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New evaluation and management of CPT codes for telemedicine in 2025
. The AMA says the new codes are designed to bring the coding system up to date with the changing landscape of health care and reflect the realities of modern medical practice.
The 17 new CPT codes will encompass a variety of telemedicine services. While the official language of the codes has not been released yet, codes for telemedicine visits using a real-time audio-visual platform could be organized similarly to existing office/outpatient E/M visits (99202-99205, 99212-99215). As part of these revisions, the current telephone E/M codes (99441-99443) will be deleted and replaced with new codes for audio-only E/M.
Implementation of so many codes will require health care providers and systems to adapt their documentation and coding practices. Typically, the exact language and code numbers for new and revised codes are not released to the public until fall of the preceding year, leaving only a few months for practices to educate their physicians and coding staff and prepare their internal systems for implementation starting Jan. 1, 2025. However, given the significant education and systems changes that will be necessary to prepare for so many new codes, we will advocate that the AMA release this information in early 2024.
Additionally, the reimbursement for telemedicine services may not ultimately be the same as for in-person E/M office visits. The AMA/Specialty Society RVS Update Committee (RUC) provides recommendations to the Centers for Medicare & Medicaid Services (CMS) for consideration in developing Relative Value Units (RVUs) for new procedures, including the telemedicine codes. The RUC’s recommendations for the telemedicine codes are not yet publicly available. However, it is important to note that regardless of the RUC recommendations, CMS makes all final decisions about Medicare payment. CMS could decide to set the payments for the telemedicine codes at parity with in-person office E/M visits or less than, more than, or some combination at the individual code level.
If payments for telemedicine visits are set at parity with or higher than office E/M visits, practices can focus primarily on physician and staff education and system implementation of the new codes. However, if telemedicine visit payments are less than in-person E/M office visits, it would have significant implications for practices, providers, and patients. Providers might be discouraged from offering virtual care, leading to a disparity in the availability of telehealth services, with patients in some areas or with certain conditions having limited access. Additionally, not all patients have access to a smartphone or stable internet. Research has shown increased use of audio-only visits among marginalized groups including African Americans, non-English speakers, older patients, those with public insurance as opposed to private insurance and patients living in rural communities and communities with low broadband access. For these patients, audio-only is a lifeline that allows them to access needed care.
Hughes HK, Hasselfeld BW, Greene JA. Health Care Access on the Line - Audio-Only Visits and Digitally Inclusive Care. N Engl J Med. 2022 Nov 17;387(20):1823-1826. doi: 10.1056/NEJMp2118292. Epub 2022 Nov 12. PMID: 36373819.
Chen J, Li KY, Andino J, Hill CE, Ng S, Steppe E, Ellimoottil C. Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic. J Gen Intern Med. 2022 Apr;37(5):1138-1144. doi: 10.1007/s11606-021-07172-y. Epub 2021 Nov 17. PMID: 34791589; PMCID: PMC8597874.
If payment for audio-only is significantly less than in-person office E/M payments, practices may not offer this option furthering health care inequities.
Beyond the extensive preparation needed and the financial implications, there could be impacts to coverage policies. Currently, telemedicine coverage is triggered by reporting the appropriate office E/M level visit with telemedicine modifier 95. If the new telemedicine codes are no longer tied to the in-person codes, laws requiring payers to provide coverage and parity may need to be adjusted accordingly or they could become less effective. If coverage parity is not maintained, that may lead to changes in practice that could also worsen access and health disparities. Some insurers have already started rolling back coverages. Recently, Aetna decided to stop covering telemedicine visits as of Dec. 1, 2023.
Other insurers may follow suit.
As practices prepare for 2024, tracking insurance coverage policies for telemedicine, staying alert for information from the AMA about the new telemedicine CPT codes, and monitoring the proposed payments for telemedicine that CMS will release in late June to early July in the 2025 Medicare Physician Fee Schedule proposed rule will be important. Participation in advocacy efforts will be critical once the full details are released by the AMA and CMS about the new telemedicine codes and their proposed values. The AGA is monitoring this issue and will continue to fight to reduce burden to physicians and practices, which includes fighting for payment parity with in-person office E/M visits and maintaining coverage benefits for patients.
The authors have reported no conflicts of interest.
. The AMA says the new codes are designed to bring the coding system up to date with the changing landscape of health care and reflect the realities of modern medical practice.
The 17 new CPT codes will encompass a variety of telemedicine services. While the official language of the codes has not been released yet, codes for telemedicine visits using a real-time audio-visual platform could be organized similarly to existing office/outpatient E/M visits (99202-99205, 99212-99215). As part of these revisions, the current telephone E/M codes (99441-99443) will be deleted and replaced with new codes for audio-only E/M.
Implementation of so many codes will require health care providers and systems to adapt their documentation and coding practices. Typically, the exact language and code numbers for new and revised codes are not released to the public until fall of the preceding year, leaving only a few months for practices to educate their physicians and coding staff and prepare their internal systems for implementation starting Jan. 1, 2025. However, given the significant education and systems changes that will be necessary to prepare for so many new codes, we will advocate that the AMA release this information in early 2024.
Additionally, the reimbursement for telemedicine services may not ultimately be the same as for in-person E/M office visits. The AMA/Specialty Society RVS Update Committee (RUC) provides recommendations to the Centers for Medicare & Medicaid Services (CMS) for consideration in developing Relative Value Units (RVUs) for new procedures, including the telemedicine codes. The RUC’s recommendations for the telemedicine codes are not yet publicly available. However, it is important to note that regardless of the RUC recommendations, CMS makes all final decisions about Medicare payment. CMS could decide to set the payments for the telemedicine codes at parity with in-person office E/M visits or less than, more than, or some combination at the individual code level.
If payments for telemedicine visits are set at parity with or higher than office E/M visits, practices can focus primarily on physician and staff education and system implementation of the new codes. However, if telemedicine visit payments are less than in-person E/M office visits, it would have significant implications for practices, providers, and patients. Providers might be discouraged from offering virtual care, leading to a disparity in the availability of telehealth services, with patients in some areas or with certain conditions having limited access. Additionally, not all patients have access to a smartphone or stable internet. Research has shown increased use of audio-only visits among marginalized groups including African Americans, non-English speakers, older patients, those with public insurance as opposed to private insurance and patients living in rural communities and communities with low broadband access. For these patients, audio-only is a lifeline that allows them to access needed care.
Hughes HK, Hasselfeld BW, Greene JA. Health Care Access on the Line - Audio-Only Visits and Digitally Inclusive Care. N Engl J Med. 2022 Nov 17;387(20):1823-1826. doi: 10.1056/NEJMp2118292. Epub 2022 Nov 12. PMID: 36373819.
Chen J, Li KY, Andino J, Hill CE, Ng S, Steppe E, Ellimoottil C. Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic. J Gen Intern Med. 2022 Apr;37(5):1138-1144. doi: 10.1007/s11606-021-07172-y. Epub 2021 Nov 17. PMID: 34791589; PMCID: PMC8597874.
If payment for audio-only is significantly less than in-person office E/M payments, practices may not offer this option furthering health care inequities.
Beyond the extensive preparation needed and the financial implications, there could be impacts to coverage policies. Currently, telemedicine coverage is triggered by reporting the appropriate office E/M level visit with telemedicine modifier 95. If the new telemedicine codes are no longer tied to the in-person codes, laws requiring payers to provide coverage and parity may need to be adjusted accordingly or they could become less effective. If coverage parity is not maintained, that may lead to changes in practice that could also worsen access and health disparities. Some insurers have already started rolling back coverages. Recently, Aetna decided to stop covering telemedicine visits as of Dec. 1, 2023.
Other insurers may follow suit.
As practices prepare for 2024, tracking insurance coverage policies for telemedicine, staying alert for information from the AMA about the new telemedicine CPT codes, and monitoring the proposed payments for telemedicine that CMS will release in late June to early July in the 2025 Medicare Physician Fee Schedule proposed rule will be important. Participation in advocacy efforts will be critical once the full details are released by the AMA and CMS about the new telemedicine codes and their proposed values. The AGA is monitoring this issue and will continue to fight to reduce burden to physicians and practices, which includes fighting for payment parity with in-person office E/M visits and maintaining coverage benefits for patients.
The authors have reported no conflicts of interest.
. The AMA says the new codes are designed to bring the coding system up to date with the changing landscape of health care and reflect the realities of modern medical practice.
The 17 new CPT codes will encompass a variety of telemedicine services. While the official language of the codes has not been released yet, codes for telemedicine visits using a real-time audio-visual platform could be organized similarly to existing office/outpatient E/M visits (99202-99205, 99212-99215). As part of these revisions, the current telephone E/M codes (99441-99443) will be deleted and replaced with new codes for audio-only E/M.
Implementation of so many codes will require health care providers and systems to adapt their documentation and coding practices. Typically, the exact language and code numbers for new and revised codes are not released to the public until fall of the preceding year, leaving only a few months for practices to educate their physicians and coding staff and prepare their internal systems for implementation starting Jan. 1, 2025. However, given the significant education and systems changes that will be necessary to prepare for so many new codes, we will advocate that the AMA release this information in early 2024.
Additionally, the reimbursement for telemedicine services may not ultimately be the same as for in-person E/M office visits. The AMA/Specialty Society RVS Update Committee (RUC) provides recommendations to the Centers for Medicare & Medicaid Services (CMS) for consideration in developing Relative Value Units (RVUs) for new procedures, including the telemedicine codes. The RUC’s recommendations for the telemedicine codes are not yet publicly available. However, it is important to note that regardless of the RUC recommendations, CMS makes all final decisions about Medicare payment. CMS could decide to set the payments for the telemedicine codes at parity with in-person office E/M visits or less than, more than, or some combination at the individual code level.
If payments for telemedicine visits are set at parity with or higher than office E/M visits, practices can focus primarily on physician and staff education and system implementation of the new codes. However, if telemedicine visit payments are less than in-person E/M office visits, it would have significant implications for practices, providers, and patients. Providers might be discouraged from offering virtual care, leading to a disparity in the availability of telehealth services, with patients in some areas or with certain conditions having limited access. Additionally, not all patients have access to a smartphone or stable internet. Research has shown increased use of audio-only visits among marginalized groups including African Americans, non-English speakers, older patients, those with public insurance as opposed to private insurance and patients living in rural communities and communities with low broadband access. For these patients, audio-only is a lifeline that allows them to access needed care.
Hughes HK, Hasselfeld BW, Greene JA. Health Care Access on the Line - Audio-Only Visits and Digitally Inclusive Care. N Engl J Med. 2022 Nov 17;387(20):1823-1826. doi: 10.1056/NEJMp2118292. Epub 2022 Nov 12. PMID: 36373819.
Chen J, Li KY, Andino J, Hill CE, Ng S, Steppe E, Ellimoottil C. Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic. J Gen Intern Med. 2022 Apr;37(5):1138-1144. doi: 10.1007/s11606-021-07172-y. Epub 2021 Nov 17. PMID: 34791589; PMCID: PMC8597874.
If payment for audio-only is significantly less than in-person office E/M payments, practices may not offer this option furthering health care inequities.
Beyond the extensive preparation needed and the financial implications, there could be impacts to coverage policies. Currently, telemedicine coverage is triggered by reporting the appropriate office E/M level visit with telemedicine modifier 95. If the new telemedicine codes are no longer tied to the in-person codes, laws requiring payers to provide coverage and parity may need to be adjusted accordingly or they could become less effective. If coverage parity is not maintained, that may lead to changes in practice that could also worsen access and health disparities. Some insurers have already started rolling back coverages. Recently, Aetna decided to stop covering telemedicine visits as of Dec. 1, 2023.
Other insurers may follow suit.
As practices prepare for 2024, tracking insurance coverage policies for telemedicine, staying alert for information from the AMA about the new telemedicine CPT codes, and monitoring the proposed payments for telemedicine that CMS will release in late June to early July in the 2025 Medicare Physician Fee Schedule proposed rule will be important. Participation in advocacy efforts will be critical once the full details are released by the AMA and CMS about the new telemedicine codes and their proposed values. The AGA is monitoring this issue and will continue to fight to reduce burden to physicians and practices, which includes fighting for payment parity with in-person office E/M visits and maintaining coverage benefits for patients.
The authors have reported no conflicts of interest.
Hypertensive disorders of pregnancy and high stroke risk in Black women
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
I’d like to talk with you about a recent report from the large-scale Black Women’s Health Study, published in the new journal NEJM Evidence.
This study looked at the association between hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, and the risk for stroke over the next 20 (median, 22) years. Previous studies have linked hypertensive disorders of pregnancy with an increased risk for stroke. However, most of these studies have been done in White women of European ancestry, and evidence in Black women has been very limited, despite a disproportionately high risk of having a hypertensive disorder of pregnancy and also of stroke.
– overall, a 66% increased risk, an 80% increased risk with gestational hypertension, and about a 50% increased risk with preeclampsia.
We know that pregnancy itself can lead to some remodeling of the vascular system, but we don’t know whether a direct causal relationship exists between preeclampsia or gestational hypertension and subsequent stroke. Another potential explanation is that these complications of pregnancy serve as a window into a woman’s future cardiometabolic health and a marker of her cardiovascular risk.
Regardless, the clinical implications are the same. First, we would want to prevent these complications of pregnancy whenever possible. Some women will be candidates for the use of aspirin if they are at high risk for preeclampsia, and certainly for monitoring blood pressure very closely during pregnancy. It will also be important to maintain blood pressure control in the postpartum period and during the subsequent years of adulthood to minimize risk for stroke, because hypertension is such a powerful risk factor for stroke.
It will also be tremendously important to intensify lifestyle modifications such as increasing physical activity and having a heart-healthy diet. These complications of pregnancy have also been linked in other studies to an increased risk for subsequent coronary heart disease events and heart failure.
This transcript has been edited for clarity.
Dr. Manson is professor of medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School, and chief of the division of preventive medicine, Brigham and Women’s Hospital, both in Boston, and past president, North American Menopause Society, 2011-2012. She disclosed receiving study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).
A version of this article appeared on Medscape.com.
Even one night in the ED raises risk for death
This transcript has been edited for clarity.
As a consulting nephrologist, I go all over the hospital. Medicine floors, surgical floors, the ICU – I’ve even done consults in the operating room. And more and more, I do consults in the emergency department.
The reason I am doing more consults in the ED is not because the ED docs are getting gun shy with creatinine increases; it’s because patients are staying for extended periods in the ED despite being formally admitted to the hospital. It’s a phenomenon known as boarding, because there are simply not enough beds. You know the scene if you have ever been to a busy hospital: The ED is full to breaking, with patients on stretchers in hallways. It can often feel more like a warzone than a place for healing.
This is a huge problem.
The Joint Commission specifies that admitted patients should spend no more than 4 hours in the ED waiting for a bed in the hospital.
That is, based on what I’ve seen, hugely ambitious. But I should point out that I work in a hospital that runs near capacity all the time, and studies – from some of my Yale colleagues, actually – have shown that once hospital capacity exceeds 85%, boarding rates skyrocket.
I want to discuss some of the causes of extended boarding and some solutions. But before that, I should prove to you that this really matters, and for that we are going to dig in to a new study which suggests that ED boarding kills.
To put some hard numbers to the boarding problem, we turn to this paper out of France, appearing in JAMA Internal Medicine.
This is a unique study design. Basically, on a single day – Dec. 12, 2022 – researchers fanned out across France to 97 EDs and started counting patients. The study focused on those older than age 75 who were admitted to a hospital ward from the ED. The researchers then defined two groups: those who were sent up to the hospital floor before midnight, and those who spent at least from midnight until 8 AM in the ED (basically, people forced to sleep in the ED for a night). The middle-ground people who were sent up between midnight and 8 AM were excluded.
The baseline characteristics between the two groups of patients were pretty similar: median age around 86, 55% female. There were no significant differences in comorbidities. That said, comporting with previous studies, people in an urban ED, an academic ED, or a busy ED were much more likely to board overnight.
So, what we have are two similar groups of patients treated quite differently. Not quite a randomized trial, given the hospital differences, but not bad for purposes of analysis.
Here are the most important numbers from the trial:
This difference held up even after adjustment for patient and hospital characteristics. Put another way, you’d need to send 22 patients to the floor instead of boarding in the ED to save one life. Not a bad return on investment.
It’s not entirely clear what the mechanism for the excess mortality might be, but the researchers note that patients kept in the ED overnight were about twice as likely to have a fall during their hospital stay – not surprising, given the dangers of gurneys in hallways and the sleep deprivation that trying to rest in a busy ED engenders.
I should point out that this could be worse in the United States. French ED doctors continue to care for admitted patients boarding in the ED, whereas in many hospitals in the United States, admitted patients are the responsibility of the floor team, regardless of where they are, making it more likely that these individuals may be neglected.
So, if boarding in the ED is a life-threatening situation, why do we do it? What conditions predispose to this?
You’ll hear a lot of talk, mostly from hospital administrators, saying that this is simply a problem of supply and demand. There are not enough beds for the number of patients who need beds. And staffing shortages don’t help either.
However, they never want to talk about the reasons for the staffing shortages, like poor pay, poor support, and, of course, the moral injury of treating patients in hallways.
The issue of volume is real. We could do a lot to prevent ED visits and hospital admissions by providing better access to preventive and primary care and improving our outpatient mental health infrastructure. But I think this framing passes the buck a little.
Another reason ED boarding occurs is the way our health care system is paid for. If you are building a hospital, you have little incentive to build in excess capacity. The most efficient hospital, from a profit-and-loss standpoint, is one that is 100% full as often as possible. That may be fine at times, but throw in a respiratory virus or even a pandemic, and those systems fracture under the pressure.
Let us also remember that not all hospital beds are given to patients who acutely need hospital beds. Many beds, in many hospitals, are necessary to handle postoperative patients undergoing elective procedures. Those patients having a knee replacement or abdominoplasty don’t spend the night in the ED when they leave the OR; they go to a hospital bed. And those procedures are – let’s face it – more profitable than an ED admission for a medical issue. That’s why, even when hospitals expand the number of beds they have, they do it with an eye toward increasing the rate of those profitable procedures, not decreasing the burden faced by their ED.
For now, the band-aid to the solution might be to better triage individuals boarding in the ED for floor access, prioritizing those of older age, greater frailty, or more medical complexity. But it feels like a stop-gap measure as long as the incentives are aligned to view an empty hospital bed as a sign of failure in the health system instead of success.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
As a consulting nephrologist, I go all over the hospital. Medicine floors, surgical floors, the ICU – I’ve even done consults in the operating room. And more and more, I do consults in the emergency department.
The reason I am doing more consults in the ED is not because the ED docs are getting gun shy with creatinine increases; it’s because patients are staying for extended periods in the ED despite being formally admitted to the hospital. It’s a phenomenon known as boarding, because there are simply not enough beds. You know the scene if you have ever been to a busy hospital: The ED is full to breaking, with patients on stretchers in hallways. It can often feel more like a warzone than a place for healing.
This is a huge problem.
The Joint Commission specifies that admitted patients should spend no more than 4 hours in the ED waiting for a bed in the hospital.
That is, based on what I’ve seen, hugely ambitious. But I should point out that I work in a hospital that runs near capacity all the time, and studies – from some of my Yale colleagues, actually – have shown that once hospital capacity exceeds 85%, boarding rates skyrocket.
I want to discuss some of the causes of extended boarding and some solutions. But before that, I should prove to you that this really matters, and for that we are going to dig in to a new study which suggests that ED boarding kills.
To put some hard numbers to the boarding problem, we turn to this paper out of France, appearing in JAMA Internal Medicine.
This is a unique study design. Basically, on a single day – Dec. 12, 2022 – researchers fanned out across France to 97 EDs and started counting patients. The study focused on those older than age 75 who were admitted to a hospital ward from the ED. The researchers then defined two groups: those who were sent up to the hospital floor before midnight, and those who spent at least from midnight until 8 AM in the ED (basically, people forced to sleep in the ED for a night). The middle-ground people who were sent up between midnight and 8 AM were excluded.
The baseline characteristics between the two groups of patients were pretty similar: median age around 86, 55% female. There were no significant differences in comorbidities. That said, comporting with previous studies, people in an urban ED, an academic ED, or a busy ED were much more likely to board overnight.
So, what we have are two similar groups of patients treated quite differently. Not quite a randomized trial, given the hospital differences, but not bad for purposes of analysis.
Here are the most important numbers from the trial:
This difference held up even after adjustment for patient and hospital characteristics. Put another way, you’d need to send 22 patients to the floor instead of boarding in the ED to save one life. Not a bad return on investment.
It’s not entirely clear what the mechanism for the excess mortality might be, but the researchers note that patients kept in the ED overnight were about twice as likely to have a fall during their hospital stay – not surprising, given the dangers of gurneys in hallways and the sleep deprivation that trying to rest in a busy ED engenders.
I should point out that this could be worse in the United States. French ED doctors continue to care for admitted patients boarding in the ED, whereas in many hospitals in the United States, admitted patients are the responsibility of the floor team, regardless of where they are, making it more likely that these individuals may be neglected.
So, if boarding in the ED is a life-threatening situation, why do we do it? What conditions predispose to this?
You’ll hear a lot of talk, mostly from hospital administrators, saying that this is simply a problem of supply and demand. There are not enough beds for the number of patients who need beds. And staffing shortages don’t help either.
However, they never want to talk about the reasons for the staffing shortages, like poor pay, poor support, and, of course, the moral injury of treating patients in hallways.
The issue of volume is real. We could do a lot to prevent ED visits and hospital admissions by providing better access to preventive and primary care and improving our outpatient mental health infrastructure. But I think this framing passes the buck a little.
Another reason ED boarding occurs is the way our health care system is paid for. If you are building a hospital, you have little incentive to build in excess capacity. The most efficient hospital, from a profit-and-loss standpoint, is one that is 100% full as often as possible. That may be fine at times, but throw in a respiratory virus or even a pandemic, and those systems fracture under the pressure.
Let us also remember that not all hospital beds are given to patients who acutely need hospital beds. Many beds, in many hospitals, are necessary to handle postoperative patients undergoing elective procedures. Those patients having a knee replacement or abdominoplasty don’t spend the night in the ED when they leave the OR; they go to a hospital bed. And those procedures are – let’s face it – more profitable than an ED admission for a medical issue. That’s why, even when hospitals expand the number of beds they have, they do it with an eye toward increasing the rate of those profitable procedures, not decreasing the burden faced by their ED.
For now, the band-aid to the solution might be to better triage individuals boarding in the ED for floor access, prioritizing those of older age, greater frailty, or more medical complexity. But it feels like a stop-gap measure as long as the incentives are aligned to view an empty hospital bed as a sign of failure in the health system instead of success.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
As a consulting nephrologist, I go all over the hospital. Medicine floors, surgical floors, the ICU – I’ve even done consults in the operating room. And more and more, I do consults in the emergency department.
The reason I am doing more consults in the ED is not because the ED docs are getting gun shy with creatinine increases; it’s because patients are staying for extended periods in the ED despite being formally admitted to the hospital. It’s a phenomenon known as boarding, because there are simply not enough beds. You know the scene if you have ever been to a busy hospital: The ED is full to breaking, with patients on stretchers in hallways. It can often feel more like a warzone than a place for healing.
This is a huge problem.
The Joint Commission specifies that admitted patients should spend no more than 4 hours in the ED waiting for a bed in the hospital.
That is, based on what I’ve seen, hugely ambitious. But I should point out that I work in a hospital that runs near capacity all the time, and studies – from some of my Yale colleagues, actually – have shown that once hospital capacity exceeds 85%, boarding rates skyrocket.
I want to discuss some of the causes of extended boarding and some solutions. But before that, I should prove to you that this really matters, and for that we are going to dig in to a new study which suggests that ED boarding kills.
To put some hard numbers to the boarding problem, we turn to this paper out of France, appearing in JAMA Internal Medicine.
This is a unique study design. Basically, on a single day – Dec. 12, 2022 – researchers fanned out across France to 97 EDs and started counting patients. The study focused on those older than age 75 who were admitted to a hospital ward from the ED. The researchers then defined two groups: those who were sent up to the hospital floor before midnight, and those who spent at least from midnight until 8 AM in the ED (basically, people forced to sleep in the ED for a night). The middle-ground people who were sent up between midnight and 8 AM were excluded.
The baseline characteristics between the two groups of patients were pretty similar: median age around 86, 55% female. There were no significant differences in comorbidities. That said, comporting with previous studies, people in an urban ED, an academic ED, or a busy ED were much more likely to board overnight.
So, what we have are two similar groups of patients treated quite differently. Not quite a randomized trial, given the hospital differences, but not bad for purposes of analysis.
Here are the most important numbers from the trial:
This difference held up even after adjustment for patient and hospital characteristics. Put another way, you’d need to send 22 patients to the floor instead of boarding in the ED to save one life. Not a bad return on investment.
It’s not entirely clear what the mechanism for the excess mortality might be, but the researchers note that patients kept in the ED overnight were about twice as likely to have a fall during their hospital stay – not surprising, given the dangers of gurneys in hallways and the sleep deprivation that trying to rest in a busy ED engenders.
I should point out that this could be worse in the United States. French ED doctors continue to care for admitted patients boarding in the ED, whereas in many hospitals in the United States, admitted patients are the responsibility of the floor team, regardless of where they are, making it more likely that these individuals may be neglected.
So, if boarding in the ED is a life-threatening situation, why do we do it? What conditions predispose to this?
You’ll hear a lot of talk, mostly from hospital administrators, saying that this is simply a problem of supply and demand. There are not enough beds for the number of patients who need beds. And staffing shortages don’t help either.
However, they never want to talk about the reasons for the staffing shortages, like poor pay, poor support, and, of course, the moral injury of treating patients in hallways.
The issue of volume is real. We could do a lot to prevent ED visits and hospital admissions by providing better access to preventive and primary care and improving our outpatient mental health infrastructure. But I think this framing passes the buck a little.
Another reason ED boarding occurs is the way our health care system is paid for. If you are building a hospital, you have little incentive to build in excess capacity. The most efficient hospital, from a profit-and-loss standpoint, is one that is 100% full as often as possible. That may be fine at times, but throw in a respiratory virus or even a pandemic, and those systems fracture under the pressure.
Let us also remember that not all hospital beds are given to patients who acutely need hospital beds. Many beds, in many hospitals, are necessary to handle postoperative patients undergoing elective procedures. Those patients having a knee replacement or abdominoplasty don’t spend the night in the ED when they leave the OR; they go to a hospital bed. And those procedures are – let’s face it – more profitable than an ED admission for a medical issue. That’s why, even when hospitals expand the number of beds they have, they do it with an eye toward increasing the rate of those profitable procedures, not decreasing the burden faced by their ED.
For now, the band-aid to the solution might be to better triage individuals boarding in the ED for floor access, prioritizing those of older age, greater frailty, or more medical complexity. But it feels like a stop-gap measure as long as the incentives are aligned to view an empty hospital bed as a sign of failure in the health system instead of success.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. He reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
Missing Table and a Clarification
Correction
In: Barbeito A, Raghunathan K, Connolly S, et al. Barriers to implementation of telehealth pre-anesthesia evaluation visits in the Department of Veterans Affairs. Fed Pract. 2023;40(7):210-217a. doi:10.12788/fp.0387. Federal Practitioner inadvertently excluded Table 2. It has been updated online and in PubMed Central.
Clarification
In: Weaver M, Geppert CMA. Salute to service dogs. Fed Pract . 2023;40(9):278-280. doi:10.12788/fp.0414, The PAWS Act was noted and the authors want to provide the following
Correction
In: Barbeito A, Raghunathan K, Connolly S, et al. Barriers to implementation of telehealth pre-anesthesia evaluation visits in the Department of Veterans Affairs. Fed Pract. 2023;40(7):210-217a. doi:10.12788/fp.0387. Federal Practitioner inadvertently excluded Table 2. It has been updated online and in PubMed Central.
Clarification
In: Weaver M, Geppert CMA. Salute to service dogs. Fed Pract . 2023;40(9):278-280. doi:10.12788/fp.0414, The PAWS Act was noted and the authors want to provide the following
Correction
In: Barbeito A, Raghunathan K, Connolly S, et al. Barriers to implementation of telehealth pre-anesthesia evaluation visits in the Department of Veterans Affairs. Fed Pract. 2023;40(7):210-217a. doi:10.12788/fp.0387. Federal Practitioner inadvertently excluded Table 2. It has been updated online and in PubMed Central.
Clarification
In: Weaver M, Geppert CMA. Salute to service dogs. Fed Pract . 2023;40(9):278-280. doi:10.12788/fp.0414, The PAWS Act was noted and the authors want to provide the following
Who Gets to Determine Whether Home Is “Unsafe” at the End of Life?
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
Sometimes a patient at the end of life (EOL) just wants to go home. We recently treated such a patient, “Joe,” a 66-year-old veteran with end-stage chronic obstructive pulmonary disorder (COPD), severe hearing loss, and heavy alcohol use. A neighbor brought Joe to the hospital when he developed a urinary tract infection. Before hospitalization, Joe spent his days in bed. His neighbor was his designated health care agent (HCA) and caregiver, dropping off meals and bringing Joe to medical appointments. Joe had no other social support. In the hospital, Joe could not participate in physical therapy (PT) evaluations due to severe dyspnea on exertion. He was recommended for home PT, a home health aide, and home nursing, but Joe declined these services out of concern for encroachment on his independence. Given his heavy alcohol use, limited support, and functional limitations, the hospitalist team felt that Joe would be best served in a skilled nursing facility. As the palliative care team, we were consulted and felt that he was eligible for hospice. Joe simply wanted to go home.
Many patients like Joe experience functional decline at EOL, leading to increased care needs and transitions between sites of care.1 Some hospitalized patients at EOL want to transition directly to home, but due to their limited functioning and social support, discharge home may be deemed unsafe by health care professionals (HCPs). Clinicians then face the difficult balancing act of honoring patient wishes and avoiding a bad outcome. For patients at EOL, issues of capacity and risk become particularly salient. Furthermore, the unique structure of the US Department of Veterans Affairs (VA) health system and the psychosocial needs of some veterans add additional considerations for complex EOL discharges.2
End-of-life Decision Making
While patients may express strong preferences regarding their health care, their decision-making ability may worsen as they approach EOL. Contributing factors include older age, effects of hospitalization, treatment adverse effects, and comorbidities, including cognitive impairment. Studies of terminally ill patients show high rates of impaired decisional capacity.3,4 It is critical to assess capacity as part of discharge planning. Even when patients have the capacity, families and caregivers have an important voice, since they are often instrumental in maintaining patients at home.
Defining Risk
Determining whether a discharge is risky or unsafe is highly subjective, with differing opinions among clinicians and between patients and clinicians.5-7 In a qualitative study by Coombs and colleagues, HCPs tended toward a risk-averse approach to discharge decisions, sometimes favoring discharge to care facilities despite patient preferences.6 This approach also reflects pressures from the health care system to decrease the length of stay and reduce readmissions, important metrics for patient care and cost containment. However, keeping patients hospitalized or in nursing facilities does not completely mitigate risks (eg, falls) and carries other hazards (eg, nosocomial infections), as highlighted during the COVID-19 pandemic.7,8 The prospect of malpractice lawsuits and HCP moral distress about perceived risky home situations can also understandably affect decision making.
At the same time, risk calculation changes depending on the patient’s clinical status and priorities. