a public health suicide prevention strategy, the preferred method for prevention, in hospitals and institutions around the country. A public health model for preventing suicide is a multifaceted approach that includes universal education, health promotion, selective and targeted prevention, and treatment and recovery. 

These physicians hope to continue creating and implementing these and other risk-reduction measures across all health care organizations.
 

Our physician experts for this discussion

Mary Moffit, PhD, is an associate professor in the department of psychiatry at Oregon Health & Science University, Portland. She directs the resident and faculty wellness program and is director of the OHSU peer support program. She helped design and developed a comprehensive wellness program that is now a national model for academic medical centers.

Christine Yu Moutier, MD, is the chief medical officer of the American Foundation for Suicide Prevention. She is the author of “Suicide Prevention,” a Cambridge University Press clinical handbook. She has been a practicing psychiatrist, professor of psychiatry, dean in the medical school at the University of California, San Diego, and medical director of the inpatient psychiatric unit at the VA Medical Center in La Jolla, Calif.

Michael F. Myers, MD, is a professor of clinical psychiatry in the department of psychiatry & behavioral sciences at the State University of New York, Brooklyn. He is recent past vice-chair of education and director of training in the department of psychiatry & behavioral sciences at the university. He is the author of several books, including “Why Physicians Die By Suicide,” “The Physician as Patient,” and “Touched by Suicide.”

The participants discussed these risk-reduction initiatives as having much potential for helping physicians at risk for suicide and suicidal ideations.
 

The importance of peer support programs

Peer support program models may differ across institutions but typically describe colleagues providing some degree of emotional first aid to peers who may be at risk.

Dr. Moffit: The Pew support program that we have in place at OHSU, similar to what’s available in many hospitals and systems nationwide, trains individual physicians across multiple specialties in a peer support model. It’s not specifically emotional first aid, although that’s integral to it. It’s also for adverse events: Having a tragic patient death, having learned that you will be named in a lawsuit, and exposure to trauma in the medical role.

Peer to peer is not where we anticipate physicians seeking someone to talk to about their marital relationship not going well. However, the peer supporter will know about resources throughout the university and the community for what is needed. We’ve got 20-30 peer supporters. We try to match them – for example, a surgeon with a surgeon, a primary care doc with a primary care doc. Physicians who use peer support aren’t tracked, and no notes are taken or documented. It takes place informally but has changed the culture and lowered a barrier. We have a waiting list of people who want to be peer supporters. 

Dr. Moutier: Peer-to-peer support is usually part of a multi-pronged program and is usually not the only effort going on. Depending on how they’re set up, the goals may be slightly different for each program. Peer-to-peer can be one of the most powerful ways to augment awareness raising and education, which is almost always a basic first step.

Dr. Myers: It doesn’t feel as threatening when people start in a peer-to-peer support group. Users may have been afraid of getting a mental health diagnosis, but with peers, many of whom are often not psychiatrists, that eases distress. Peer support can break down that sense of isolation and loneliness so that someone can take the next step.

Dr. Moutier: To be connected to family, to any community resource, frankly, is a protective factor that mitigates suicide risk. So that’s the logic model from a suicide prevention standpoint. It may be the only opportunity for someone to start disclosing what they’re experiencing, receive validation and support, and not a judgmental response. It can open up the avenue toward help-seeking.

Opt-in/opt-out support for medical residents

This initiative matches residents with a counselor as part of their orientation.

Dr. Moffit: Each resident has a meet and greet with a counselor when they arrive or in their first 6 months at their university. The resident can opt out and cancel the meeting, but they’re scheduled for it as part of their “curriculum.” Institutions like Michigan, Columbia, Montefiore, Mount Sinai, and the University of California, San Diego, have this in place. It starts something like: ‘Hello. Good afternoon. How’s it going? I’m Dr. Moffitt, and here are the services available in this program.’

Dr. Myers: It’s another excellent example of normalizing the stress in the rigors of training and making it part of the wellness initiative.

Dr. Moutier:  It’s just a normal part of orientation. Again, as a universal strategy, one thing that I was doing at UCSD with a particular group of medical students, who were at higher risk, was a postbaccalaureate program that found students from underrepresented, under-resourced backgrounds and brought them into this post-bacc year. I was directing it and mentoring these students.

So, I could afford a lot more intensive time and attention to them because it was a small group, but every one of them had regular meetings with me every 2 weeks. My approach was to help them uncover their unique strengths and vulnerabilities as they started this program. They all made it into med school.

It was a very intensive and more concierge-personalized approach. It’s like personalized medicine. What specific self-care, mentoring, and mental health care plan would each student codesign with me to stay on track?

And it would involve very holistic things, like if part of their vulnerability was that leaving their Chicano family was creating stress because their father had said: ‘You’re leaving our culture and our family by going into the profession of medicine,’ then we had specific plans around how to care for that aspect of their struggle. It was a much more informed, customized mentoring approach called the UCSD CAP (Conditional Acceptance Post-Baccalaureate Program). It could be a feature in a more specialized opt-in/opt-out program.
 

One-question survey: How full is your gas tank?

This initiative is a one-question survey emailed/texted to residents to check in on their wellness. We ask, how full is your gas tank? Select 1 to 5 (Empty to Full). If they flag low, they receive a follow-up.

Dr. Moffit: It’s certainly a metaphor that we use. It’s the idea of being depleted in combination with being extremely sleep deprived and the inability to access the usual sources of support or outlets, and how that can create a perfect storm of a level of distress that can put physicians at risk.

Dr. Moutier: It is a way to help people realize that there are things they can do proactively to keep that tank at least somewhat full enough.

Dr. Myers: Using colloquial or figurative language can get better buy-in than “Here’s a PHQ-9.” It also has a caring or intimate tone to it. Somebody could feel they’re a 1 in this rotation but a 4-5 the next. We know from a lot of the literature that when residents get a good, welcoming orientation, their satisfaction with that rotation is uniformly better than if they’re thrown to the wolves. And we know trial by fire can put trainees at risk.

A buddy to check in with

This initiative is when you’re assigned a buddy in or out of residency that you regularly check in with about how you’re doing.

Dr. Myers: Not to be cynical, but there has been some mentor/mentee research that if you’re assigned a mentor, the results are not nearly as good. And if it’s left to the individual to find a mentor, results could be marginal as well. You need a guide to say, ‘Here are some potential mentors for you, but you decide.’ We do a lot of that at (SUNY) Downstate instead of assigning a person. So, it may require some oversight. Picking a check-in buddy from a list provided rather than having one assigned may be more beneficial.

A lot of what we’re talking about are universal strategies that allow for increased interpersonal connection, which is a protective factor that normalizes help-seeking.
 

A platform or social media forum to share experiences

An online forum or platform where medical students, residents, and physicians can discuss mental health and suicide prevention. Physicians with personal experience could provide testimonials.

Dr. Myers: I’ve recently signed a book contract, and the working title is “Physicians With Lived Experience: How Their Stories Give Clinical Guidance.” When I talk with doctors who have published their personal stories in the New England Journal of Medicine, JAMA, or sometimes The Washington Post or The New York Times, many of them have said they had no idea at the beginning of their journey that they would do something like this: be transparent about their story. It’s a measure of their health, growth, and grace.

Dr. Moutier: The current president of the Academic Association of Surgeons, Carrie Cunningham, MD, MPH, used her platform at the annual AAS conference in 2022 to focus on suicide prevention. She told her own recent story of having gotten into recovery after having been near suicide and struggling with addiction. It was a groundbreaking moment for the field of surgery and produced a ripple effect. She risked everything to tell her story, which was highly emotional since it was still raw. It got everyone engaged, a real turning point for that field. Storytelling and a place for trainees to discuss suicide prevention, and physicians to recall their lived experiences can be highly beneficial.

Interactive Screening Program

The Interactive Screening Program (ISP) is used in higher education to allow physicians to take a safe, confidential screening test and receive a personalized response that can connect them to mental health services before a crisis emerges.

Dr. Moutier: ISP is a tool within a public health model that can afford anonymity to the user so they can safely have their needs addressed. It’s a way for high-risk individuals to sync up with treatment and support. It’s sometimes used in the universal approach because it can be offered to everyone within the health system community of physicians and staff.

It can produce a ripple effect of normalizing that we all have mental health to take care of. Its intended value is in identifying those with a higher risk for suicide, but it doesn’t stop at identifying those at risk. It helps physicians move past a stage of suffering in silence.

Our data show that 86% of a very high-risk group (currently having suicidal ideation, a recent attempt, or other high-risk factors for suicide) aren’t in any form of treatment and have not disclosed their situation to anyone. A fairly high percentage of those going through ISP request a referral to treatment. It’s a unique, very niche tool, and because users remain anonymous, that affords safety around confidentiality.

It’s usually part of a multipronged approach with education, stigma reduction, storytelling, peer support, and other modalities. In my experience with the UCSD HEAR (Healer Assessment Education and Recovery) program, which is still going strong in about its 15th year, the program went from seeing 13 physicians die by suicide in the years leading up to its launch and in the 15 years since it’s been going, one suicide. We all believe that the ISP is the heart of prevention.

Even though all of the universal strategies are important, they probably wouldn’t be sufficient by themselves because the risk [for suicide] is dynamic, and you have to catch people when they are suffering and ready to seek treatment. Suicide prevention is challenging and must be strategic, multifaceted, and sustained over time.
 

The importance of confidentiality for physicians

In the past, physicians may have been hesitant to seek treatment when struggling with mental health, substance use disorder and suicidal ideations because they heard stories from doctors who said they had to disclose mental health treatment to medical and state licensing boards.

Dr. Myers: There is so much dated stuff out there, and it gets propagated by people who have had a bad experience. I’m not challenging the authenticity of that, but I feel like those are in the minority. The vast majority of people are seeking help. The Federation of State Physician Health Programs is working with state boards to update and get rid of antiquated questions, and they’re working with credentialing groups.

When I was in practice and my patient was petrified of having to come into the hospital [because of confidentiality] I would just be their physician and say: “Look, I know that this is a worry for you [licensing and credentialing issues] but trust me, I’m going to help you get well; that’s my job. And I’m going to help you sort all that out afterward.” It was part of my work as their physician that if they were going to have to jump through hurdles to get their license reinstated, etc., I could help. 

The Dr. Lorna Breen Heroes’ Foundation is also doing so much good work in this area, especially with their toolkits to audit, change, remove, and communicate the changes about intrusive language in licensing applications and credentialing. (Dr. Breen was a New York City ED physician who died by suicide in April 2020 during the early days and height of the COVID-19 pandemic. Her father was quoted as saying: “She was in the trenches. She was a hero.”)

Dr. Moutier: We’re seeing hundreds of physicians get therapy and psychiatric treatment annually. And the advocacy effort is incredibly important, and I think we are witnessing a swifter pace to eliminate those inappropriate and illegal questions about mental health and mental health treatment for physicians and nurses.

Dr. Moffit: We have lowered barriers, not only in individual institutions but also with programming. We have also worked with the Federation of State Medical Boards and The Lorna Breen Foundation to change the legislation. The Foundation has audited and changed 20 state medical boards to remove intrusive language from licensing applications.

Support for colleagues working to help each other

Dr. Myers: One final note for those physicians who need to take time out for medical leave: In my clinical experience, I find that they felt lonely as they were getting well. I can’t tell you how much it made a difference for those who received a phone call, a card, or an email from their colleagues at work. It doesn’t take long for a vibrant, active physician to feel out of the loop when ill.

We know from suicide literature that when somebody’s discharged from the hospital or the emergency department, caring communications, brief expressions of care and concern by email, letter, card, text message, etc., can make all the difference to their recovery. Reaching out to those struggling and those in recovery can help your fellow physician.

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

Physician suicide continues to be a challenging problem in the United States. Each year, 1 in 10 doctors think about or attempt suicide, and 400 die by suicide each year. More than half of the doctors reading this know a colleague who has attempted or died by suicide.

This news organization recently sat down with three psychiatric experts to talk about the newest risk-reduction initiatives. These are part of a public health suicide prevention strategy, the preferred method for prevention, in hospitals and institutions around the country. A public health model for preventing suicide is a multifaceted approach that includes universal education, health promotion, selective and targeted prevention, and treatment and recovery. 

These physicians hope to continue creating and implementing these and other risk-reduction measures across all health care organizations.
 

Our physician experts for this discussion

Mary Moffit, PhD, is an associate professor in the department of psychiatry at Oregon Health & Science University, Portland. She directs the resident and faculty wellness program and is director of the OHSU peer support program. She helped design and developed a comprehensive wellness program that is now a national model for academic medical centers.

Christine Yu Moutier, MD, is the chief medical officer of the American Foundation for Suicide Prevention. She is the author of “Suicide Prevention,” a Cambridge University Press clinical handbook. She has been a practicing psychiatrist, professor of psychiatry, dean in the medical school at the University of California, San Diego, and medical director of the inpatient psychiatric unit at the VA Medical Center in La Jolla, Calif.

Michael F. Myers, MD, is a professor of clinical psychiatry in the department of psychiatry & behavioral sciences at the State University of New York, Brooklyn. He is recent past vice-chair of education and director of training in the department of psychiatry & behavioral sciences at the university. He is the author of several books, including “Why Physicians Die By Suicide,” “The Physician as Patient,” and “Touched by Suicide.”

The participants discussed these risk-reduction initiatives as having much potential for helping physicians at risk for suicide and suicidal ideations.
 

The importance of peer support programs

Peer support program models may differ across institutions but typically describe colleagues providing some degree of emotional first aid to peers who may be at risk.

Dr. Moffit: The Pew support program that we have in place at OHSU, similar to what’s available in many hospitals and systems nationwide, trains individual physicians across multiple specialties in a peer support model. It’s not specifically emotional first aid, although that’s integral to it. It’s also for adverse events: Having a tragic patient death, having learned that you will be named in a lawsuit, and exposure to trauma in the medical role.

Peer to peer is not where we anticipate physicians seeking someone to talk to about their marital relationship not going well. However, the peer supporter will know about resources throughout the university and the community for what is needed. We’ve got 20-30 peer supporters. We try to match them – for example, a surgeon with a surgeon, a primary care doc with a primary care doc. Physicians who use peer support aren’t tracked, and no notes are taken or documented. It takes place informally but has changed the culture and lowered a barrier. We have a waiting list of people who want to be peer supporters. 

Dr. Moutier: Peer-to-peer support is usually part of a multi-pronged program and is usually not the only effort going on. Depending on how they’re set up, the goals may be slightly different for each program. Peer-to-peer can be one of the most powerful ways to augment awareness raising and education, which is almost always a basic first step.

Dr. Myers: It doesn’t feel as threatening when people start in a peer-to-peer support group. Users may have been afraid of getting a mental health diagnosis, but with peers, many of whom are often not psychiatrists, that eases distress. Peer support can break down that sense of isolation and loneliness so that someone can take the next step.

Dr. Moutier: To be connected to family, to any community resource, frankly, is a protective factor that mitigates suicide risk. So that’s the logic model from a suicide prevention standpoint. It may be the only opportunity for someone to start disclosing what they’re experiencing, receive validation and support, and not a judgmental response. It can open up the avenue toward help-seeking.

Opt-in/opt-out support for medical residents

This initiative matches residents with a counselor as part of their orientation.

Dr. Moffit: Each resident has a meet and greet with a counselor when they arrive or in their first 6 months at their university. The resident can opt out and cancel the meeting, but they’re scheduled for it as part of their “curriculum.” Institutions like Michigan, Columbia, Montefiore, Mount Sinai, and the University of California, San Diego, have this in place. It starts something like: ‘Hello. Good afternoon. How’s it going? I’m Dr. Moffitt, and here are the services available in this program.’

