Child Psychiatry Consult

In the midst of the cold and flu season, we should reflect on the fact that our patients are laying down billions of dollars annually on preventions and cures for respiratory tract infections.

An aside: I am frequently turned down on my offer of the influenza vaccine, for which we probably have the best evidence. But $60 per month for a completely unproven preventive/curative agent made in some random factory in some random foreign land with no guarantee of good manufacturing practices (never mind the lack of active ingredients)? Stores can’t keep it in stock.

But I digress.

Our patients may lack the awareness of where to access evidence-based information when seeking answers about efficacy for cold remedies. So, it’s up to us to have at least some sense of where to get reliable information.

Truth be told, I am an enormous fan of safe and effective nonmedication therapies for the treatment and prevention of disease. So, when time permits, I will do a quick PubMed.gov search limiting my articles to randomized trials or systematic reviews on the latest and greatest home remedy.

Probiotics have been around for a while, and I think of them as a cure in search of a disease. The Cochrane Collaboration conducted a systematic review evaluating probiotics for the prevention of upper respiratory tract infection. In this review, 13 randomized, controlled trials were included (Explore [NY]. 2015 Sep-Oct;11[5]:418-20).

Probiotics were observed to be significantly better than placebo for reducing episodes of upper respiratory tract infection, the mean duration of episodes, antibiotic prescription rates, and cold-related absences. The evidence was of moderate to low quality.

Some may wonder how an ingested probiotic helps the respiratory tract stave off or fight infection. The prevailing theory appears to be that probiotics may function by mobilizing cells from the intestine to immunomodulate respiratory mucosa.

As for what probiotic/organism to prescribe? On this issue, there is a lot of smoke and not a lot of heat.

In general, the product should be encapsulated, and the label should include the genus and species of the strains (e.g., Lactobacillus acidophilus), the number of organisms (e.g., 5 billion), storage conditions (e.g., refrigerated or room temperature), and the shelf life. Pharmacy chain house brands may be cheaper. Gummy and chewable products tend to have 92% fewer beneficial bacteria than standard formulations.

How can we ensure purity?

That is tough, because supplements like probiotics are not regulated by the Food and Drug Administration above and beyond the agency’s trying to ensure good manufacturing practices. However, companies such as LabDoor (which generates revenue through affiliate links) test and grade supplements for label accuracy and purity. Websites like this might be the best place to start.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

In the midst of the cold and flu season, we should reflect on the fact that our patients are laying down billions of dollars annually on preventions and cures for respiratory tract infections.

An aside: I am frequently turned down on my offer of the influenza vaccine, for which we probably have the best evidence. But $60 per month for a completely unproven preventive/curative agent made in some random factory in some random foreign land with no guarantee of good manufacturing practices (never mind the lack of active ingredients)? Stores can’t keep it in stock.

But I digress.

Our patients may lack the awareness of where to access evidence-based information when seeking answers about efficacy for cold remedies. So, it’s up to us to have at least some sense of where to get reliable information.

Truth be told, I am an enormous fan of safe and effective nonmedication therapies for the treatment and prevention of disease. So, when time permits, I will do a quick PubMed.gov search limiting my articles to randomized trials or systematic reviews on the latest and greatest home remedy.

Probiotics have been around for a while, and I think of them as a cure in search of a disease. The Cochrane Collaboration conducted a systematic review evaluating probiotics for the prevention of upper respiratory tract infection. In this review, 13 randomized, controlled trials were included (Explore [NY]. 2015 Sep-Oct;11[5]:418-20).

Probiotics were observed to be significantly better than placebo for reducing episodes of upper respiratory tract infection, the mean duration of episodes, antibiotic prescription rates, and cold-related absences. The evidence was of moderate to low quality.

Some may wonder how an ingested probiotic helps the respiratory tract stave off or fight infection. The prevailing theory appears to be that probiotics may function by mobilizing cells from the intestine to immunomodulate respiratory mucosa.

As for what probiotic/organism to prescribe? On this issue, there is a lot of smoke and not a lot of heat.

In general, the product should be encapsulated, and the label should include the genus and species of the strains (e.g., Lactobacillus acidophilus), the number of organisms (e.g., 5 billion), storage conditions (e.g., refrigerated or room temperature), and the shelf life. Pharmacy chain house brands may be cheaper. Gummy and chewable products tend to have 92% fewer beneficial bacteria than standard formulations.

How can we ensure purity?

That is tough, because supplements like probiotics are not regulated by the Food and Drug Administration above and beyond the agency’s trying to ensure good manufacturing practices. However, companies such as LabDoor (which generates revenue through affiliate links) test and grade supplements for label accuracy and purity. Websites like this might be the best place to start.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

In the midst of the cold and flu season, we should reflect on the fact that our patients are laying down billions of dollars annually on preventions and cures for respiratory tract infections.

An aside: I am frequently turned down on my offer of the influenza vaccine, for which we probably have the best evidence. But $60 per month for a completely unproven preventive/curative agent made in some random factory in some random foreign land with no guarantee of good manufacturing practices (never mind the lack of active ingredients)? Stores can’t keep it in stock.

But I digress.

Our patients may lack the awareness of where to access evidence-based information when seeking answers about efficacy for cold remedies. So, it’s up to us to have at least some sense of where to get reliable information.

Truth be told, I am an enormous fan of safe and effective nonmedication therapies for the treatment and prevention of disease. So, when time permits, I will do a quick PubMed.gov search limiting my articles to randomized trials or systematic reviews on the latest and greatest home remedy.

Probiotics have been around for a while, and I think of them as a cure in search of a disease. The Cochrane Collaboration conducted a systematic review evaluating probiotics for the prevention of upper respiratory tract infection. In this review, 13 randomized, controlled trials were included (Explore [NY]. 2015 Sep-Oct;11[5]:418-20).

Probiotics were observed to be significantly better than placebo for reducing episodes of upper respiratory tract infection, the mean duration of episodes, antibiotic prescription rates, and cold-related absences. The evidence was of moderate to low quality.

Some may wonder how an ingested probiotic helps the respiratory tract stave off or fight infection. The prevailing theory appears to be that probiotics may function by mobilizing cells from the intestine to immunomodulate respiratory mucosa.

As for what probiotic/organism to prescribe? On this issue, there is a lot of smoke and not a lot of heat.

In general, the product should be encapsulated, and the label should include the genus and species of the strains (e.g., Lactobacillus acidophilus), the number of organisms (e.g., 5 billion), storage conditions (e.g., refrigerated or room temperature), and the shelf life. Pharmacy chain house brands may be cheaper. Gummy and chewable products tend to have 92% fewer beneficial bacteria than standard formulations.

How can we ensure purity?

That is tough, because supplements like probiotics are not regulated by the Food and Drug Administration above and beyond the agency’s trying to ensure good manufacturing practices. However, companies such as LabDoor (which generates revenue through affiliate links) test and grade supplements for label accuracy and purity. Websites like this might be the best place to start.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no financial disclosures relevant to this article.

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

The patient, a 10-year-old girl, was exhibiting defiant and angry behavior at home. Her pediatrician in rural Vermont was not able to support the family optimally, so he referred her to Dr. David C. Rettew.

Dr. Rettew soon learned that the girl blamed herself for her father’s absence, and she interpreted efforts by her mother to set limits as evidence that her mom didn’t love her.

Courtesy David C. Rettew, MD

“During the course of the interview, it became clear that the girl had some specific thoughts that were likely fueling her anger,” said Dr. Rettew, director of the Pediatric Psychiatry Clinic at the University of Vermont, Burlington. “She also met criteria clearly for ADHD, which had never been diagnosed. The consultation recommendations not only included some possible medications to try, but also some specific areas that could be addressed for psychotherapy that could really help the relationship between this child and her mother.”

The successful intervention took place via a secure, two-way videoconference. It is one example of how physicians at the University of Vermont are using telemental health to treat children in underserved areas. As part of a state-funded training program, child psychiatry fellows at the university consult with primary care doctors at federally qualified health centers across the state. The primary care physicians discuss patient cases with fellows via phone or email and can refer patients for in-person or telemental health assessments.

The program has been running for about 5 years and so far has yielded countless benefits, said Dr. Rettew, who directs the university’s Child and Adolescent Psychiatry Fellowship Program. “It helps keep the care housed and centered within the primary care home. That can help coordination of services so that care isn’t fragmented around multiple centers. It also allows evaluations to happen that wouldn’t happen otherwise because it’s too much of a hardship for families to travel long distances and come for regular follow-up appointments.”

University of Vermont physicians also use telemedicine to consult with other mental health clinicians across the state. Child psychiatrist Allison Y. Hall provides in-person training to clinicians and then counsels and supervises their efforts through a telemedicine unit.

“For this purpose, it’s great,” said Dr. Hall, who practices at the Vermont Center for Children, Youth, and Families, which is housed within the university’s psychiatry department. “There’s more confidentiality than Skype, for instance. It’s wonderful to be able to reach clinicians at a great distance.”

On a broader scale, telemental health is a promising tool to address the shortage of mental health providers in the United States, said Dr. Robert C. Gunther, a pediatrician at the University of Virginia Health System in Fishersville. Recent research found that one in three children receiving outpatient care for mental health conditions saw only their primary care doctor for care (Pediatrics. 2015 Nov;136;e1178-85).

“There is a tremendous need for pediatric mental health care,” Dr. Gunther said in an interview. “There is a great shortage of child psychiatrists and other child mental health specialists. Telemental health can help in areas where geography or financial barriers exist to accessing care.”

Data from the Children’s ADHD Telemental Health Treatment Study (CATTS) illustrates the impact that telemental health can have on children facing such barriers to care. Researchers randomized 223 children referred by 88 primary care providers in seven underserved communities into two study groups. Children in the first group were seen by child psychiatrists via videoconference six times over 22 weeks; treatment included pharmacotherapy. Their caregivers received behavior training provided in person by community therapists who were supervised remotely. Children in the second group were treated by their primary care physicians and received one telepsychiatry consult.

Children in both groups improved; however, those randomized to the telemental health model improved “significantly more than patients in the augmented primary care arm” (J Am Acad Child Adolesc Psychiatry. 2015 Apr;54[4]:263-74).

Courtesy David C. Rettew, MD

“The CATTS trial demonstrated the effectiveness of a telehealth service model to treat ADHD in communities with limited access to specialty mental health services,” investigators concluded.

But Dr. Joshua J. Alexander, chair of the American Academy of Pediatrics Section on Telehealth Care, notes that some mental health conditions fit more smoothly within the telemental health model than others. ADHD is the most common condition treated by telemental health, he said. The model also has shown success in the treatment of childhood adjustment disorders, anxiety, oppositional defiant disorder, mood disorders, anxiety, and depression.

“I think you have to be careful in determining where telemental health would be beneficial to use and in which cases it might not be an appropriate method to deliver care,” Dr. Alexander said in an interview.

Developing trust and rapport with patients through videoconferencing also can be a challenge, added Dr. Alexander, who is director of the TelAbility telehealth program at the University of North Carolina at Chapel Hill. He recommends that specialists use the technology to continue an existing doctor-patient relationship or to provide care in a consultative model in which the child’s primary care doctor is present along with the patient and patient’s family.

The AAP advocates for the use of telemedicine so long as it is conducted within the context of the medical home. Fragmented telemedicine services that could disrupt continuity of care should be avoided, according to a 2015 AAP policy statement (Pediatrics. 2015 Jun. doi: 10.1542/peds.2015-1253). The academy also calls for the expansion of pediatric telemedicine to increase access to care for underserved communities and improve quality of care for children.

More partnerships between mental health specialists and primary care providers are a key step in delivering high quality pediatric telemental care, Dr. Alexander said.

“Some larger pediatric practices already do this by hiring and colocating individuals at their practice site, but other, smaller practices might not have the room, finances, sufficient patient population, or enough local providers to make this happen,” he said. “A telemedicine program, located within the practice, could enable this specialized service to be provided in a convenient, coordinated setting.”

[email protected]

On Twitter @legal_med

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.

Is there another way?

Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.

Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).

In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.

However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).

These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.

A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.

Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:

©Stockphoto4u/ iStockphoto.com

•  The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.

•  The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.

•  An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).

•  Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.

•  The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.

One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.

Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).

These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.

A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.

Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:

©Stockphoto4u/ iStockphoto.com

•  The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.

•  The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.

•  An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).

•  Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.

•  The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.

One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.

Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

As more and more states consider legalizing marijuana for recreational use, the widely held belief that cannabis is associated with few serious health consequences has been challenged by many medical and substance use professionals. One potential risk that has been discussed is the possibility that cannabis use increases the risk for psychotic symptoms that may be long lasting and develop into schizophrenia. The data, however, have not been completely consistent and often are methodologically flawed, leading proponents of legalization to downplay this possible risk. This debate has even made its way to prominent science journals such as Nature where scholars have presented opposing views (Nature. 2015 Sep 24;525[7570]:S14and Nature. 2015 Nov 19;527[7578]:305).

These divergent opinions can lead to some confusion and hesitancy on the part of pediatricians who may be asked to offer an opinion about the dangers of cannabis use to individual patients and families during this time of public debate. Thus, this column will attempt to offer a brief overview and synthesis of the evidence that cannabis plays a causal role in the progression of psychotic disorders.

A recent review of the subject examined 10 epidemiological studies that have now been performed on the association between cannabis and psychotic disorders. Overall, a nearly 50% increased risk of psychosis was found among cannabis users, compared to nonusers (Biol Psychiatry. 2015 Aug 12. pii: S0006-3223[15]00647-2). This association rises among heavier cannabis users (Lancet. 2007 Jul 28;370[9584]:319-28). Because all of these longitudinal studies were observational in nature, however, proving causation in the face of association has remained challenging. Many of these studies have attempted to control for baseline psychotic symptoms to address the “reverse causation hypothesis,” which posits that early psychotic symptoms leads to cannabis use rather than the other way around. It is also worth pointing out that the inevitable limitations and potential biases of these studies could potentially lead to both overestimation and underestimation of the actual risk.

Putting all of this together, the authors concluded that “there is a strong body of epidemiologic evidence to support the view that regular or heavy cannabis use increases the risk of developing psychotic disorders that persist beyond the direct effects of exogenous cannabinoids.” In making this conclusion, despite the inherent uncertainties of interpreting observational studies, the authors describe a number of lines of evidence that support the likelihood of a causal connection. These include the following:

©Stockphoto4u/ iStockphoto.com

•  The well-known fact that acute intoxication of cannabis can produce transient psychotic symptoms.

•  The replicated finding that there is a dose-dependent response between amount of cannabis use and psychosis.

•  An increased risk of psychosis among cannabis users who carry specific risk genes (Biol Psychiatry. 2012 Nov 15;72[10]:811-6).

•  Increasing evidence that the more potent marijuana that is available now may be associated with additional risk.

•  The finding that the link between cannabis and psychosis is not equal for all age groups, but may be stronger for adolescents.

One line of argument against a causal role of cannabis in the development of psychotic disorders is that the rate of schizophrenia has remained relatively flat over the years that cannabis use has increased. Countering that assertion, however, Large and colleagues pointed out that some studies do show increasing rates of schizophrenia (Nature. 2015 Nov 19;527[7578]:305). Further, it is somewhat precarious to conclude that a possible risk factor is not consequential when it moves in a different direction than a multifactorial disorder such as schizophrenia. Lead toxicity, for example, is an accepted risk factor for attention-deficit/hyperactivity disorder (ADHD), yet exposure has been decreasing while rates of ADHD climb.

Overall, the data appear to be strengthening that cannabis does play a causal role in the development of psychosis and psychotic disorders. This risk is combined with data showing links between cannabis use and decreased IQ, academic underachievement, car accidents, and use of other types of drugs (Addiction. 2015 Jan;110[1]:19-35). These dangers need to be articulated in discussions about the wisdom of legalizing cannabis at the state and federal level.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

We are in the midst of an epidemic of heroin and prescription opioid abuse. While the two do not completely explain each other, they are tragically and irrevocably linked.

From 2001 to 2013, we have observed a threefold increase in the total number of overdose deaths from opioid pain relievers (about 16,000 in 2013) and a fivefold increase in the total number of overdose deaths from heroin (about 8,000 in 2013).

Heroin initiation is almost 20 times higher among individuals reporting nonmedical prescription pain reliever use. Among opioid-treatment seekers, the majority of individuals who initiated opioid use in the 1960s were first exposed to heroin. This is in contrast to those who initiated in the 2000s, among whom the majority were exposed to prescription opioids. For young adults, the main sources of opioids are family, friends … and clinicians.

Opioids are powerfully addictive and can be snorted, swallowed, smoked, or shot. Data from the START (Starting Treatment with Agonist Replacement Therapies) trial suggest that individuals who inject opioids are less likely to remain in treatment than noninjectors. This necessarily increases the risk for injectors to inject again and be at risk for overdose.

Opioid overdose can be reversed with the use of naloxone. But naloxone has to be immediately or quickly available for it to be effective. Take-home naloxone programs are located in 30 U.S. states and the District of Columbia. Since 1996, home naloxone programs have reported more than 26,000 drug overdose reversals with naloxone.

On Nov. 18, the Food and Drug Administration announced the approval of a naloxone nasal spray. Prior to this approval, naloxone was only available in the injectable form (syringe or auto-injector), and needle management likely posed a barrier to first responders. The nasal spray can be administered easily without medical training. Naloxone nasal spray administered in one nostril delivered approximately the same levels or higher of naloxone as a single dose of an FDA-approved naloxone intramuscular injection in approximately the same time frame.

It is one thing to save a heroin addict who has just overdosed with nasal naloxone followed by appropriate medical attention. It is entirely another to engage them in an effective drug treatment program.

If naloxone revives them, it is treatment that can save them.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

One-half of my practice is taking care of employees and dependents employed by the organization for which I work. Most of these patients sit … a lot … and present to me with musculoskeletal pain and weight concerns. My patients have a high degree of health literacy and are fully aware that 6 hours of sitting might have at least something to do with these problems.

We currently seem to be on the other side of the “walk station” mania. Sanity has been restored through a combination of concerns about medical liability for work-related treadmill injuries, expense, space issues, and reports that walkers were more forgetful and less focused. The last study resulted in some personal email for my own indulgences in walking while researching.

But let us not throw out an upright posture with the treadmill. Sitters have an increased risk for elevated blood sugars, cardiovascular disease, cancer, and death. Standers have been suggested to burn 50 more calories per hour. Some experts recommend that people should stand for at least 2 hours each day, and 4 hours is even better.

Dr. Graves and colleagues conducted a randomized controlled trial to evaluate the impact of a sit-stand workstation on sitting time, vascular, metabolic, and musculoskeletal outcomes and to investigate workstation acceptability and feasibility. Forty-seven participants without any bodily symptoms were randomized to either a sit-stand workstation or no intervention for 8 weeks. The sit-stand workstation was associated with decreased sit time (80 minutes per 8-hour work day), increased standing time (73 minutes per 8-hour work day), and a decrease in total cholesterol. No increase in musculoskeletal pain was observed with a suggestion of possible benefit in the neck and upper back (BMC Public Health. 2015;15:1145. doi 10.1186/s12889-015-2469-8).

Each of the devices cost about $550 to install for a single monitor ($20 more for a dual monitor). The intervention was only 8 weeks in duration and stronger effects in musculoskeletal and cardiovascular risk markers might be seen with longer durations of study. The qualitative work in this study suggested that several factors may influence use of a sit-stand desk such as social environment (for example, other colleagues not using it may decrease use), work tasks (for example, paperwork made difficult by limited elevated work surface), and design (for example, keyboard surface bounces too much). From personal experience, the sit-stand desk is ideal if the vast majority of work is on the computer. I’d also like to say I was standing when I wrote this. But I wasn’t. And I wasn’t walking either because I can’t remember where that desk is.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Is it just me? I don’t think that I have visited with a single patient this week who’s not struggling with sleep. Our heavily caffeinated, media-obsessed, melatonin-killing, computer-screen-staring, tragic work-life imbalances explain away a lot of it. Knowing that, though, patients in front of me seek immediate relief.

A prescription takes substantially less effort than does training patients on sleep hygiene or sleep restriction. The problem with “z” drugs is, of course, that tolerance can develop within 4 weeks with daily use. These drugs have been associated with mood and cognitive changes and increased mortality. Many of my patients cannot use them sparingly, because relief of insomnia is something of which they cannot get enough. Then we are either back to square one or playing the dose-escalation game.

I have always wondered how much of this is the “placebo effect” and how we could use this to our clinical advantage. This is certainly what I hear from my cynical colleagues when I recommend melatonin – which, by the way, I personally believe is an extremely effective and underutilized intervention. We should remind ourselves to be cognizant of the “if I can’t prescribe it, it can’t work that well” mentality.

Alexander Winkler and Winfried Rief of the University of Marburg, Germany, conducted a brilliant systematic review examining the effect of placebo conditions in randomized trials including polysomnography addressing primary insomnia (Sleep. 2015 Jun 1;38[6]:925-31).

The investigators identified 32 studies with almost 4,000 patients in 82 treatment conditions: The studies were published between 1992 and 2012. Of those 82 treatment conditions, 17 included hypnotic drugs.

Results suggest that 64% of drug response to medications for primary insomnia is achieved in the placebo group.

So what does this mean clinically? I think the first thing it means is that we should consider (re)launching frank discourse about the ethics surrounding the use of placebo in clinical medicine. Are we all too horrified to think that patients may get better despite us rather than because of us to dig too deeply here?

The second thing it means is that patients should be instructed to use the medications only when needed. If a minority of the drug effect for insomnia is from the drug itself, we should minimize the buildup of tolerance by using it sparingly. Studies that have alternated a hypnotic with a placebo show that this works just as well as using a hypnotic every night.

Patients should be encouraged to alternate therapy, such as trying melatonin first and resorting to a “z” drug only if sleep remains elusive. Alternating drug therapy may also enhance the efficacy of the medication.

Always try to combine pharmacotherapy with good sleep hygiene to maximize benefits.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

Primary care clinicians have come to realize that a large percentage of patients use alternative or complementary approaches to many types of health problems, including emotional-behavioral ones.

Families often are reluctant to bring up these interventions in primary care appointments for fear that their doctor will criticize them for using unproven and sometimes risky treatments. When it comes to dietary supplements, the evidence for many is rather weak, while others have been studied in controlled trials and now may deserve a closer look. Omega-3 fatty acid supplementation for various types of psychiatric disorders and problems may be leading the pack as an alternative treatment that has earned the right to be on the radar screen of all pediatricians. This article briefly summarizes what scientific evidence exists about the efficacy of omega-3s in pediatric emotional-behavioral problems and where significant gaps in our knowledge remain.

Case summary

Samantha is an 11-year-old girl who was adopted into a loving and supportive family at the age of 4 years after having suffered a tumultuous early childhood that included domestic violence as well as physical and emotional abuse. Despite a much improved home environment, she has continued to struggle for many years with difficulties including inattention, emotional dysregulation, and aggression toward others. Samantha and her family have worked with a mental health counselor, and her pediatrician also has started her on pharmacotherapy with a stimulant medication and an alpha-agonist. Despite some gains, significant difficulties remain. At a follow-up visit, Samantha’s mother states that she has done some research on the Internet and has heard positive things about omega-3 fatty acid supplements. She wonders if this might be appropriate for Samantha and if so, how specifically the treatment would be administered.

Discussion

The possible benefits of omega-3s in the treatment of behavioral problems has been discussed for decades, and good evidence from rigorous trials has slowly been accumulating. In October 2015 at the annual meeting of the American Academy of Child and Adolescent Psychiatry, researchers in a clinical trial called Omega-3 and Therapy Studies (OATS) presented some preliminary results to see if omega-3s could augment response in children aged 7-14 years with depression and bipolar spectrum disorders who also were receiving evidence-based psychotherapy. The daily dose was 2,000 mg, consisting of 1,400 mg of eicosapentaenoic acid (EPA), 200 mg of docosahexaenoic acid (DHA), and 400 mg of other omega-3s. Significant improvement of small to medium effect was found for omega-3s, particularly for depressive symptoms, and side effects were minimal.

Another relatively recent study from 2014 used a randomized double-blind design in 200 youth between the ages of 6 and 18 years from the island nation of Mauritius, near Madagascar (J Child Psychol Psychiatry. 2015 May;56[5]:509-20). The active treatment here was 1,000 mg of omega-3s (300 mg DHA, 200 mg EPA, 500 mg of others). After subjects were followed for a year, significant and fairly large improvements were found for omega-3s, relative to placebo, across a wide range of problems including aggression in addition to anxiety and depressive symptoms. One very interesting side note of this study was that the improvement in child behavior seemed to be partially mediated by improvements in the parents’ behavior, even though parents did not receive the supplements.

In attention-deficit/hyperactivity disorder, a meta-analysis of 10 clinical trials also was positive (J Am Acad Child Adolesc Psychiatry. 2011 Oct;50[10]:991-1000). The effect size was small, but there seemed to be a dose effect with more positive trials related to higher daily doses of EPA. Side effects again were few.

The mechanism for improvement remains to be fully understood, although evidence points to changes in cell membrane fluidity and possible anti-inflammatory properties. The biggest question mark that remains from a practical standpoint is dose, both in absolute numbers and with regard to ratios of EPA to DHA. Given the vast number of suppliers of omega-3 supplementation and the wide range of quality with regard to accurate dosing and impurities, it also is important to help families identify a specific product that can be trusted.

Case follow-up

Somewhat to the surprise of Samantha’s mother, the pediatrician supports a trial of omega-3 supplementation, given the increasing evidence of efficacy and the favorable side effect profile. They discuss reasonable expectations, dosing, and ways that the family can obtain a high-quality supplement. Six months later, the family reports noticeable further improvements in Samantha’s behavior to the point that more aggressive psychopharmacologic treatment is not indicated currently.

In sum, it is reasonable to conclude at this point that evidence supporting omega-3 use for a variety of emotional-behavioral problems now equals or exceeds that for many off-label prescription medications that are now used in similar situations. This increasing evidence, combined with the low risk for most patients, would seem to warrant pediatricians considering omega-3 supplementation as a more mainstream and evidence-based intervention that deserves a place in one’s treatment algorithm for several emotional-behavioral concerns.

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He will also be course director of the 10th annual Child Psychiatry in Primary Care conference on May 13, 2016, in Burlington. Follow him on Twitter @pedipsych.

Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.

After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?

Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).

Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.

A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.

Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.

The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).

Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.

If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.

After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?

Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).

Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.

A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.

Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.

The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).

Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.

If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Functional, a.k.a. “nonulcer,” dyspepsia is a challenging diagnosis and likely afflicts many more patients than we have identified in our practices. Functional dyspepsia (FD) is defined by the presence of postprandial fullness, early satiety, epigastric pain or burning, and no evidence of structural disease. These are the patients who do not get better with proton pump inhibitors or feel better after a bowel movement.

After a negative upper endoscopy and Helicobacter pylori stool antigen test, the task turns to symptom control. But what’s the best treatment?

Dr. Nicholas J. Talley of the University of Newcastle in Callaghan, Australia, and colleagues conducted a multicenter, randomized trial evaluating the comparative efficacy of amitriptyline or escitalopram for symptom control, gastric emptying, and meal-induced satiety in patients with FD (Gastroenterology. 2015;149(2):340-9.e2).

Participants were enrolled if they met Rome II criteria for FD requiring that folks in the preceding 12 months have at least 12 weeks of dyspepsia, absence of organic disease, and no relationship to defecation. Patients were randomized to placebo, amitriptyline 50 mg (titrated), or escitalopram 10 mg. Medication was given for 10 weeks. The primary endpoint was adequate relief of symptoms for at least 5 weeks.

A total of 292 patients (most of whom [75%] were female) with an average age of 44 years were randomized. Seventy percent had dysmotility-like FD and 30% had ulcer-like FD.

Patients with ulcer-like FD receiving amitriptyline were more likely to report adequate relief (odds ratio, 3.1; 95% confidence interval, 1.1-9.0). Neither medication affected gastric emptying or meal-induced satiety. Both medications improved overall quality of life.

The data support the use of amitriptyline for ulcer-like FD. Some of these patients may have comorbid psychiatric illness that may be improved with escitalopram. Perhaps this is what is impacting the quality-of-life metric that taps into dimensions above and beyond relief of symptoms (such as sleep disturbance or work/study).

Proton pump inhibitors tend to be overused, and many of our patients take them indefinitely without trying to see how they do off of them. Some patients for whom we have not considered a diagnosis of FD may be on PPIs because we have had nothing else to offer them. Maybe they felt better because of a PPI placebo effect and we have continued them.

If we can, we should review the diagnosis of dyspepsia, consider FD as a possibility etiology for gastrointestinal distress, stop the PPIs, and try amitriptyline.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.