Dr. Myers: It’s another excellent example of normalizing the stress in the rigors of training and making it part of the wellness initiative.

Dr. Moutier:  It’s just a normal part of orientation. Again, as a universal strategy, one thing that I was doing at UCSD with a particular group of medical students, who were at higher risk, was a postbaccalaureate program that found students from underrepresented, under-resourced backgrounds and brought them into this post-bacc year. I was directing it and mentoring these students.

So, I could afford a lot more intensive time and attention to them because it was a small group, but every one of them had regular meetings with me every 2 weeks. My approach was to help them uncover their unique strengths and vulnerabilities as they started this program. They all made it into med school.

It was a very intensive and more concierge-personalized approach. It’s like personalized medicine. What specific self-care, mentoring, and mental health care plan would each student codesign with me to stay on track?

And it would involve very holistic things, like if part of their vulnerability was that leaving their Chicano family was creating stress because their father had said: ‘You’re leaving our culture and our family by going into the profession of medicine,’ then we had specific plans around how to care for that aspect of their struggle. It was a much more informed, customized mentoring approach called the UCSD CAP (Conditional Acceptance Post-Baccalaureate Program). It could be a feature in a more specialized opt-in/opt-out program.
 

One-question survey: How full is your gas tank?

This initiative is a one-question survey emailed/texted to residents to check in on their wellness. We ask, how full is your gas tank? Select 1 to 5 (Empty to Full). If they flag low, they receive a follow-up.

Dr. Moffit: It’s certainly a metaphor that we use. It’s the idea of being depleted in combination with being extremely sleep deprived and the inability to access the usual sources of support or outlets, and how that can create a perfect storm of a level of distress that can put physicians at risk.

Dr. Moutier: It is a way to help people realize that there are things they can do proactively to keep that tank at least somewhat full enough.

Dr. Myers: Using colloquial or figurative language can get better buy-in than “Here’s a PHQ-9.” It also has a caring or intimate tone to it. Somebody could feel they’re a 1 in this rotation but a 4-5 the next. We know from a lot of the literature that when residents get a good, welcoming orientation, their satisfaction with that rotation is uniformly better than if they’re thrown to the wolves. And we know trial by fire can put trainees at risk.

A buddy to check in with

This initiative is when you’re assigned a buddy in or out of residency that you regularly check in with about how you’re doing.

Dr. Myers: Not to be cynical, but there has been some mentor/mentee research that if you’re assigned a mentor, the results are not nearly as good. And if it’s left to the individual to find a mentor, results could be marginal as well. You need a guide to say, ‘Here are some potential mentors for you, but you decide.’ We do a lot of that at (SUNY) Downstate instead of assigning a person. So, it may require some oversight. Picking a check-in buddy from a list provided rather than having one assigned may be more beneficial.

A lot of what we’re talking about are universal strategies that allow for increased interpersonal connection, which is a protective factor that normalizes help-seeking.
 

A platform or social media forum to share experiences

An online forum or platform where medical students, residents, and physicians can discuss mental health and suicide prevention. Physicians with personal experience could provide testimonials.

Dr. Myers: I’ve recently signed a book contract, and the working title is “Physicians With Lived Experience: How Their Stories Give Clinical Guidance.” When I talk with doctors who have published their personal stories in the New England Journal of Medicine, JAMA, or sometimes The Washington Post or The New York Times, many of them have said they had no idea at the beginning of their journey that they would do something like this: be transparent about their story. It’s a measure of their health, growth, and grace.

Dr. Moutier: The current president of the Academic Association of Surgeons, Carrie Cunningham, MD, MPH, used her platform at the annual AAS conference in 2022 to focus on suicide prevention. She told her own recent story of having gotten into recovery after having been near suicide and struggling with addiction. It was a groundbreaking moment for the field of surgery and produced a ripple effect. She risked everything to tell her story, which was highly emotional since it was still raw. It got everyone engaged, a real turning point for that field. Storytelling and a place for trainees to discuss suicide prevention, and physicians to recall their lived experiences can be highly beneficial.

Interactive Screening Program

The Interactive Screening Program (ISP) is used in higher education to allow physicians to take a safe, confidential screening test and receive a personalized response that can connect them to mental health services before a crisis emerges.

Dr. Moutier: ISP is a tool within a public health model that can afford anonymity to the user so they can safely have their needs addressed. It’s a way for high-risk individuals to sync up with treatment and support. It’s sometimes used in the universal approach because it can be offered to everyone within the health system community of physicians and staff.

It can produce a ripple effect of normalizing that we all have mental health to take care of. Its intended value is in identifying those with a higher risk for suicide, but it doesn’t stop at identifying those at risk. It helps physicians move past a stage of suffering in silence.

Our data show that 86% of a very high-risk group (currently having suicidal ideation, a recent attempt, or other high-risk factors for suicide) aren’t in any form of treatment and have not disclosed their situation to anyone. A fairly high percentage of those going through ISP request a referral to treatment. It’s a unique, very niche tool, and because users remain anonymous, that affords safety around confidentiality.

It’s usually part of a multipronged approach with education, stigma reduction, storytelling, peer support, and other modalities. In my experience with the UCSD HEAR (Healer Assessment Education and Recovery) program, which is still going strong in about its 15th year, the program went from seeing 13 physicians die by suicide in the years leading up to its launch and in the 15 years since it’s been going, one suicide. We all believe that the ISP is the heart of prevention.

Even though all of the universal strategies are important, they probably wouldn’t be sufficient by themselves because the risk [for suicide] is dynamic, and you have to catch people when they are suffering and ready to seek treatment. Suicide prevention is challenging and must be strategic, multifaceted, and sustained over time.
 

The importance of confidentiality for physicians

In the past, physicians may have been hesitant to seek treatment when struggling with mental health, substance use disorder and suicidal ideations because they heard stories from doctors who said they had to disclose mental health treatment to medical and state licensing boards.

Dr. Myers: There is so much dated stuff out there, and it gets propagated by people who have had a bad experience. I’m not challenging the authenticity of that, but I feel like those are in the minority. The vast majority of people are seeking help. The Federation of State Physician Health Programs is working with state boards to update and get rid of antiquated questions, and they’re working with credentialing groups.

When I was in practice and my patient was petrified of having to come into the hospital [because of confidentiality] I would just be their physician and say: “Look, I know that this is a worry for you [licensing and credentialing issues] but trust me, I’m going to help you get well; that’s my job. And I’m going to help you sort all that out afterward.” It was part of my work as their physician that if they were going to have to jump through hurdles to get their license reinstated, etc., I could help. 

The Dr. Lorna Breen Heroes’ Foundation is also doing so much good work in this area, especially with their toolkits to audit, change, remove, and communicate the changes about intrusive language in licensing applications and credentialing. (Dr. Breen was a New York City ED physician who died by suicide in April 2020 during the early days and height of the COVID-19 pandemic. Her father was quoted as saying: “She was in the trenches. She was a hero.”)

Dr. Moutier: We’re seeing hundreds of physicians get therapy and psychiatric treatment annually. And the advocacy effort is incredibly important, and I think we are witnessing a swifter pace to eliminate those inappropriate and illegal questions about mental health and mental health treatment for physicians and nurses.

Dr. Moffit: We have lowered barriers, not only in individual institutions but also with programming. We have also worked with the Federation of State Medical Boards and The Lorna Breen Foundation to change the legislation. The Foundation has audited and changed 20 state medical boards to remove intrusive language from licensing applications.

Support for colleagues working to help each other

Dr. Myers: One final note for those physicians who need to take time out for medical leave: In my clinical experience, I find that they felt lonely as they were getting well. I can’t tell you how much it made a difference for those who received a phone call, a card, or an email from their colleagues at work. It doesn’t take long for a vibrant, active physician to feel out of the loop when ill.

We know from suicide literature that when somebody’s discharged from the hospital or the emergency department, caring communications, brief expressions of care and concern by email, letter, card, text message, etc., can make all the difference to their recovery. Reaching out to those struggling and those in recovery can help your fellow physician.

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

To the Editor:

A 58-year-old woman presented to our dermatology clinic with a pruritic weeping eruption circumferentially on the distal digits of both hands of 5 weeks’ duration. The patient disclosed that she had been receiving dip powder manicures at a local nail salon approximately every 2 weeks over the last 3 to 6 months. She had received frequent acrylic nail extensions over the last 8 years prior to starting the dip powder manicures. Physical examination revealed well-demarcated eczematous plaques involving the lateral and proximal nail folds of the right thumb with an overlying serous crust and loss of the cuticle (Figure 1A). Erythematous plaques with firm deep-seated microvesicles also were present on the other digits, distributed distal to the distal interphalangeal joints (Figure 1B). She was diagnosed with dyshidroticlike contact dermatitis and paronychia. Treatment included phenol 1.5% colorless solution and clobetasol ointment 0.05% for twice-daily application to the affected areas. The patient also was advised to stop receiving manicures. At 1-month follow-up, the paronychia had resolved and the dermatitis had nearly resolved.

Dip powder manicures use a wet adhesive base coat with acrylic powder and an activator topcoat to initiate a chemical reaction that hardens and sets the nail polish. The colored powder typically is applied by dipping the digit up to the distal interphalangeal joint into a small container of loose powder and then brushing away the excess (Figure 2). Acrylate, a chemical present in dip powders, is a known allergen and has been associated with the development of allergic contact dermatitis and onychodystrophy in patients after receiving acrylic and UV-cured gel polish manicures.^1,2 Inadequate sanitation practices at nail salons also have been associated with infection transmission.^3,4 Additionally, the news media has covered the potential risk of infection due to contamination from reused dip manicure powder and the use of communal powder containers.⁵

To increase clinical awareness of the dip manicure technique, we describe the presentation and successful treatment of dyshidroticlike contact dermatitis and paronychia that occurred in a patient after she received a dip powder manicure. Dermatoses and infection limited to the distal phalanges will present in patients more frequently as dip powder manicures continue to increase in popularity and frequency.

To the Editor:

A 58-year-old woman presented to our dermatology clinic with a pruritic weeping eruption circumferentially on the distal digits of both hands of 5 weeks’ duration. The patient disclosed that she had been receiving dip powder manicures at a local nail salon approximately every 2 weeks over the last 3 to 6 months. She had received frequent acrylic nail extensions over the last 8 years prior to starting the dip powder manicures. Physical examination revealed well-demarcated eczematous plaques involving the lateral and proximal nail folds of the right thumb with an overlying serous crust and loss of the cuticle (Figure 1A). Erythematous plaques with firm deep-seated microvesicles also were present on the other digits, distributed distal to the distal interphalangeal joints (Figure 1B). She was diagnosed with dyshidroticlike contact dermatitis and paronychia. Treatment included phenol 1.5% colorless solution and clobetasol ointment 0.05% for twice-daily application to the affected areas. The patient also was advised to stop receiving manicures. At 1-month follow-up, the paronychia had resolved and the dermatitis had nearly resolved.

Dip powder manicures use a wet adhesive base coat with acrylic powder and an activator topcoat to initiate a chemical reaction that hardens and sets the nail polish. The colored powder typically is applied by dipping the digit up to the distal interphalangeal joint into a small container of loose powder and then brushing away the excess (Figure 2). Acrylate, a chemical present in dip powders, is a known allergen and has been associated with the development of allergic contact dermatitis and onychodystrophy in patients after receiving acrylic and UV-cured gel polish manicures.^1,2 Inadequate sanitation practices at nail salons also have been associated with infection transmission.^3,4 Additionally, the news media has covered the potential risk of infection due to contamination from reused dip manicure powder and the use of communal powder containers.⁵

To increase clinical awareness of the dip manicure technique, we describe the presentation and successful treatment of dyshidroticlike contact dermatitis and paronychia that occurred in a patient after she received a dip powder manicure. Dermatoses and infection limited to the distal phalanges will present in patients more frequently as dip powder manicures continue to increase in popularity and frequency.

To the Editor:

A 58-year-old woman presented to our dermatology clinic with a pruritic weeping eruption circumferentially on the distal digits of both hands of 5 weeks’ duration. The patient disclosed that she had been receiving dip powder manicures at a local nail salon approximately every 2 weeks over the last 3 to 6 months. She had received frequent acrylic nail extensions over the last 8 years prior to starting the dip powder manicures. Physical examination revealed well-demarcated eczematous plaques involving the lateral and proximal nail folds of the right thumb with an overlying serous crust and loss of the cuticle (Figure 1A). Erythematous plaques with firm deep-seated microvesicles also were present on the other digits, distributed distal to the distal interphalangeal joints (Figure 1B). She was diagnosed with dyshidroticlike contact dermatitis and paronychia. Treatment included phenol 1.5% colorless solution and clobetasol ointment 0.05% for twice-daily application to the affected areas. The patient also was advised to stop receiving manicures. At 1-month follow-up, the paronychia had resolved and the dermatitis had nearly resolved.

Dip powder manicures use a wet adhesive base coat with acrylic powder and an activator topcoat to initiate a chemical reaction that hardens and sets the nail polish. The colored powder typically is applied by dipping the digit up to the distal interphalangeal joint into a small container of loose powder and then brushing away the excess (Figure 2). Acrylate, a chemical present in dip powders, is a known allergen and has been associated with the development of allergic contact dermatitis and onychodystrophy in patients after receiving acrylic and UV-cured gel polish manicures.^1,2 Inadequate sanitation practices at nail salons also have been associated with infection transmission.^3,4 Additionally, the news media has covered the potential risk of infection due to contamination from reused dip manicure powder and the use of communal powder containers.⁵

To increase clinical awareness of the dip manicure technique, we describe the presentation and successful treatment of dyshidroticlike contact dermatitis and paronychia that occurred in a patient after she received a dip powder manicure. Dermatoses and infection limited to the distal phalanges will present in patients more frequently as dip powder manicures continue to increase in popularity and frequency.

AUSTIN, TEX. – Transnasal evaporative cooling appears promising as a nonpharmacologic treatment to abort migraine attacks, according to the results of a small study. Most patients reported relief of their symptoms after receiving 15 minutes of transnasal evaporative cooling, without any need for rescue medication.

The cooling may modulate the sphenopalatine ganglion, a large ganglion implicated in migraine, said lead author Larry Charleston IV, MD, director of the headache and facial pain division, and professor of neurology at Michigan State University, East Lansing.

“The transnasal evaporative cooling device cools by blowing dry, ambient air across the nasal turbinates and may work by neuromodulation via the sphenopalatine ganglion for migraine,” Dr. Charleston said.

The findings were presented at the annual meeting of the American Headache Society.
 

A ‘cool’ approach to migraine treatment

“Everyone who has migraine disease needs abortive treatment,” Dr. Charleston said. “There is a need for safe and effective acute treatment for migraine. As we understand more about the pathophysiology of migraine, we learn that peripheral input plays a role in migraine disease.

“I was excited to learn of the device and to learn how we might take advantage of our knowledge of the sphenopalatine ganglia in the treatment of migraine, and was very enthusiastic to be involved in researching a nonpharmacological treatment to abort migraine attacks,” he said. “I thought this approach to migraine treatment was really ‘cool.’ ”   

Twenty-four patients who met diagnostic criteria for episodic migraine with or without aura were randomized to receive 15 minutes of cooling induced by the CoolStat Transnasal Thermal Regulating Device (CoolTech LLC), or to a sham treatment with a CoolStat sham device.

Participants receiving active treatment were further randomized to receive one of the following flow rates: 24 liters per minute (LPM; n = 6 patients), 18 LPM (n = 9 patients), and 6 LPM (n = 9 patients).

All patients were instructed to get to their headache clinic during a migraine attack to start treatment.

The researchers looked at pain levels and most bothersome symptoms at baseline, and then at 2 and 24 hours after treatment. The primary endpoint was pain relief at 2 hours. Other endpoints included tolerability, relief from most bothersome symptoms, and freedom from pain at 2 hours.

The results showed that 88% (8/9 patients) of the 6-LPM group reported pain relief at 2 hours. Of these, 44% (4/9) reported being pain free at 2 hours, all without need for rescue medication. Similarly, pain relief at 2 hours occurred in 44% (4/9) of patients in the 18-LPM group, and in 50% (3/6) of the patients in the 24-LPM group.

No participants in the 18-LPM or the 24-LPM groups reported pain freedom at 2 hours.

Most bothersome symptoms were reduced. Response was greater with 6-LPM treatment. At 2 hours, 77% (7/9) of patients in the 6-LPM group reported relief of their symptoms, followed by 66% (6/9) of the 18-LPM group and 50% (3/6) of the 24-LPM group.

However, nasal discomfort was a bothersome adverse effect, Dr. Charleston noted. The rate of nasal discomfort occurred in all groups but was lower in the 6-LPM group.

Moderate intranasal discomfort during treatment was reported by 11% of the 6-LPM group, compared with 33% (3/9) in the 18-LPM group and 83% (5/6) in the 24-LPM group.

However, the study was terminated due to insufficient subject accrual rate.

“Originally, 87 participants were recruited and consented. It may have been challenging for some to come in to study clinic sites for the study treatment at the onset of their migraine attacks. The next iteration of the treatment device is a more portable model and study treatment may be used at home. This will likely be more convenient and enhance study participation,” Dr. Charleston said. 

The data in the current study will help inform dose ranging analyses in future studies, to optimize efficacy and increase tolerability, he added.

The findings are promising and merit further assessment in a larger study with a sham control group, said Richard B. Lipton, MD, Edwin S. Lowe Professor and vice chair of neurology, and director of the Montefiore Headache Center, Albert Einstein College of Medicine, New York.   

“Charleston et al. report that the lowest flow dose (6 liters per minute) was most effective, with a 2-hour pain-relief rate of 88% and a 2-hour pain-free rate of 50%, but, though these rates of pain relief and pain freedom are high, caution in interpretation is required,” Dr. Lipton said.

“The sample size is very modest with only nine patients in the 6-liter-per-minute treatment arm. In addition, the study lacks results from the group that got the sham device, making it difficult to contextualize the findings,” Dr. Lipton said.

He added that it is unusual for higher doses to be less effective but that may be because air flow higher than 6 LPM is irritating to the nasal mucosa during migraine attacks.
 

Always a need for effective nonpharmaceuticals  

Also commenting on this study, Nina Riggins, MD, director of the Headache Center at the University of California, San Diego, said she found the novel device “exciting and really clever.

“I really enjoyed reviewing this abstract because I am a big fan of sphenopalatine ganglion block in the palatine ganglion. When we do those, we basically apply numbing medication to decrease the sensation and discharges coming from this group of neural cells in order to decrease pain,” Dr. Riggins said. “The procedure is very well tolerated and usually sphenopalatine ganglion blocks are used in patients when we do not want any side effects, such as in pregnant and postpartum women.”

The novel technique has the potential to have fewer side effects than those of oral medications, she said. “For example, the triptans are effective drugs but they constrict the blood vessels and we don’t want to use them in people with heart disease or history of stroke. This is where these potentially safer devices can play an important role. We can have more options to offer our patients,” Dr. Riggins said.

“I am super excited and looking forward to see what will come out of future research. I am really grateful that the authors are looking into new neuromodulation devices which can be so useful,” she said.

Migraine is the second leading cause of disability worldwide, Dr. Riggins noted. “It peaks in the years when people are most productive and affects families and communities. Medications are good, of course, but now with these novel devices, these are wonderful areas for research. Also now, we can offer so much more to people with migraine and other headache disorders,” she said.

“When I started in the field, I remember we were very limited in resources, and now, it’s just so wonderful.”

The study was sponsored by CoolTech Corp LLC. Dr. Charleston reports financial relationships with Allergan/AbbVie, Amgen, Amneal, Biohaven, Haleon, Linpharma, Satsuma, and Teva, and that he has received CME honoraria from the American Headache Society and the American Academy of Neurology. Dr. Lipton reports financial relationships with multiple pharmaceutical companies. Dr. Riggins reports no relevant financial relationships.

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

AUSTIN, TEX. – Transnasal evaporative cooling appears promising as a nonpharmacologic treatment to abort migraine attacks, according to the results of a small study. Most patients reported relief of their symptoms after receiving 15 minutes of transnasal evaporative cooling, without any need for rescue medication.

The cooling may modulate the sphenopalatine ganglion, a large ganglion implicated in migraine, said lead author Larry Charleston IV, MD, director of the headache and facial pain division, and professor of neurology at Michigan State University, East Lansing.

“The transnasal evaporative cooling device cools by blowing dry, ambient air across the nasal turbinates and may work by neuromodulation via the sphenopalatine ganglion for migraine,” Dr. Charleston said.

The findings were presented at the annual meeting of the American Headache Society.
 

A ‘cool’ approach to migraine treatment

“Everyone who has migraine disease needs abortive treatment,” Dr. Charleston said. “There is a need for safe and effective acute treatment for migraine. As we understand more about the pathophysiology of migraine, we learn that peripheral input plays a role in migraine disease.

“I was excited to learn of the device and to learn how we might take advantage of our knowledge of the sphenopalatine ganglia in the treatment of migraine, and was very enthusiastic to be involved in researching a nonpharmacological treatment to abort migraine attacks,” he said. “I thought this approach to migraine treatment was really ‘cool.’ ”   

Twenty-four patients who met diagnostic criteria for episodic migraine with or without aura were randomized to receive 15 minutes of cooling induced by the CoolStat Transnasal Thermal Regulating Device (CoolTech LLC), or to a sham treatment with a CoolStat sham device.

Participants receiving active treatment were further randomized to receive one of the following flow rates: 24 liters per minute (LPM; n = 6 patients), 18 LPM (n = 9 patients), and 6 LPM (n = 9 patients).

All patients were instructed to get to their headache clinic during a migraine attack to start treatment.

The researchers looked at pain levels and most bothersome symptoms at baseline, and then at 2 and 24 hours after treatment. The primary endpoint was pain relief at 2 hours. Other endpoints included tolerability, relief from most bothersome symptoms, and freedom from pain at 2 hours.

The results showed that 88% (8/9 patients) of the 6-LPM group reported pain relief at 2 hours. Of these, 44% (4/9) reported being pain free at 2 hours, all without need for rescue medication. Similarly, pain relief at 2 hours occurred in 44% (4/9) of patients in the 18-LPM group, and in 50% (3/6) of the patients in the 24-LPM group.

No participants in the 18-LPM or the 24-LPM groups reported pain freedom at 2 hours.

Most bothersome symptoms were reduced. Response was greater with 6-LPM treatment. At 2 hours, 77% (7/9) of patients in the 6-LPM group reported relief of their symptoms, followed by 66% (6/9) of the 18-LPM group and 50% (3/6) of the 24-LPM group.

However, nasal discomfort was a bothersome adverse effect, Dr. Charleston noted. The rate of nasal discomfort occurred in all groups but was lower in the 6-LPM group.

Moderate intranasal discomfort during treatment was reported by 11% of the 6-LPM group, compared with 33% (3/9) in the 18-LPM group and 83% (5/6) in the 24-LPM group.

However, the study was terminated due to insufficient subject accrual rate.

“Originally, 87 participants were recruited and consented. It may have been challenging for some to come in to study clinic sites for the study treatment at the onset of their migraine attacks. The next iteration of the treatment device is a more portable model and study treatment may be used at home. This will likely be more convenient and enhance study participation,” Dr. Charleston said. 

The data in the current study will help inform dose ranging analyses in future studies, to optimize efficacy and increase tolerability, he added.

The findings are promising and merit further assessment in a larger study with a sham control group, said Richard B. Lipton, MD, Edwin S. Lowe Professor and vice chair of neurology, and director of the Montefiore Headache Center, Albert Einstein College of Medicine, New York.   

“Charleston et al. report that the lowest flow dose (6 liters per minute) was most effective, with a 2-hour pain-relief rate of 88% and a 2-hour pain-free rate of 50%, but, though these rates of pain relief and pain freedom are high, caution in interpretation is required,” Dr. Lipton said.

“The sample size is very modest with only nine patients in the 6-liter-per-minute treatment arm. In addition, the study lacks results from the group that got the sham device, making it difficult to contextualize the findings,” Dr. Lipton said.

He added that it is unusual for higher doses to be less effective but that may be because air flow higher than 6 LPM is irritating to the nasal mucosa during migraine attacks.
 

Always a need for effective nonpharmaceuticals  

Also commenting on this study, Nina Riggins, MD, director of the Headache Center at the University of California, San Diego, said she found the novel device “exciting and really clever.

“I really enjoyed reviewing this abstract because I am a big fan of sphenopalatine ganglion block in the palatine ganglion. When we do those, we basically apply numbing medication to decrease the sensation and discharges coming from this group of neural cells in order to decrease pain,” Dr. Riggins said. “The procedure is very well tolerated and usually sphenopalatine ganglion blocks are used in patients when we do not want any side effects, such as in pregnant and postpartum women.”

The novel technique has the potential to have fewer side effects than those of oral medications, she said. “For example, the triptans are effective drugs but they constrict the blood vessels and we don’t want to use them in people with heart disease or history of stroke. This is where these potentially safer devices can play an important role. We can have more options to offer our patients,” Dr. Riggins said.

“I am super excited and looking forward to see what will come out of future research. I am really grateful that the authors are looking into new neuromodulation devices which can be so useful,” she said.

Migraine is the second leading cause of disability worldwide, Dr. Riggins noted. “It peaks in the years when people are most productive and affects families and communities. Medications are good, of course, but now with these novel devices, these are wonderful areas for research. Also now, we can offer so much more to people with migraine and other headache disorders,” she said.

“When I started in the field, I remember we were very limited in resources, and now, it’s just so wonderful.”

The study was sponsored by CoolTech Corp LLC. Dr. Charleston reports financial relationships with Allergan/AbbVie, Amgen, Amneal, Biohaven, Haleon, Linpharma, Satsuma, and Teva, and that he has received CME honoraria from the American Headache Society and the American Academy of Neurology. Dr. Lipton reports financial relationships with multiple pharmaceutical companies. Dr. Riggins reports no relevant financial relationships.

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

AUSTIN, TEX. – Transnasal evaporative cooling appears promising as a nonpharmacologic treatment to abort migraine attacks, according to the results of a small study. Most patients reported relief of their symptoms after receiving 15 minutes of transnasal evaporative cooling, without any need for rescue medication.

The cooling may modulate the sphenopalatine ganglion, a large ganglion implicated in migraine, said lead author Larry Charleston IV, MD, director of the headache and facial pain division, and professor of neurology at Michigan State University, East Lansing.

“The transnasal evaporative cooling device cools by blowing dry, ambient air across the nasal turbinates and may work by neuromodulation via the sphenopalatine ganglion for migraine,” Dr. Charleston said.

The findings were presented at the annual meeting of the American Headache Society.
 

A ‘cool’ approach to migraine treatment

“Everyone who has migraine disease needs abortive treatment,” Dr. Charleston said. “There is a need for safe and effective acute treatment for migraine. As we understand more about the pathophysiology of migraine, we learn that peripheral input plays a role in migraine disease.

“I was excited to learn of the device and to learn how we might take advantage of our knowledge of the sphenopalatine ganglia in the treatment of migraine, and was very enthusiastic to be involved in researching a nonpharmacological treatment to abort migraine attacks,” he said. “I thought this approach to migraine treatment was really ‘cool.’ ”   

Twenty-four patients who met diagnostic criteria for episodic migraine with or without aura were randomized to receive 15 minutes of cooling induced by the CoolStat Transnasal Thermal Regulating Device (CoolTech LLC), or to a sham treatment with a CoolStat sham device.

Participants receiving active treatment were further randomized to receive one of the following flow rates: 24 liters per minute (LPM; n = 6 patients), 18 LPM (n = 9 patients), and 6 LPM (n = 9 patients).

All patients were instructed to get to their headache clinic during a migraine attack to start treatment.

The researchers looked at pain levels and most bothersome symptoms at baseline, and then at 2 and 24 hours after treatment. The primary endpoint was pain relief at 2 hours. Other endpoints included tolerability, relief from most bothersome symptoms, and freedom from pain at 2 hours.

The results showed that 88% (8/9 patients) of the 6-LPM group reported pain relief at 2 hours. Of these, 44% (4/9) reported being pain free at 2 hours, all without need for rescue medication. Similarly, pain relief at 2 hours occurred in 44% (4/9) of patients in the 18-LPM group, and in 50% (3/6) of the patients in the 24-LPM group.

No participants in the 18-LPM or the 24-LPM groups reported pain freedom at 2 hours.

Most bothersome symptoms were reduced. Response was greater with 6-LPM treatment. At 2 hours, 77% (7/9) of patients in the 6-LPM group reported relief of their symptoms, followed by 66% (6/9) of the 18-LPM group and 50% (3/6) of the 24-LPM group.

However, nasal discomfort was a bothersome adverse effect, Dr. Charleston noted. The rate of nasal discomfort occurred in all groups but was lower in the 6-LPM group.

Moderate intranasal discomfort during treatment was reported by 11% of the 6-LPM group, compared with 33% (3/9) in the 18-LPM group and 83% (5/6) in the 24-LPM group.

However, the study was terminated due to insufficient subject accrual rate.

“Originally, 87 participants were recruited and consented. It may have been challenging for some to come in to study clinic sites for the study treatment at the onset of their migraine attacks. The next iteration of the treatment device is a more portable model and study treatment may be used at home. This will likely be more convenient and enhance study participation,” Dr. Charleston said. 

The data in the current study will help inform dose ranging analyses in future studies, to optimize efficacy and increase tolerability, he added.

The findings are promising and merit further assessment in a larger study with a sham control group, said Richard B. Lipton, MD, Edwin S. Lowe Professor and vice chair of neurology, and director of the Montefiore Headache Center, Albert Einstein College of Medicine, New York.   

“Charleston et al. report that the lowest flow dose (6 liters per minute) was most effective, with a 2-hour pain-relief rate of 88% and a 2-hour pain-free rate of 50%, but, though these rates of pain relief and pain freedom are high, caution in interpretation is required,” Dr. Lipton said.

“The sample size is very modest with only nine patients in the 6-liter-per-minute treatment arm. In addition, the study lacks results from the group that got the sham device, making it difficult to contextualize the findings,” Dr. Lipton said.

He added that it is unusual for higher doses to be less effective but that may be because air flow higher than 6 LPM is irritating to the nasal mucosa during migraine attacks.
 

Always a need for effective nonpharmaceuticals  

Also commenting on this study, Nina Riggins, MD, director of the Headache Center at the University of California, San Diego, said she found the novel device “exciting and really clever.

“I really enjoyed reviewing this abstract because I am a big fan of sphenopalatine ganglion block in the palatine ganglion. When we do those, we basically apply numbing medication to decrease the sensation and discharges coming from this group of neural cells in order to decrease pain,” Dr. Riggins said. “The procedure is very well tolerated and usually sphenopalatine ganglion blocks are used in patients when we do not want any side effects, such as in pregnant and postpartum women.”

The novel technique has the potential to have fewer side effects than those of oral medications, she said. “For example, the triptans are effective drugs but they constrict the blood vessels and we don’t want to use them in people with heart disease or history of stroke. This is where these potentially safer devices can play an important role. We can have more options to offer our patients,” Dr. Riggins said.

“I am super excited and looking forward to see what will come out of future research. I am really grateful that the authors are looking into new neuromodulation devices which can be so useful,” she said.

Migraine is the second leading cause of disability worldwide, Dr. Riggins noted. “It peaks in the years when people are most productive and affects families and communities. Medications are good, of course, but now with these novel devices, these are wonderful areas for research. Also now, we can offer so much more to people with migraine and other headache disorders,” she said.

“When I started in the field, I remember we were very limited in resources, and now, it’s just so wonderful.”

The study was sponsored by CoolTech Corp LLC. Dr. Charleston reports financial relationships with Allergan/AbbVie, Amgen, Amneal, Biohaven, Haleon, Linpharma, Satsuma, and Teva, and that he has received CME honoraria from the American Headache Society and the American Academy of Neurology. Dr. Lipton reports financial relationships with multiple pharmaceutical companies. Dr. Riggins reports no relevant financial relationships.

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

New longitudinal data from the TRACK TBI investigators show that recovery from traumatic brain injury (TBI) is a dynamic process that continues to evolve well beyond the initial 12 months after injury.

The data show that patients with TBI may continue to improve or decline during a period of up to 7 years after injury, making it more of a chronic condition, the investigators report.

“Our results dispute the notion that TBI is a discrete, isolated medical event with a finite, static functional outcome following a relatively short period of upward recovery (typically up to 1 year),” Benjamin Brett, PhD, assistant professor, departments of neurosurgery and neurology, Medical College of Wisconsin, Milwaukee, told this news organization.

“Rather, individuals continue to exhibit improvement and decline across a range of domains, including psychiatric, cognitive, and functional outcomes, even 2-7 years after their injury,” Dr. Brett said.

“Ultimately, our findings support conceptualizing TBI as a chronic condition for many patients, which requires routine follow-up, medical monitoring, responsive care, and support, adapting to their evolving needs many years following injury,” he said.

Results of the TRACK TBI LONG (Transforming Research and Clinical Knowledge in TBI Longitudinal study) were published online in Neurology.
 

Chronic and evolving

The results are based on 1,264 adults (mean age at injury, 41 years) from the initial TRACK TBI study, including 917 with mild TBI (mTBI) and 193 with moderate/severe TBI (msTBI), who were matched to 154 control patients who had experienced orthopedic trauma without evidence of head injury (OTC).

The participants were followed annually for up to 7 years after injury using the Glasgow Outcome Scale–Extended (GOSE), Brief Symptom Inventory–18 (BSI), and the Brief Test of Adult Cognition by Telephone (BTACT), as well as a self-reported perception of function. The researchers calculated rates of change (classified as stable, improved, or declined) for individual outcomes at each long-term follow-up.

In general, “stable” was the most frequent change outcome for the individual measures from postinjury baseline assessment to 7 years post injury.

However, a substantial proportion of patients with TBI (regardless of severity) experienced changes in psychiatric status, cognition, and functional outcomes over the years.

When the GOSE, BSI, and BTACT were considered collectively, rates of decline were 21% for mTBI, 26% for msTBI, and 15% for OTC.

The highest rates of decline were in functional outcomes (GOSE scores). On average, over the course of 2-7 years post injury, 29% of patients with mTBI and 23% of those with msTBI experienced a decline in the ability to function with daily activities.

A pattern of improvement on the GOSE was noted in 36% of patients with msTBI and 22% patients with mTBI.

Notably, said Dr. Brett, patients who experienced greater difficulties near the time of injury showed improvement for a period of 2-7 years post injury. Patient factors, such as older age at the time of the injury, were associated with greater risk of long-term decline.

“Our findings highlight the need to embrace conceptualization of TBI as a chronic condition in order to establish systems of care that provide continued follow-up with treatment and supports that adapt to evolving patient needs, regardless of the directions of change,” Dr. Brett told this news organization.
 

Important and novel work

In a linked editorial, Robynne Braun, MD, PhD, with the department of neurology, University of Maryland, Baltimore, notes that there have been “few prospective studies examining postinjury outcomes on this longer timescale, especially in mild TBI, making this an important and novel body of work.”

The study “effectively demonstrates that changes in function across multiple domains continue to occur well beyond the conventionally tracked 6- to 12-month period of injury recovery,” Dr. Braun writes.

The observation that over the 7-year follow-up, a substantial proportion of patients with mTBI and msTBI exhibited a pattern of decline on the GOSE suggests that they “may have needed more ongoing medical monitoring, rehabilitation, or supportive services to prevent worsening,” Dr. Braun adds.

At the same time, the improvement pattern on the GOSE suggests “opportunities for recovery that further rehabilitative or medical services might have enhanced.”

The study was funded by the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, the National Football League Scientific Advisory Board, and the U.S. Department of Defense. Dr. Brett and Dr. Braun have disclosed no relevant financial relationships.

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

New longitudinal data from the TRACK TBI investigators show that recovery from traumatic brain injury (TBI) is a dynamic process that continues to evolve well beyond the initial 12 months after injury.

The data show that patients with TBI may continue to improve or decline during a period of up to 7 years after injury, making it more of a chronic condition, the investigators report.

“Our results dispute the notion that TBI is a discrete, isolated medical event with a finite, static functional outcome following a relatively short period of upward recovery (typically up to 1 year),” Benjamin Brett, PhD, assistant professor, departments of neurosurgery and neurology, Medical College of Wisconsin, Milwaukee, told this news organization.

“Rather, individuals continue to exhibit improvement and decline across a range of domains, including psychiatric, cognitive, and functional outcomes, even 2-7 years after their injury,” Dr. Brett said.

“Ultimately, our findings support conceptualizing TBI as a chronic condition for many patients, which requires routine follow-up, medical monitoring, responsive care, and support, adapting to their evolving needs many years following injury,” he said.

Results of the TRACK TBI LONG (Transforming Research and Clinical Knowledge in TBI Longitudinal study) were published online in Neurology.
 

Chronic and evolving

The results are based on 1,264 adults (mean age at injury, 41 years) from the initial TRACK TBI study, including 917 with mild TBI (mTBI) and 193 with moderate/severe TBI (msTBI), who were matched to 154 control patients who had experienced orthopedic trauma without evidence of head injury (OTC).

The participants were followed annually for up to 7 years after injury using the Glasgow Outcome Scale–Extended (GOSE), Brief Symptom Inventory–18 (BSI), and the Brief Test of Adult Cognition by Telephone (BTACT), as well as a self-reported perception of function. The researchers calculated rates of change (classified as stable, improved, or declined) for individual outcomes at each long-term follow-up.

In general, “stable” was the most frequent change outcome for the individual measures from postinjury baseline assessment to 7 years post injury.

However, a substantial proportion of patients with TBI (regardless of severity) experienced changes in psychiatric status, cognition, and functional outcomes over the years.

When the GOSE, BSI, and BTACT were considered collectively, rates of decline were 21% for mTBI, 26% for msTBI, and 15% for OTC.

The highest rates of decline were in functional outcomes (GOSE scores). On average, over the course of 2-7 years post injury, 29% of patients with mTBI and 23% of those with msTBI experienced a decline in the ability to function with daily activities.

A pattern of improvement on the GOSE was noted in 36% of patients with msTBI and 22% patients with mTBI.

Notably, said Dr. Brett, patients who experienced greater difficulties near the time of injury showed improvement for a period of 2-7 years post injury. Patient factors, such as older age at the time of the injury, were associated with greater risk of long-term decline.

“Our findings highlight the need to embrace conceptualization of TBI as a chronic condition in order to establish systems of care that provide continued follow-up with treatment and supports that adapt to evolving patient needs, regardless of the directions of change,” Dr. Brett told this news organization.
 

Important and novel work

In a linked editorial, Robynne Braun, MD, PhD, with the department of neurology, University of Maryland, Baltimore, notes that there have been “few prospective studies examining postinjury outcomes on this longer timescale, especially in mild TBI, making this an important and novel body of work.”

The study “effectively demonstrates that changes in function across multiple domains continue to occur well beyond the conventionally tracked 6- to 12-month period of injury recovery,” Dr. Braun writes.

The observation that over the 7-year follow-up, a substantial proportion of patients with mTBI and msTBI exhibited a pattern of decline on the GOSE suggests that they “may have needed more ongoing medical monitoring, rehabilitation, or supportive services to prevent worsening,” Dr. Braun adds.

At the same time, the improvement pattern on the GOSE suggests “opportunities for recovery that further rehabilitative or medical services might have enhanced.”

The study was funded by the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, the National Football League Scientific Advisory Board, and the U.S. Department of Defense. Dr. Brett and Dr. Braun have disclosed no relevant financial relationships.

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

New longitudinal data from the TRACK TBI investigators show that recovery from traumatic brain injury (TBI) is a dynamic process that continues to evolve well beyond the initial 12 months after injury.

The data show that patients with TBI may continue to improve or decline during a period of up to 7 years after injury, making it more of a chronic condition, the investigators report.

“Our results dispute the notion that TBI is a discrete, isolated medical event with a finite, static functional outcome following a relatively short period of upward recovery (typically up to 1 year),” Benjamin Brett, PhD, assistant professor, departments of neurosurgery and neurology, Medical College of Wisconsin, Milwaukee, told this news organization.

“Rather, individuals continue to exhibit improvement and decline across a range of domains, including psychiatric, cognitive, and functional outcomes, even 2-7 years after their injury,” Dr. Brett said.

“Ultimately, our findings support conceptualizing TBI as a chronic condition for many patients, which requires routine follow-up, medical monitoring, responsive care, and support, adapting to their evolving needs many years following injury,” he said.

Results of the TRACK TBI LONG (Transforming Research and Clinical Knowledge in TBI Longitudinal study) were published online in Neurology.
 

Chronic and evolving

The results are based on 1,264 adults (mean age at injury, 41 years) from the initial TRACK TBI study, including 917 with mild TBI (mTBI) and 193 with moderate/severe TBI (msTBI), who were matched to 154 control patients who had experienced orthopedic trauma without evidence of head injury (OTC).

The participants were followed annually for up to 7 years after injury using the Glasgow Outcome Scale–Extended (GOSE), Brief Symptom Inventory–18 (BSI), and the Brief Test of Adult Cognition by Telephone (BTACT), as well as a self-reported perception of function. The researchers calculated rates of change (classified as stable, improved, or declined) for individual outcomes at each long-term follow-up.

In general, “stable” was the most frequent change outcome for the individual measures from postinjury baseline assessment to 7 years post injury.

However, a substantial proportion of patients with TBI (regardless of severity) experienced changes in psychiatric status, cognition, and functional outcomes over the years.

When the GOSE, BSI, and BTACT were considered collectively, rates of decline were 21% for mTBI, 26% for msTBI, and 15% for OTC.

The highest rates of decline were in functional outcomes (GOSE scores). On average, over the course of 2-7 years post injury, 29% of patients with mTBI and 23% of those with msTBI experienced a decline in the ability to function with daily activities.

A pattern of improvement on the GOSE was noted in 36% of patients with msTBI and 22% patients with mTBI.

Notably, said Dr. Brett, patients who experienced greater difficulties near the time of injury showed improvement for a period of 2-7 years post injury. Patient factors, such as older age at the time of the injury, were associated with greater risk of long-term decline.

“Our findings highlight the need to embrace conceptualization of TBI as a chronic condition in order to establish systems of care that provide continued follow-up with treatment and supports that adapt to evolving patient needs, regardless of the directions of change,” Dr. Brett told this news organization.
 

Important and novel work

In a linked editorial, Robynne Braun, MD, PhD, with the department of neurology, University of Maryland, Baltimore, notes that there have been “few prospective studies examining postinjury outcomes on this longer timescale, especially in mild TBI, making this an important and novel body of work.”

The study “effectively demonstrates that changes in function across multiple domains continue to occur well beyond the conventionally tracked 6- to 12-month period of injury recovery,” Dr. Braun writes.

The observation that over the 7-year follow-up, a substantial proportion of patients with mTBI and msTBI exhibited a pattern of decline on the GOSE suggests that they “may have needed more ongoing medical monitoring, rehabilitation, or supportive services to prevent worsening,” Dr. Braun adds.

At the same time, the improvement pattern on the GOSE suggests “opportunities for recovery that further rehabilitative or medical services might have enhanced.”

The study was funded by the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, the National Football League Scientific Advisory Board, and the U.S. Department of Defense. Dr. Brett and Dr. Braun have disclosed no relevant financial relationships.

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

A new framework from the American Academy of Pediatrics aims to aid general pediatricians in better caring for premature babies who are at risk of developing developmental disabilities.

About 1 in 10 babies in the United States are born before full term. Even when they are discharged from neonatal intensive care units (NICUs), these babies are still at risk for conditions like cerebral palsy, autism spectrum disorder, deafness, and severe hearing loss.

The framework, published in Pediatrics, consolidates existing research into a guide for busy pediatricians to categorize patients as very high risk, high risk, or moderate-low risk for neurodevelopmental disabilities. The guidance also lists key identifiers to help providers flag issues early, such as asymmetry of hand use.

Beth Ellen Davis, MD, MPH, a framework author, said the goal is to help pediatricians determine what surveillance and screening they can conduct to promote positive health outcomes.

Dr. Davis said she wished she had this guidance on caring for children who were born prematurely during her 10 years as a general pediatrician in the U.S. Army Medical Corps.

“I didn’t know what I was supposed to do differently with [the former NICU babies],” said Dr. Davis, a professor in the division of neurodevelopmental behavioral pediatrics at the University of Virginia, Charlottesville. 

For instance, babies born earlier than 28 weeks who have hypoxic ischemic encephalopathy or retinopathy of prematurity requiring surgery or intervention are classified as very high risk for the adverse outcomes, including intellectual disability.

The authors recommend follow-up and surveillance based on risk level at roughly 9-month intervals until around age 5. Each visit includes assessing for developmental milestones, like walking by 18 months or noting atypical pencil grasp at age 3.

Kendell German, MD, a neonatologist at University of Washington Medical Center, Seattle, and Seattle Children’s Hospital and a coauthor of the publication, said the tool will hopefully ensure that children are referred earlier to specialists.

“As neonatologists, we think about risk factors, but further out from birth, some of those things may be missed – particularly when we start thinking about kids who are transitioning in school and thinking about learning disabilities,” Dr. German said.

The guidance also outlines when pediatricians should – or should not – reassure families that an intellectual disability won’t develop. According to the authors, by age 3, the majority of children who have severe developmental disabilities will have been diagnosed.

“Some say you have to always keep suspicion out there for families of children who are born premature,” Dr. Davis said. “But we feel that after a period of time of monitoring and a child meeting their milestones, we can reassure parents that it is very unlikely their child will develop some of these severe developmental disabilities.”

Douglas Vanderbilt, MD, MS, chief of the developmental-behavioral pediatrics division and director of newborn and infant follow-up program at Children’s Hospital Los Angeles, said that general pediatricians and family practice clinicians may face barriers to implementation such as not having enough time to screen patients or difficulty collaborating with specialists.

But, “whatever we can do to articulate, educate, and facilitate a capacity within general pediatrics to improve training is a really good thing,” said Dr. Vanderbilt, who was not involved with the guidance.

The authors also highlighted lower-severity conditions that can result from prematurity, such as language and speech disorders, developmental coordination disorders, ADHD, and visual motor integration problems.

“Those of us in the medical field can be quite focused on the most severe disabilities that are possible,” said Andrea Duncan, MD, MSc, director of the neonatal follow-up program at the Children’s Hospital of Philadelphia, who was not associated with the report. But, “most of the disabilities we see in follow-up are more subtle or milder but can have a very significant impact on school function, participation, and the overall quality of a child’s life.

Dr. Duncan said the framework doesn’t entirely put the onus on primary care clinicians, but helps stratify risk and indicates when referrals to specialists may be appropriate.

“The importance of partnerships really comes through,” with specialties like neurology, audiology, and developmental behavioral pediatrics, Dr. Duncan said. “As long as those partnerships are made and families have access to services, implementation should be relatively easy.”

The authors of the report declared no relevant financial relationships. Dr. Vanderbilt is a consultant for a startup called Develo. He has no equity in the company.

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

A new framework from the American Academy of Pediatrics aims to aid general pediatricians in better caring for premature babies who are at risk of developing developmental disabilities.

About 1 in 10 babies in the United States are born before full term. Even when they are discharged from neonatal intensive care units (NICUs), these babies are still at risk for conditions like cerebral palsy, autism spectrum disorder, deafness, and severe hearing loss.

The framework, published in Pediatrics, consolidates existing research into a guide for busy pediatricians to categorize patients as very high risk, high risk, or moderate-low risk for neurodevelopmental disabilities. The guidance also lists key identifiers to help providers flag issues early, such as asymmetry of hand use.

Beth Ellen Davis, MD, MPH, a framework author, said the goal is to help pediatricians determine what surveillance and screening they can conduct to promote positive health outcomes.

Dr. Davis said she wished she had this guidance on caring for children who were born prematurely during her 10 years as a general pediatrician in the U.S. Army Medical Corps.

“I didn’t know what I was supposed to do differently with [the former NICU babies],” said Dr. Davis, a professor in the division of neurodevelopmental behavioral pediatrics at the University of Virginia, Charlottesville. 

For instance, babies born earlier than 28 weeks who have hypoxic ischemic encephalopathy or retinopathy of prematurity requiring surgery or intervention are classified as very high risk for the adverse outcomes, including intellectual disability.

The authors recommend follow-up and surveillance based on risk level at roughly 9-month intervals until around age 5. Each visit includes assessing for developmental milestones, like walking by 18 months or noting atypical pencil grasp at age 3.

Kendell German, MD, a neonatologist at University of Washington Medical Center, Seattle, and Seattle Children’s Hospital and a coauthor of the publication, said the tool will hopefully ensure that children are referred earlier to specialists.

“As neonatologists, we think about risk factors, but further out from birth, some of those things may be missed – particularly when we start thinking about kids who are transitioning in school and thinking about learning disabilities,” Dr. German said.

The guidance also outlines when pediatricians should – or should not – reassure families that an intellectual disability won’t develop. According to the authors, by age 3, the majority of children who have severe developmental disabilities will have been diagnosed.

“Some say you have to always keep suspicion out there for families of children who are born premature,” Dr. Davis said. “But we feel that after a period of time of monitoring and a child meeting their milestones, we can reassure parents that it is very unlikely their child will develop some of these severe developmental disabilities.”

Douglas Vanderbilt, MD, MS, chief of the developmental-behavioral pediatrics division and director of newborn and infant follow-up program at Children’s Hospital Los Angeles, said that general pediatricians and family practice clinicians may face barriers to implementation such as not having enough time to screen patients or difficulty collaborating with specialists.

But, “whatever we can do to articulate, educate, and facilitate a capacity within general pediatrics to improve training is a really good thing,” said Dr. Vanderbilt, who was not involved with the guidance.

The authors also highlighted lower-severity conditions that can result from prematurity, such as language and speech disorders, developmental coordination disorders, ADHD, and visual motor integration problems.

“Those of us in the medical field can be quite focused on the most severe disabilities that are possible,” said Andrea Duncan, MD, MSc, director of the neonatal follow-up program at the Children’s Hospital of Philadelphia, who was not associated with the report. But, “most of the disabilities we see in follow-up are more subtle or milder but can have a very significant impact on school function, participation, and the overall quality of a child’s life.

Dr. Duncan said the framework doesn’t entirely put the onus on primary care clinicians, but helps stratify risk and indicates when referrals to specialists may be appropriate.

“The importance of partnerships really comes through,” with specialties like neurology, audiology, and developmental behavioral pediatrics, Dr. Duncan said. “As long as those partnerships are made and families have access to services, implementation should be relatively easy.”

The authors of the report declared no relevant financial relationships. Dr. Vanderbilt is a consultant for a startup called Develo. He has no equity in the company.

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

A new framework from the American Academy of Pediatrics aims to aid general pediatricians in better caring for premature babies who are at risk of developing developmental disabilities.

About 1 in 10 babies in the United States are born before full term. Even when they are discharged from neonatal intensive care units (NICUs), these babies are still at risk for conditions like cerebral palsy, autism spectrum disorder, deafness, and severe hearing loss.

The framework, published in Pediatrics, consolidates existing research into a guide for busy pediatricians to categorize patients as very high risk, high risk, or moderate-low risk for neurodevelopmental disabilities. The guidance also lists key identifiers to help providers flag issues early, such as asymmetry of hand use.

Beth Ellen Davis, MD, MPH, a framework author, said the goal is to help pediatricians determine what surveillance and screening they can conduct to promote positive health outcomes.

Dr. Davis said she wished she had this guidance on caring for children who were born prematurely during her 10 years as a general pediatrician in the U.S. Army Medical Corps.

“I didn’t know what I was supposed to do differently with [the former NICU babies],” said Dr. Davis, a professor in the division of neurodevelopmental behavioral pediatrics at the University of Virginia, Charlottesville. 

For instance, babies born earlier than 28 weeks who have hypoxic ischemic encephalopathy or retinopathy of prematurity requiring surgery or intervention are classified as very high risk for the adverse outcomes, including intellectual disability.

The authors recommend follow-up and surveillance based on risk level at roughly 9-month intervals until around age 5. Each visit includes assessing for developmental milestones, like walking by 18 months or noting atypical pencil grasp at age 3.

Kendell German, MD, a neonatologist at University of Washington Medical Center, Seattle, and Seattle Children’s Hospital and a coauthor of the publication, said the tool will hopefully ensure that children are referred earlier to specialists.

“As neonatologists, we think about risk factors, but further out from birth, some of those things may be missed – particularly when we start thinking about kids who are transitioning in school and thinking about learning disabilities,” Dr. German said.

The guidance also outlines when pediatricians should – or should not – reassure families that an intellectual disability won’t develop. According to the authors, by age 3, the majority of children who have severe developmental disabilities will have been diagnosed.

“Some say you have to always keep suspicion out there for families of children who are born premature,” Dr. Davis said. “But we feel that after a period of time of monitoring and a child meeting their milestones, we can reassure parents that it is very unlikely their child will develop some of these severe developmental disabilities.”

Douglas Vanderbilt, MD, MS, chief of the developmental-behavioral pediatrics division and director of newborn and infant follow-up program at Children’s Hospital Los Angeles, said that general pediatricians and family practice clinicians may face barriers to implementation such as not having enough time to screen patients or difficulty collaborating with specialists.

But, “whatever we can do to articulate, educate, and facilitate a capacity within general pediatrics to improve training is a really good thing,” said Dr. Vanderbilt, who was not involved with the guidance.

The authors also highlighted lower-severity conditions that can result from prematurity, such as language and speech disorders, developmental coordination disorders, ADHD, and visual motor integration problems.

“Those of us in the medical field can be quite focused on the most severe disabilities that are possible,” said Andrea Duncan, MD, MSc, director of the neonatal follow-up program at the Children’s Hospital of Philadelphia, who was not associated with the report. But, “most of the disabilities we see in follow-up are more subtle or milder but can have a very significant impact on school function, participation, and the overall quality of a child’s life.

Dr. Duncan said the framework doesn’t entirely put the onus on primary care clinicians, but helps stratify risk and indicates when referrals to specialists may be appropriate.

“The importance of partnerships really comes through,” with specialties like neurology, audiology, and developmental behavioral pediatrics, Dr. Duncan said. “As long as those partnerships are made and families have access to services, implementation should be relatively easy.”

The authors of the report declared no relevant financial relationships. Dr. Vanderbilt is a consultant for a startup called Develo. He has no equity in the company.

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

A group of more than 30 academics and researchers in psychiatry and psychopharmacology is challenging the conclusions of an umbrella review published last year that concluded there is no convincing evidence that serotonin deficiency is the primary cause of depression. The authors of the article, however, stand by their conclusion.

“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.

In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
 

‘No convincing evidence’

Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.

Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.

The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT_1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.

The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.

Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
 

‘Unconventional, odd’ methodology

However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”

Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.

Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.

For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.

He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”

With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.

For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.

“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.

Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
 

No new data

An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.

And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.

In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.

Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.

“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.

“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”

If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
 

Dr. Moncrieff pushes back

Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.

“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”

These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”

In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.

In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”

It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.

Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.

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

A group of more than 30 academics and researchers in psychiatry and psychopharmacology is challenging the conclusions of an umbrella review published last year that concluded there is no convincing evidence that serotonin deficiency is the primary cause of depression. The authors of the article, however, stand by their conclusion.

“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.

In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
 

‘No convincing evidence’

Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.

Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.

The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT_1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.

The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.

Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
 

‘Unconventional, odd’ methodology

However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”

Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.

Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.

For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.

He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”

With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.

For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.

“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.

Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
 

No new data

An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.

And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.

In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.

Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.

“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.

“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”

If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
 

Dr. Moncrieff pushes back

Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.

“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”

These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”

In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.

In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”

It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.

Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.

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

A group of more than 30 academics and researchers in psychiatry and psychopharmacology is challenging the conclusions of an umbrella review published last year that concluded there is no convincing evidence that serotonin deficiency is the primary cause of depression. The authors of the article, however, stand by their conclusion.

“The methodology doesn’t conform to a conventional umbrella review,” said the commentary’s lead author, Sameer Jauhar, MD, PhD, first author of the commentary criticizing the review, which was published online in Molecular Psychiatry.

In addition, preeminent psychiatrist David J. Nutt, MD, PhD, Edmond J. Safra Professor of Neuropsychopharmacology, Imperial College London, is calling for the review to be retracted. In an interview with The Daily Mail, he said the article is “full of flaws and it should never have been published in the first place. Yet it has been frequently cited and people believe it is true. It’s essentially misinformation. That’s why I’m calling on the journal to retract it.” Dr. Nutt is one of the authors of the published commentary.
 

‘No convincing evidence’

Led by Joanna Moncrieff, MD, professor of clinical and social psychiatry, University College London, the authors analyzed systematic reviews and meta-analyses to determine whether low serotonin levels are, in fact, associated with depression.

Of 361 potential studies, 17 were selected for the review, including meta-analyses, systematic reviews, and a genetic association study.

The review included examinations of 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in “body fluids,” 5HT_1A receptor and serotonin transporter protein (SERT) availability in imaging and postmortem studies, investigations of SERT gene polymorphisms, interactions between SERT and stress in depression, and effects of tryptophan depletion on mood.

The tryptophan hypothesis suggests depression occurs through tryptophan depletion, which lowers available serotonin. According to the review, two crossover studies of patients with depression who were currently receiving or had recently received antidepressant treatment did not show substantial effects of depletion, and data from studies involving volunteers largely showed no effect.

Ultimately, Dr. Moncrieff and colleagues concluded that “there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.”
 

‘Unconventional, odd’ methodology

However, Dr. Jauhar and the commentary’s coauthors disagree with the study’s conclusion. The researchers claim that “we don’t see depression symptoms in healthy volunteers when given tryptophan depletion; everyone knows that and agrees with that; it’s only in people vulnerable to depression who will have it.”

Furthermore, he said, the study’s conclusion does not consider that experimental medicine studies of tryptophan depletion are difficult to conduct. “You’re not going to have huge sample sizes as you would in a genetic study or big epidemiological studies.

Dr. Jauhar said he found it “unconventional” and “odd” that the review included individual tryptophan depletion studies that were not in the prespecified protocol.

For studies involving molecular imaging, Dr. Jauhar said the review’s inferences were “simplistic” and the review authors are “basically shaping the argument” to fit their desired narrative.

He also noted factual errors in the review. “They make a mistake when they talk about serotonin transporter imaging; they say there are no consistent findings across studies when, in fact, there are.”

With both tryptophan depletion and molecular imaging studies, the review “glosses over findings” from the original studies, said Dr. Jauhar.

For tryptophan depletion, “a more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed,” the commentators wrote.

“The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position,” they added.

Dr. Jauhar also took issue with criteria for certainty of finding of these and other studies used in the review. “If you’re setting the criteria yourself, it’s arbitrary.”
 

No new data

An umbrella review is supposed to be of the highest quality and should entail “taking out the studies and analysing them yourself,” but here, “all they have done is put a synthesis forward of other people’s reviews, so essentially there’s no new data there,” said Dr. Jauhar.

And sometimes the review’s findings differ from the original research. “When you have people who haven’t conducted original research themselves quoting someone else’s work and ignoring what those people say, we’re all in trouble,” said Dr. Jauhar.

In an additional commentary also published in Molecular Psychiatry, Jacob Pade Ramsøe Jacobsen, Evecxia Therapeutics, Durham, N.C., also criticized the review by Dr. Moncrieff and colleagues.

Its authors appear unfamiliar with serotonin biology and pharmacology, Dr. Jacobsen wrote.

“The review contains factual errors, makes conclusions serotonin neurobiology may not support, and quotes the cited literature in a selective manner,” he added.

“Most troubling, they misinterpret some data reviewed and intimate that serotonin reuptake inhibitor antidepressants, e.g., SSRIs, may decrease, rather than increase, serotonin function.”

If accepted by general practitioners and the public, the review’s conclusions “could lead to reduced use of antidepressants among patients in need and increased morbidity related to depression.”
 

Dr. Moncrieff pushes back

Responding to the torrent of criticism of her study, Dr. Moncrieff told this news organization via email that they stand by the review, adding that Dr. Jauhar and others “don’t want to let the cat out of the bag” that there’s no good evidence to support the hypothesis that low serotonin causes depression because it challenges antidepressant use.

“The idea that antidepressants work by correcting an underlying chemical imbalance or serotonin abnormality has led research up a blind alley and meant scientists have not taken the harmful effects of these drugs seriously enough.”

These critics, she added, “want business as usual – which means people will continue to be misinformed and exposed to harmful effects of drugs that have minimal and uncertain benefits.”

In a letter to the editor of Molecular Psychiatry, Dr. Moncrieff and her fellow authors maintain that they used approved and well-accepted methods for the umbrella review, including preregistering the protocol and using recommended search methods and quality assessments, and that they did not miss certain studies, as has been claimed.

In her blog, Dr. Moncrieff wrote that the “marginal differences between antidepressants and placebo that are apparent in clinical trials are likely to be produced by alternative, more plausible mechanisms like the emotional blunting effects of the drugs or by amplified placebo effects, rather than by targeting underlying biological mechanisms (since these have not been demonstrated).”

It also highlights “how we don’t know what antidepressants do to the brain exactly, which is a cause for concern,” she adds.

Dr. Jauhar has received honoraria for nonpromotional educational talks on antipsychotics from Janssen, Sunovion, and Lundbeck and on causes of schizophrenia for Boehringer-Ingelheim. He has also received honoraria for consulting on antipsychotics for LB Pharmaceuticals. He sits on Council for the British Association for Psychopharmacology and was a recent panel member for the Wellcome Trust.

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

Stage III non–small cell lung cancer, depending on tumor stage and histology, may be managed in multiple ways. Because of the range of treatments available and the numerous factors that inform the optimal approach, management by a multidisciplinary team is considered advantageous.  

Weekly meetings of the multidisciplinary team facilitate the efficient review of tumor histology and molecular status, surgical and radiation options, and pre- and post-surgery care for individual patients.  

Pulmonologist Dr Anne Gonzalez, from McGill University Health Centre; thoracic oncologist Dr Jyoti D. Patel, of Northwestern University; and thoracic surgeon Dr John Howington, from Virginia Mason Franciscan Health, discuss the vital roles that specialists play in the coordinated treatment of a patient. The panelists also consider factors in treatment selection and how multidisciplinary care is managed at each of their institutions. 

--

Anne V. Gonzalez, MD, MSc, FCCP, Associate Professor of Medicine, McGill University Health Centre, Montreal, Quebec, Canada 

Anne V. Gonzalez, MD, MSc, FCCP, has disclosed the following relevant financial relationships: 

Received research grant from: Lung Cancer Canada 

DSMB for: Laurent Pharmaceuticals; GSK; Idorsia; Janssen; Pfizer 

Jyoti D. Patel, MD, Professor of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 

Jyoti Patel, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Astra Zeneca; AnHeart; Takeda; Lilly 

John Howington, MD, MBA, FCCP, Thoracic Surgeon, Virginia Mason Franciscan Health, Franciscan Cardiothoracic Surgery Associates at Saint Michael, Silverdale, Washington 

John Howington, MD, MBA, FCCP, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: President Designate of American College of Chest Physicians 

Stage III non–small cell lung cancer, depending on tumor stage and histology, may be managed in multiple ways. Because of the range of treatments available and the numerous factors that inform the optimal approach, management by a multidisciplinary team is considered advantageous.  

Weekly meetings of the multidisciplinary team facilitate the efficient review of tumor histology and molecular status, surgical and radiation options, and pre- and post-surgery care for individual patients.  

Pulmonologist Dr Anne Gonzalez, from McGill University Health Centre; thoracic oncologist Dr Jyoti D. Patel, of Northwestern University; and thoracic surgeon Dr John Howington, from Virginia Mason Franciscan Health, discuss the vital roles that specialists play in the coordinated treatment of a patient. The panelists also consider factors in treatment selection and how multidisciplinary care is managed at each of their institutions. 

--

Anne V. Gonzalez, MD, MSc, FCCP, Associate Professor of Medicine, McGill University Health Centre, Montreal, Quebec, Canada 

Anne V. Gonzalez, MD, MSc, FCCP, has disclosed the following relevant financial relationships: 

Received research grant from: Lung Cancer Canada 

DSMB for: Laurent Pharmaceuticals; GSK; Idorsia; Janssen; Pfizer 

Jyoti D. Patel, MD, Professor of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 

Jyoti Patel, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Astra Zeneca; AnHeart; Takeda; Lilly 

John Howington, MD, MBA, FCCP, Thoracic Surgeon, Virginia Mason Franciscan Health, Franciscan Cardiothoracic Surgery Associates at Saint Michael, Silverdale, Washington 

John Howington, MD, MBA, FCCP, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: President Designate of American College of Chest Physicians 

Stage III non–small cell lung cancer, depending on tumor stage and histology, may be managed in multiple ways. Because of the range of treatments available and the numerous factors that inform the optimal approach, management by a multidisciplinary team is considered advantageous.  

Weekly meetings of the multidisciplinary team facilitate the efficient review of tumor histology and molecular status, surgical and radiation options, and pre- and post-surgery care for individual patients.  

Pulmonologist Dr Anne Gonzalez, from McGill University Health Centre; thoracic oncologist Dr Jyoti D. Patel, of Northwestern University; and thoracic surgeon Dr John Howington, from Virginia Mason Franciscan Health, discuss the vital roles that specialists play in the coordinated treatment of a patient. The panelists also consider factors in treatment selection and how multidisciplinary care is managed at each of their institutions. 

--

Anne V. Gonzalez, MD, MSc, FCCP, Associate Professor of Medicine, McGill University Health Centre, Montreal, Quebec, Canada 

Anne V. Gonzalez, MD, MSc, FCCP, has disclosed the following relevant financial relationships: 

Received research grant from: Lung Cancer Canada 

DSMB for: Laurent Pharmaceuticals; GSK; Idorsia; Janssen; Pfizer 

Jyoti D. Patel, MD, Professor of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 

Jyoti Patel, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Astra Zeneca; AnHeart; Takeda; Lilly 

John Howington, MD, MBA, FCCP, Thoracic Surgeon, Virginia Mason Franciscan Health, Franciscan Cardiothoracic Surgery Associates at Saint Michael, Silverdale, Washington 

John Howington, MD, MBA, FCCP, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: President Designate of American College of Chest Physicians 

In the absence of a formal diagnostic test for Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), the current approach employed by most clinicians tends to overlabel patients as allergic to drugs that are unlikely to be the cause, results from a small retrospective cohort study demonstrated.

“Prompt identification and discontinuation of a culprit drug is critical to improving patient outcomes and preventing recurrence,” researchers led by Sherrie J. Divito, MD, PhD, of the department of dermatology at Brigham and Women’s Hospital, Boston, wrote in the study, which was published online in JAMA Dermatology. “Identification is difficult because there is no laboratory test or other criterion standard (in the absence of rechallenge) to identify a culprit drug, and patients take on average six medications at the time of their reaction. Consequently, many patients may be labeled as allergic to multiple agents.”

Although failing to identify the culprit drug can have severe consequences, they added, “overlabeling” (labeling a patient as allergic to a drug or drugs that they can tolerate safely) “is not insignificant.” As a result of overlabeling, “the patient may receive a less efficacious, more toxic, and/or more expensive agent than necessary, and in some cases may be left without treatment for their underlying disease.”

To evaluate the outcomes of patients’ allergy lists, current approaches to identify culprit drugs such as the Algorithm for Drug Causality for Epidermal Necrolysis (ALDEN), which was published in 2010, and potential methods of improving culprit drug identification, the researchers performed a retrospective cohort study of 48 patients at Brigham and Women’s Hospital and Massachusetts General Hospital, with clinically and histologically confirmed cases of SJS/TEN between January 2000 and July 2018. Of the 48 patients, 26 had SJS/TEN overlap and 22 had TEN. Their median age at diagnosis was 40 years; 60.4% were female; and 52.1% were white, 12.5% were Black, 10.4% were Hispanic, and 8.3% were Asian. They took a median of 6.5 drugs in the 3 months prior to disease onset.

The researchers observed that all patients had at least one drug labeled as an allergy. A single culprit drug was labeled in 17 cases, but physicians communicated certainty in only 7 of those cases. Among all 48 patients, 104 drugs were labeled as allergies.

To identify a culprit drug, physicians appeared to mainly rely on two factors: drug notoriety and timing of exposure, compared with the onset of SJS/TEN. “Identifying high-risk medications seemed heuristic, with one or more drugs in question noted in the record as a common culprit without reference to published or vetted data regarding risk,” the researchers wrote. “Regarding timing, drug charts when present in medical records were incomplete, as they focused predominantly on high-notoriety drugs.”

In other findings, ALDEN scoring was discordant with physician-labeled lists in 28 cases. It labeled an additional 9 drugs missed by physicians and scored 43 drugs labeled as allergens by physicians as “unlikely.” The researchers also reported that 20 cases could have potentially benefited from human leukocyte antigen testing.

Their results “underscore the need for a laboratory test to identify culprit drugs,” but without such a test, “a systematic unbiased approach, such as ALDEN or the RegiSCAR database, with possibly HLA testing, should be considered to ensure the true culprit drug is not missed and exonerate as many nonculprit drugs as possible,” Dr. Divito and colleagues concluded.

They acknowledged certain limitations of the analysis, including its retrospective design and that many cases predated research advances in the topic area that took place during the 18-year study period.

Karl Saardi, MD, director of the inpatient dermatology service at George Washington University Hospital, Washington, who was asked to comment on the study, said that the findings “are consistent with clinical practice in that drug causality is usually determined by ‘gestalt’ rather than objective tools like the ALDEN algorithm.”

“The main limitation is the small size, which suggests the study sites are low-volume centers for SJS/TEN. The fact that the ALDEN score wasn’t developed until 2010 means that all the cases included prior to 2010 would not have applied the ALDEN algorithm, so I think the metric about how infrequently ALDEN was applied is not very meaningful.”

Still, he said that he was “surprised” by the number of medications that were added as allergies based on clinical impression, “and I’m glad this article does cast some light on the issue. In my experience, beta-lactam antibiotics are often – incorrectly – deemed to be the cause of SJS/TEN when further review of the patient’s medication history clearly shows they have tolerated these drugs multiple times in the past.”

Since 2000, he added, “our understanding of SJS/TEN has grown substantially including the identification of MIRM [mycoplasma-induced rash and mucositis]/RIME [reactive infections mucocutaneous eruptions] and GBFDE [generalized bullous fixed drug eruption] as mimickers.”

Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was also asked to comment on the study, agreed that a limitation of the study is that it partially preceded development of the unbiased approaches to determining the cause of a medication reaction, such as the ALDEN system. “A strength of this study is the examination of heuristics in dermatology and how they relate to patient safety,” she added.

The study was funded by grants from the National Institutes of Health, a Dermatology Foundation Diversity Research Supplement Award, and by the German Research Foundation. Dr. Divito reported receiving personal fees from Adaptimmune and MEI Pharma and a provisional patent issued from Brigham and Women’s Hospital outside the submitted work. Neither Dr. Saardi nor Dr. Ko reported having relevant disclosures.

In the absence of a formal diagnostic test for Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), the current approach employed by most clinicians tends to overlabel patients as allergic to drugs that are unlikely to be the cause, results from a small retrospective cohort study demonstrated.

“Prompt identification and discontinuation of a culprit drug is critical to improving patient outcomes and preventing recurrence,” researchers led by Sherrie J. Divito, MD, PhD, of the department of dermatology at Brigham and Women’s Hospital, Boston, wrote in the study, which was published online in JAMA Dermatology. “Identification is difficult because there is no laboratory test or other criterion standard (in the absence of rechallenge) to identify a culprit drug, and patients take on average six medications at the time of their reaction. Consequently, many patients may be labeled as allergic to multiple agents.”

Although failing to identify the culprit drug can have severe consequences, they added, “overlabeling” (labeling a patient as allergic to a drug or drugs that they can tolerate safely) “is not insignificant.” As a result of overlabeling, “the patient may receive a less efficacious, more toxic, and/or more expensive agent than necessary, and in some cases may be left without treatment for their underlying disease.”

To evaluate the outcomes of patients’ allergy lists, current approaches to identify culprit drugs such as the Algorithm for Drug Causality for Epidermal Necrolysis (ALDEN), which was published in 2010, and potential methods of improving culprit drug identification, the researchers performed a retrospective cohort study of 48 patients at Brigham and Women’s Hospital and Massachusetts General Hospital, with clinically and histologically confirmed cases of SJS/TEN between January 2000 and July 2018. Of the 48 patients, 26 had SJS/TEN overlap and 22 had TEN. Their median age at diagnosis was 40 years; 60.4% were female; and 52.1% were white, 12.5% were Black, 10.4% were Hispanic, and 8.3% were Asian. They took a median of 6.5 drugs in the 3 months prior to disease onset.

The researchers observed that all patients had at least one drug labeled as an allergy. A single culprit drug was labeled in 17 cases, but physicians communicated certainty in only 7 of those cases. Among all 48 patients, 104 drugs were labeled as allergies.

To identify a culprit drug, physicians appeared to mainly rely on two factors: drug notoriety and timing of exposure, compared with the onset of SJS/TEN. “Identifying high-risk medications seemed heuristic, with one or more drugs in question noted in the record as a common culprit without reference to published or vetted data regarding risk,” the researchers wrote. “Regarding timing, drug charts when present in medical records were incomplete, as they focused predominantly on high-notoriety drugs.”

In other findings, ALDEN scoring was discordant with physician-labeled lists in 28 cases. It labeled an additional 9 drugs missed by physicians and scored 43 drugs labeled as allergens by physicians as “unlikely.” The researchers also reported that 20 cases could have potentially benefited from human leukocyte antigen testing.

Their results “underscore the need for a laboratory test to identify culprit drugs,” but without such a test, “a systematic unbiased approach, such as ALDEN or the RegiSCAR database, with possibly HLA testing, should be considered to ensure the true culprit drug is not missed and exonerate as many nonculprit drugs as possible,” Dr. Divito and colleagues concluded.

They acknowledged certain limitations of the analysis, including its retrospective design and that many cases predated research advances in the topic area that took place during the 18-year study period.

Karl Saardi, MD, director of the inpatient dermatology service at George Washington University Hospital, Washington, who was asked to comment on the study, said that the findings “are consistent with clinical practice in that drug causality is usually determined by ‘gestalt’ rather than objective tools like the ALDEN algorithm.”

“The main limitation is the small size, which suggests the study sites are low-volume centers for SJS/TEN. The fact that the ALDEN score wasn’t developed until 2010 means that all the cases included prior to 2010 would not have applied the ALDEN algorithm, so I think the metric about how infrequently ALDEN was applied is not very meaningful.”

Still, he said that he was “surprised” by the number of medications that were added as allergies based on clinical impression, “and I’m glad this article does cast some light on the issue. In my experience, beta-lactam antibiotics are often – incorrectly – deemed to be the cause of SJS/TEN when further review of the patient’s medication history clearly shows they have tolerated these drugs multiple times in the past.”

Since 2000, he added, “our understanding of SJS/TEN has grown substantially including the identification of MIRM [mycoplasma-induced rash and mucositis]/RIME [reactive infections mucocutaneous eruptions] and GBFDE [generalized bullous fixed drug eruption] as mimickers.”

Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was also asked to comment on the study, agreed that a limitation of the study is that it partially preceded development of the unbiased approaches to determining the cause of a medication reaction, such as the ALDEN system. “A strength of this study is the examination of heuristics in dermatology and how they relate to patient safety,” she added.

The study was funded by grants from the National Institutes of Health, a Dermatology Foundation Diversity Research Supplement Award, and by the German Research Foundation. Dr. Divito reported receiving personal fees from Adaptimmune and MEI Pharma and a provisional patent issued from Brigham and Women’s Hospital outside the submitted work. Neither Dr. Saardi nor Dr. Ko reported having relevant disclosures.

In the absence of a formal diagnostic test for Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), the current approach employed by most clinicians tends to overlabel patients as allergic to drugs that are unlikely to be the cause, results from a small retrospective cohort study demonstrated.

“Prompt identification and discontinuation of a culprit drug is critical to improving patient outcomes and preventing recurrence,” researchers led by Sherrie J. Divito, MD, PhD, of the department of dermatology at Brigham and Women’s Hospital, Boston, wrote in the study, which was published online in JAMA Dermatology. “Identification is difficult because there is no laboratory test or other criterion standard (in the absence of rechallenge) to identify a culprit drug, and patients take on average six medications at the time of their reaction. Consequently, many patients may be labeled as allergic to multiple agents.”

Although failing to identify the culprit drug can have severe consequences, they added, “overlabeling” (labeling a patient as allergic to a drug or drugs that they can tolerate safely) “is not insignificant.” As a result of overlabeling, “the patient may receive a less efficacious, more toxic, and/or more expensive agent than necessary, and in some cases may be left without treatment for their underlying disease.”

To evaluate the outcomes of patients’ allergy lists, current approaches to identify culprit drugs such as the Algorithm for Drug Causality for Epidermal Necrolysis (ALDEN), which was published in 2010, and potential methods of improving culprit drug identification, the researchers performed a retrospective cohort study of 48 patients at Brigham and Women’s Hospital and Massachusetts General Hospital, with clinically and histologically confirmed cases of SJS/TEN between January 2000 and July 2018. Of the 48 patients, 26 had SJS/TEN overlap and 22 had TEN. Their median age at diagnosis was 40 years; 60.4% were female; and 52.1% were white, 12.5% were Black, 10.4% were Hispanic, and 8.3% were Asian. They took a median of 6.5 drugs in the 3 months prior to disease onset.

The researchers observed that all patients had at least one drug labeled as an allergy. A single culprit drug was labeled in 17 cases, but physicians communicated certainty in only 7 of those cases. Among all 48 patients, 104 drugs were labeled as allergies.

To identify a culprit drug, physicians appeared to mainly rely on two factors: drug notoriety and timing of exposure, compared with the onset of SJS/TEN. “Identifying high-risk medications seemed heuristic, with one or more drugs in question noted in the record as a common culprit without reference to published or vetted data regarding risk,” the researchers wrote. “Regarding timing, drug charts when present in medical records were incomplete, as they focused predominantly on high-notoriety drugs.”

In other findings, ALDEN scoring was discordant with physician-labeled lists in 28 cases. It labeled an additional 9 drugs missed by physicians and scored 43 drugs labeled as allergens by physicians as “unlikely.” The researchers also reported that 20 cases could have potentially benefited from human leukocyte antigen testing.

Their results “underscore the need for a laboratory test to identify culprit drugs,” but without such a test, “a systematic unbiased approach, such as ALDEN or the RegiSCAR database, with possibly HLA testing, should be considered to ensure the true culprit drug is not missed and exonerate as many nonculprit drugs as possible,” Dr. Divito and colleagues concluded.

They acknowledged certain limitations of the analysis, including its retrospective design and that many cases predated research advances in the topic area that took place during the 18-year study period.

Karl Saardi, MD, director of the inpatient dermatology service at George Washington University Hospital, Washington, who was asked to comment on the study, said that the findings “are consistent with clinical practice in that drug causality is usually determined by ‘gestalt’ rather than objective tools like the ALDEN algorithm.”

“The main limitation is the small size, which suggests the study sites are low-volume centers for SJS/TEN. The fact that the ALDEN score wasn’t developed until 2010 means that all the cases included prior to 2010 would not have applied the ALDEN algorithm, so I think the metric about how infrequently ALDEN was applied is not very meaningful.”

Still, he said that he was “surprised” by the number of medications that were added as allergies based on clinical impression, “and I’m glad this article does cast some light on the issue. In my experience, beta-lactam antibiotics are often – incorrectly – deemed to be the cause of SJS/TEN when further review of the patient’s medication history clearly shows they have tolerated these drugs multiple times in the past.”

Since 2000, he added, “our understanding of SJS/TEN has grown substantially including the identification of MIRM [mycoplasma-induced rash and mucositis]/RIME [reactive infections mucocutaneous eruptions] and GBFDE [generalized bullous fixed drug eruption] as mimickers.”

Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was also asked to comment on the study, agreed that a limitation of the study is that it partially preceded development of the unbiased approaches to determining the cause of a medication reaction, such as the ALDEN system. “A strength of this study is the examination of heuristics in dermatology and how they relate to patient safety,” she added.

The study was funded by grants from the National Institutes of Health, a Dermatology Foundation Diversity Research Supplement Award, and by the German Research Foundation. Dr. Divito reported receiving personal fees from Adaptimmune and MEI Pharma and a provisional patent issued from Brigham and Women’s Hospital outside the submitted work. Neither Dr. Saardi nor Dr. Ko reported having relevant disclosures.

As the pandemic wanes, the public is clamoring for a return to normal. But individuals with long COVID face a challenging journey to get back to their baseline. Here’s what clinicians need to know to help patients with long COVID. 

The COVID-19 pandemic is waning. The official federal public health emergency ended on May 11, 2023. Moreover, the public is ready to move on 3 years after the beginning of a pandemic that resulted in over a million deaths in the United States.  

But not everyone can go back to normal. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 13 US adults (7.5%) have long COVID symptoms. Many of these people feel as if they are the forgotten patients. While everyone else is moving on, a significant number of people have not returned to their baseline. 

A group from Yale School of Medicine, myself included, reviewed a number of studies to gain a better understanding of 1) how long COVID manifests and 2) potential treatment options. Highlights of our evaluation are presented here.

Long COVID: The Basics
What exactly is long COVID-19, and how is it thought to develop? 

The World Health Organization (WHO) defines long COVID as symptoms that persist 3 months postinfection, last for ≥ 2 months, and are not attributable to another cause. 

Hypotheses about the mechanisms of long COVID include the presence of a persistent viral reservoir, an imbalance in the viral and microbial ecosystems, reactivation of latent DNA viruses, and endothelial dysfunction. 

Who is most at risk?

• Females

• Older individuals

• Individuals with preexisting conditions, including hypertension, diabetes, obesity, and lung disease 

• Individuals who experienced > 5 symptoms within the first week of COVID-19 illness 

• Individuals with breakthrough infections after vaccination against COVID-19 appear to be at increased risk of at least 1 postacute condition

Additionally, as the risk of contracting COVID-19 is demonstrably higher in certain racial and ethnic populations, it stands to reason that more of these individuals will experience long COVID. 

Long COVID symptoms: how long is long?

Long COVID symptoms may persist for 2 years after initial infection. One analysis from China showed that nearly 7 in 10 patients experienced at least 1 ongoing symptom 6 months following infection, with more than half reporting symptoms at 24 months. Dyspnea, anxiety, and depression are especially persistent. 

In another analysis, 90% of individuals reported symptoms 35 weeks postinfection. Symptoms did not only occur in people who were hospitalized; they also occurred in people who had a “mild case.”

Clinical Manifestations of Long COVID

More than 50 symptoms have been identified as potentially associated with long COVID. The most common manifestations involve pulmonary, cardiac, and neuropsychiatric sequelae. There is no single test to determine if symptoms are due to long COVID.

Pulmonary

How it manifests

• Chronic cough 

• Shortness of breath 

• Interstitial lung disease

Treatment options

Treatment options are variable and depend on predominant symptoms. Chronic cough should be managed based on primary etiology. Treatment for interstitial lung disease depends on whether the process continues to evolve or stabilizes. The role of antifibrotics in these patients is being investigated. Lung transplantation has largely been reserved for unresolved acute injury. 

Cardiac

How it manifests

• Postacute sequelae cardiovascular disease, where cardiovascular disorders are uncovered during diagnostic testing

• Postacute sequelae cardiovascular syndrome, such as exercise intolerance, tachycardia and chest pain, and dyspnea

Other important considerations:

• Cardiac symptoms can occur independent of preexisting conditions, severity, course of acute illness, and time from original diagnosis

• Cardiac involvement can occur in any age group

• One analysis revealed increased risk of stroke, arrythmias, pericarditis, myocarditis, and ischemic heart disease 1 year after COVID-19 infection

• Postural orthostatic tachycardia syndrome (POTS) and neurogenic orthostatic hypotension have also been observed

Treatment options

Treatment options are dictated by clinical manifestations and course. Patients who have autonomic dysfunction can be advised to increase salt and water intake since hypovolemia can worsen symptoms. Consider fludrocortisone and midodrine along with recumbent and semirecumbent exercises as tolerated, as exercise can sometimes worsen symptoms.

Neuropsychiatric

How it manifests

Patients can present with fatigue, memory disorders, headache, vertigo, myalgia, neuropathy, and smell and taste disorders, and there have been reports of cognitive decline postinfection. 

Other important considerations:

• A retrospective cohort study revealed that 34% of individuals had a new neurological or psychiatric diagnosis in the first 6 months after infection, including intracranial hemorrhage, ischemic stroke, parkinsonism, and dementia. Many COVID survivors experienced critical illness requiring mechanical ventilation, sedation, and paralytics, increasing the odds of developing postintensive care syndrome

Treatment options

Use of standard of care treatments, as well as neurocognitive rehabilitation and psychosocial support, is recommended for specific neuropsychiatric conditions. Patients with headache may benefit from treatment with amitriptyline or similar medications. Olfactory training and intranasal treatments can benefit those with loss of smell. 

Future Directions

Two medications that may hold promise for treating individuals long COVID symptoms are currently undergoing early investigation.

Pyridostigmine may help improve peak exercise capacity

Pyridostigmine improved peak exercise oxygen uptake in patients with chronic fatigue syndrome in a randomized, double-blind, placebo-controlled trial involving 45 individuals. Participants were assigned to receive either pyridostigmine 60 mg orally or placebo, and the pyridostigmine group showed an improved peak exercise uptake via increased cardiac output and right ventricular filling pressures. 

An investigational compound may improve fatigue-based symptoms

A 4-week protocol using the compound AXA1125 improved fatigue-based symptoms in patients with long COVID in a double-blind, randomized, controlled phase 2a pilot study involving 41 individuals. Investigators looked at average change in postexertional skeletal muscle phosphocreatine (PCr) recovery rate from baseline to day 28 after moderate exercise as well as fatigue levels. Although PCr recovery rate did not differ significantly between groups, use of the compound was linked with significant reduction in fatigue-based symptoms.

Summary

It is important to exercise caution when interpreting data involving individuals with long COVID. Most studies to date are retrospective and observational, definitions and assessments are not yet standardized, and long-term follow-up is lacking, among other factors. 

Clinicians should remain vigilant, keeping the following in mind as they see patients who may be experiencing long COVID: 

• Those most at risk include females, older individuals, those with obesity, people with preexisting conditions, individuals who experienced multiple symptoms early in their COVID-19 illness, and those who had breakthrough infections after COVID-19 vaccination 

• Symptoms may persist up to 2 years after acute infection

• The most common manifestations of long COVID involve pulmonary, cardiac, and neuropsychiatric complications

• Two medications, pyridostigmine and the compound AXA1125, are under investigation and may hold promise in treating some symptoms

As the pandemic wanes, the public is clamoring for a return to normal. But individuals with long COVID face a challenging journey to get back to their baseline. Here’s what clinicians need to know to help patients with long COVID. 

The COVID-19 pandemic is waning. The official federal public health emergency ended on May 11, 2023. Moreover, the public is ready to move on 3 years after the beginning of a pandemic that resulted in over a million deaths in the United States.  

But not everyone can go back to normal. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 13 US adults (7.5%) have long COVID symptoms. Many of these people feel as if they are the forgotten patients. While everyone else is moving on, a significant number of people have not returned to their baseline. 

A group from Yale School of Medicine, myself included, reviewed a number of studies to gain a better understanding of 1) how long COVID manifests and 2) potential treatment options. Highlights of our evaluation are presented here.

Long COVID: The Basics
What exactly is long COVID-19, and how is it thought to develop? 

The World Health Organization (WHO) defines long COVID as symptoms that persist 3 months postinfection, last for ≥ 2 months, and are not attributable to another cause. 

Hypotheses about the mechanisms of long COVID include the presence of a persistent viral reservoir, an imbalance in the viral and microbial ecosystems, reactivation of latent DNA viruses, and endothelial dysfunction. 

Who is most at risk?

• Females

• Older individuals

• Individuals with preexisting conditions, including hypertension, diabetes, obesity, and lung disease 

• Individuals who experienced > 5 symptoms within the first week of COVID-19 illness 

• Individuals with breakthrough infections after vaccination against COVID-19 appear to be at increased risk of at least 1 postacute condition

Additionally, as the risk of contracting COVID-19 is demonstrably higher in certain racial and ethnic populations, it stands to reason that more of these individuals will experience long COVID. 

Long COVID symptoms: how long is long?

Long COVID symptoms may persist for 2 years after initial infection. One analysis from China showed that nearly 7 in 10 patients experienced at least 1 ongoing symptom 6 months following infection, with more than half reporting symptoms at 24 months. Dyspnea, anxiety, and depression are especially persistent. 

In another analysis, 90% of individuals reported symptoms 35 weeks postinfection. Symptoms did not only occur in people who were hospitalized; they also occurred in people who had a “mild case.”

Clinical Manifestations of Long COVID

More than 50 symptoms have been identified as potentially associated with long COVID. The most common manifestations involve pulmonary, cardiac, and neuropsychiatric sequelae. There is no single test to determine if symptoms are due to long COVID.

Pulmonary

How it manifests

• Chronic cough 

• Shortness of breath 

• Interstitial lung disease

Treatment options

Treatment options are variable and depend on predominant symptoms. Chronic cough should be managed based on primary etiology. Treatment for interstitial lung disease depends on whether the process continues to evolve or stabilizes. The role of antifibrotics in these patients is being investigated. Lung transplantation has largely been reserved for unresolved acute injury. 

Cardiac

How it manifests

• Postacute sequelae cardiovascular disease, where cardiovascular disorders are uncovered during diagnostic testing

• Postacute sequelae cardiovascular syndrome, such as exercise intolerance, tachycardia and chest pain, and dyspnea

Other important considerations:

• Cardiac symptoms can occur independent of preexisting conditions, severity, course of acute illness, and time from original diagnosis

• Cardiac involvement can occur in any age group

• One analysis revealed increased risk of stroke, arrythmias, pericarditis, myocarditis, and ischemic heart disease 1 year after COVID-19 infection

• Postural orthostatic tachycardia syndrome (POTS) and neurogenic orthostatic hypotension have also been observed

Treatment options

Treatment options are dictated by clinical manifestations and course. Patients who have autonomic dysfunction can be advised to increase salt and water intake since hypovolemia can worsen symptoms. Consider fludrocortisone and midodrine along with recumbent and semirecumbent exercises as tolerated, as exercise can sometimes worsen symptoms.

Neuropsychiatric

How it manifests

Patients can present with fatigue, memory disorders, headache, vertigo, myalgia, neuropathy, and smell and taste disorders, and there have been reports of cognitive decline postinfection. 

Other important considerations:

• A retrospective cohort study revealed that 34% of individuals had a new neurological or psychiatric diagnosis in the first 6 months after infection, including intracranial hemorrhage, ischemic stroke, parkinsonism, and dementia. Many COVID survivors experienced critical illness requiring mechanical ventilation, sedation, and paralytics, increasing the odds of developing postintensive care syndrome

Treatment options

Use of standard of care treatments, as well as neurocognitive rehabilitation and psychosocial support, is recommended for specific neuropsychiatric conditions. Patients with headache may benefit from treatment with amitriptyline or similar medications. Olfactory training and intranasal treatments can benefit those with loss of smell. 

Future Directions

Two medications that may hold promise for treating individuals long COVID symptoms are currently undergoing early investigation.

Pyridostigmine may help improve peak exercise capacity

Pyridostigmine improved peak exercise oxygen uptake in patients with chronic fatigue syndrome in a randomized, double-blind, placebo-controlled trial involving 45 individuals. Participants were assigned to receive either pyridostigmine 60 mg orally or placebo, and the pyridostigmine group showed an improved peak exercise uptake via increased cardiac output and right ventricular filling pressures. 

An investigational compound may improve fatigue-based symptoms

A 4-week protocol using the compound AXA1125 improved fatigue-based symptoms in patients with long COVID in a double-blind, randomized, controlled phase 2a pilot study involving 41 individuals. Investigators looked at average change in postexertional skeletal muscle phosphocreatine (PCr) recovery rate from baseline to day 28 after moderate exercise as well as fatigue levels. Although PCr recovery rate did not differ significantly between groups, use of the compound was linked with significant reduction in fatigue-based symptoms.

Summary

It is important to exercise caution when interpreting data involving individuals with long COVID. Most studies to date are retrospective and observational, definitions and assessments are not yet standardized, and long-term follow-up is lacking, among other factors. 

Clinicians should remain vigilant, keeping the following in mind as they see patients who may be experiencing long COVID: 

• Those most at risk include females, older individuals, those with obesity, people with preexisting conditions, individuals who experienced multiple symptoms early in their COVID-19 illness, and those who had breakthrough infections after COVID-19 vaccination 

• Symptoms may persist up to 2 years after acute infection

• The most common manifestations of long COVID involve pulmonary, cardiac, and neuropsychiatric complications

• Two medications, pyridostigmine and the compound AXA1125, are under investigation and may hold promise in treating some symptoms

As the pandemic wanes, the public is clamoring for a return to normal. But individuals with long COVID face a challenging journey to get back to their baseline. Here’s what clinicians need to know to help patients with long COVID. 

The COVID-19 pandemic is waning. The official federal public health emergency ended on May 11, 2023. Moreover, the public is ready to move on 3 years after the beginning of a pandemic that resulted in over a million deaths in the United States.  

But not everyone can go back to normal. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 13 US adults (7.5%) have long COVID symptoms. Many of these people feel as if they are the forgotten patients. While everyone else is moving on, a significant number of people have not returned to their baseline. 

A group from Yale School of Medicine, myself included, reviewed a number of studies to gain a better understanding of 1) how long COVID manifests and 2) potential treatment options. Highlights of our evaluation are presented here.

Long COVID: The Basics
What exactly is long COVID-19, and how is it thought to develop? 

The World Health Organization (WHO) defines long COVID as symptoms that persist 3 months postinfection, last for ≥ 2 months, and are not attributable to another cause. 

Hypotheses about the mechanisms of long COVID include the presence of a persistent viral reservoir, an imbalance in the viral and microbial ecosystems, reactivation of latent DNA viruses, and endothelial dysfunction. 

Who is most at risk?

• Females

• Older individuals

• Individuals with preexisting conditions, including hypertension, diabetes, obesity, and lung disease 

• Individuals who experienced > 5 symptoms within the first week of COVID-19 illness 

• Individuals with breakthrough infections after vaccination against COVID-19 appear to be at increased risk of at least 1 postacute condition

Additionally, as the risk of contracting COVID-19 is demonstrably higher in certain racial and ethnic populations, it stands to reason that more of these individuals will experience long COVID. 

Long COVID symptoms: how long is long?

Long COVID symptoms may persist for 2 years after initial infection. One analysis from China showed that nearly 7 in 10 patients experienced at least 1 ongoing symptom 6 months following infection, with more than half reporting symptoms at 24 months. Dyspnea, anxiety, and depression are especially persistent. 

In another analysis, 90% of individuals reported symptoms 35 weeks postinfection. Symptoms did not only occur in people who were hospitalized; they also occurred in people who had a “mild case.”

Clinical Manifestations of Long COVID

More than 50 symptoms have been identified as potentially associated with long COVID. The most common manifestations involve pulmonary, cardiac, and neuropsychiatric sequelae. There is no single test to determine if symptoms are due to long COVID.

Pulmonary

How it manifests

• Chronic cough 

• Shortness of breath 

• Interstitial lung disease

Treatment options

Treatment options are variable and depend on predominant symptoms. Chronic cough should be managed based on primary etiology. Treatment for interstitial lung disease depends on whether the process continues to evolve or stabilizes. The role of antifibrotics in these patients is being investigated. Lung transplantation has largely been reserved for unresolved acute injury. 

Cardiac

How it manifests

• Postacute sequelae cardiovascular disease, where cardiovascular disorders are uncovered during diagnostic testing

• Postacute sequelae cardiovascular syndrome, such as exercise intolerance, tachycardia and chest pain, and dyspnea

Other important considerations:

• Cardiac symptoms can occur independent of preexisting conditions, severity, course of acute illness, and time from original diagnosis

• Cardiac involvement can occur in any age group

• One analysis revealed increased risk of stroke, arrythmias, pericarditis, myocarditis, and ischemic heart disease 1 year after COVID-19 infection

• Postural orthostatic tachycardia syndrome (POTS) and neurogenic orthostatic hypotension have also been observed

Treatment options

Treatment options are dictated by clinical manifestations and course. Patients who have autonomic dysfunction can be advised to increase salt and water intake since hypovolemia can worsen symptoms. Consider fludrocortisone and midodrine along with recumbent and semirecumbent exercises as tolerated, as exercise can sometimes worsen symptoms.

Neuropsychiatric

How it manifests

Patients can present with fatigue, memory disorders, headache, vertigo, myalgia, neuropathy, and smell and taste disorders, and there have been reports of cognitive decline postinfection. 

Other important considerations:

• A retrospective cohort study revealed that 34% of individuals had a new neurological or psychiatric diagnosis in the first 6 months after infection, including intracranial hemorrhage, ischemic stroke, parkinsonism, and dementia. Many COVID survivors experienced critical illness requiring mechanical ventilation, sedation, and paralytics, increasing the odds of developing postintensive care syndrome

Treatment options

Use of standard of care treatments, as well as neurocognitive rehabilitation and psychosocial support, is recommended for specific neuropsychiatric conditions. Patients with headache may benefit from treatment with amitriptyline or similar medications. Olfactory training and intranasal treatments can benefit those with loss of smell. 

Future Directions

Two medications that may hold promise for treating individuals long COVID symptoms are currently undergoing early investigation.

Pyridostigmine may help improve peak exercise capacity

Pyridostigmine improved peak exercise oxygen uptake in patients with chronic fatigue syndrome in a randomized, double-blind, placebo-controlled trial involving 45 individuals. Participants were assigned to receive either pyridostigmine 60 mg orally or placebo, and the pyridostigmine group showed an improved peak exercise uptake via increased cardiac output and right ventricular filling pressures. 

An investigational compound may improve fatigue-based symptoms

A 4-week protocol using the compound AXA1125 improved fatigue-based symptoms in patients with long COVID in a double-blind, randomized, controlled phase 2a pilot study involving 41 individuals. Investigators looked at average change in postexertional skeletal muscle phosphocreatine (PCr) recovery rate from baseline to day 28 after moderate exercise as well as fatigue levels. Although PCr recovery rate did not differ significantly between groups, use of the compound was linked with significant reduction in fatigue-based symptoms.

Summary

It is important to exercise caution when interpreting data involving individuals with long COVID. Most studies to date are retrospective and observational, definitions and assessments are not yet standardized, and long-term follow-up is lacking, among other factors. 

Clinicians should remain vigilant, keeping the following in mind as they see patients who may be experiencing long COVID: 

• Those most at risk include females, older individuals, those with obesity, people with preexisting conditions, individuals who experienced multiple symptoms early in their COVID-19 illness, and those who had breakthrough infections after COVID-19 vaccination 

• Symptoms may persist up to 2 years after acute infection

• The most common manifestations of long COVID involve pulmonary, cardiac, and neuropsychiatric complications

• Two medications, pyridostigmine and the compound AXA1125, are under investigation and may hold promise in treating some symptoms

Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.

How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.

Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.

A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.

Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.

And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.

As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.

After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.

While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that youths are aware of the dangers of social media and, given some guidance and information, can monitor themselves and limit their screen time to preserve mental health.
 

Goal: 30 minutes a day

In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.

At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.

“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”

Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”

Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
 

‘Youth are aware’

Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”

In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.

From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.

“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.

In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
 

Less FOMO, less anxiety

In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.

At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.

And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.

While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”

She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.

“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
 

Be ‘more mindful’

These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.

But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.

As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
 

Real-world strategies

Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.

But for many other teens and young adults, the struggle to stay off social media is real.

Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.

Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”

She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”

During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.

“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.

Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.

“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.

These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”

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

Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.

How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.

Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.

A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.

Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.

And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.

As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.

After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.

While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that youths are aware of the dangers of social media and, given some guidance and information, can monitor themselves and limit their screen time to preserve mental health.
 

Goal: 30 minutes a day

In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.

At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.

“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”

Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”

Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
 

‘Youth are aware’

Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”

In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.

From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.

“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.

In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
 

Less FOMO, less anxiety

In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.

At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.

And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.

While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”

She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.

“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
 

Be ‘more mindful’

These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.

But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.

As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
 

Real-world strategies

Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.

But for many other teens and young adults, the struggle to stay off social media is real.

Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.

Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”

She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”

During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.

“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.

Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.

“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.

These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”

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

Amelia Kennedy, 19, of Royersford, Pa., a point guard on the Catholic University of America, Washington, basketball team who will begin her sophomore year in the fall, uses TikTok, Snapchat, Instagram, and YouTube regularly.

How regularly? She estimates 7 hours a day and about 9 on weekends. She’s aware of the time-wasting potential. “If my mom says, ‘Do dishes,’ and I say, ‘5 more minutes,’ it can be longer,’’ she said.

Now imagine the challenge of cutting that 7 or 9 hours a day of social media use down to 30 minutes.

A very tall order, considering a 2022 Pew Research Center survey of more than 1,300 teens found 35% are “nearly constantly” on at least one of the top five social media platforms: YouTube, TikTok, Instagram, Snapchat, and Facebook.

Researchers from Iowa State University, Ames, recently took on that daunting challenge, limiting a group of students to only 30 minutes of social media a day to see what happens. Two weeks into the study, the students reported improvement in psychological well-being and other important measures, including sleep quality, compared with a control group assigned to continue using social media as usual.

And the dreaded FOMO, or fear of missing out, didn’t happen, the researchers said. At the end, the students were rethinking their social media use and feeling positive about it.

As social media becomes more common and youth mental health more endangered, experts are sounding the alarm. In late May, U.S. Surgeon General Vivek Murthy, MD, issued an advisory on social media and youth mental health, calling for tech companies to do better, policymakers to strengthen safety, and researchers to get more information, among other actions.

After that, the Biden administration took actions including the launch of a task force on kids’ online health and safety. The American Psychological Association has issued recommendations on social media use in youths. And the Social Media Victims Law Center in Seattle has sued numerous social media companies for online activity resulting in death and other tragedies.

While experts acknowledge that much more research is needed to sort out how to balance social media’s risks and benefits to preserve youth mental health and prevent such disasters, the new Iowa State study, as well as other recent research, suggests that youths are aware of the dangers of social media and, given some guidance and information, can monitor themselves and limit their screen time to preserve mental health.
 

Goal: 30 minutes a day

In the Iowa State study, 230 undergraduate students were assigned to one of two groups, with 99 in the 30-minute-a-day social media use group and 131 in the “usual” or control group, which made no changes. For those in the intervention group, “we sent a daily reminder email,” said Ella Faulhaber, a PhD candidate at Iowa State and the study’s lead author. It simply reminded them to limit social medial use to the 30-minute maximum.

At the study start and end, all participants provided a screenshot of their weekly social media usage time. The researchers gave both groups a battery of tests to assess anxiety, depression, loneliness, fear of missing out, and negative and positive feelings.

“By limiting their social media time, that resulted in less anxiety, less depression, less FOMO, fewer negative emotions, and greater positive emotions,” said Douglas Gentile, PhD, a distinguished professor of psychology at Iowa State and a study coauthor. “We know that it is the limiting [of] the social media that is causing that.”

Ms. Faulhaber recalled one participant who mentioned having trouble at first adjusting to the 30-minute time frame, but once sleep improved, it was easier to stick to that guidance. Another who gave up phone use at bedtime found: “Instead of looking at my phone, it was much easier to go straight to bed.”

Sleep improvements, of course, affect many parts of physical and mental health, Dr. Gentile said. And the study also showed that even with reduced screen time, “we can still get the benefit of being connected.” Those who didn’t make the 30-minute mark, but cut back, got benefits, too, the researchers said.
 

‘Youth are aware’

Self-monitoring works, agreed Jane Harness, DO, an adjunct clinical assistant professor of psychiatry at the University of Michigan, Ann Arbor, because “having that insight is often the first step.”

In a study she conducted, Dr. Harness aimed to gather youths’ insights about how their social media use affected them. With her colleagues, she asked more than 1,100 youths, aged 14-24, what advice they would give to those new to social media, if they ever felt they needed to change social media habits, and if they have deleted or considered deleting social media accounts.

From the 871 responses, Harness found that youths were especially concerned about safety online, that most had thought about deleting a social media app and some had, and that youths were more likely to say they wanted to change the amount of time spent on social media, compared with the content they view.

“Users responded with great advice for each other,” she said. “Safety was brought up,” with users reminding others to keep accounts private and to be aware of location tracking links and content that seems to promote eating disorders, suicide, and other harms.

In the study report, Dr. Harness concluded: “Youth are aware of ways in which social media could be negatively impacting them and they have employed methods to modulate their use because of this awareness.”
 

Less FOMO, less anxiety

In an earlier study, University of Pennsylvania, Philadelphia, researchers had 143 college students self-monitor social media for a week, then randomly assigned them either to a group told to limit Facebook, Instagram, and Snapchat use to 10 minutes per platform, per day, or to a group told to use social media as usual for 3 weeks.

At the end of the study, the researchers evaluated both groups and found “significant reductions in loneliness and depression over 3 weeks’’ in the limited-use group, compared with the usual-use group, according to study researcher Melissa G. Hunt, PhD, associate director of clinical training at the University of Pennsylvania.

And both groups showed declines in anxiety and fear of missing out, suggesting a benefit tied to self-monitoring itself, she said.

While Dr. Hunt’s study focused on 30 minutes a day, she said “about an hour a day seems to be the sweet spot for maximizing the positive effects of connecting, but limiting the negative effects of social media use.”

She also suggested that smartphones have no place in middle or high school classrooms. Instead, they should be on lockdown during classes.

“Parents need to set real limits of cellphone use during meals and in bedrooms,” Dr. Hunt said. At mealtime, for instance, all phones should be absent from the table. And after 10 p.m., “all family phones remain in the kitchen.”
 

Be ‘more mindful’

These recent study findings about self-monitoring and limiting social media time may not work the same for everyone, especially among those who aren’t as motivated, said psychiatrist Elizabeth Ortiz-Schwartz, MD, team lead for the adolescent inpatient unit at Silver Hill Hospital in New Canaan, Conn.

But “the bigger take-home piece is that being intentional and attempting to decrease the use in these individuals, even if they were not always successful, was clearly beneficial,” she said.

As we await clearer guidelines about what is the “right” amount of use in terms of social media content and time, Dr. Ortiz-Schwartz said, “becoming more mindful and aware of the risks and benefits can hopefully help individuals become more mindful and deliberate about its use.”
 

Real-world strategies

Max Schwandt, 23, is an outlier, but a happy one. He works as a sales clerk at a Los Angeles–area recreational gear shop, and he uses no social media. Why not? “It takes up too much time,” he explained. As simple as that.

But for many other teens and young adults, the struggle to stay off social media is real.

Amelia Kennedy, the Catholic University of America student, is trying to reduce her screen time. One way is to track it on her phone. These days, her summer job at a restaurant serving breakfast gets her up early. “If I have to work, I still go on my phone, but not that long.” And once at work, she only has time for quick checks between work responsibilities. “I definitely am more productive,” she said about days when she has work.

Last December, Lauren Young, 25, whose father was a researcher on the Iowa State study, was finishing law school at Georgetown University, Washington, and decided to take a break from social media for the entire month. “I can’t say I was always successful in avoiding it,” she said. But cutting down greatly “made me a lot more present in my day-to-day life, and it was easier to concentrate.”

She could even get through a meal, out with friends, without her phone, keeping it in her purse. That was a definite change from the norm. “I noticed I would go out to dinner and the standard for people my age is having the phone on the table. If you are being polite, you turn it over.”

During her social media “blackout,” Ms. Young had deleted TikTok, Instagram, and Facebook apps. Then, when she graduated, she had to reinstall to post a picture. But now, she is back to minimal social media use.

“I’m studying for the bar, so it’s kind of necessary, but it always makes me happier.” She figures she can always text family and friends if necessary, instead of posting. “I felt for a while I was missing out on things, but not now,” she said.

Others, including Sarah Goldstein, 22, of Chatsworth, Calif., a supermarket courtesy clerk who is thinking of returning to college, said she has developed a healthier attitude toward social media as she has gotten older.

“In middle and early high school, I would see parties, things I wasn’t invited to, on Snapchat and Instagram.” While she realized there could be legitimate reasons for not being included, she said it was easy to internalize those feelings of being left out.

These days, she said she doesn’t let it affect her mental health that way. She enjoys social media – especially TikTok and Instagram – for its benefits. “It kills time, gives you something to watch, can make you laugh and feel like you have a connection with other people.”

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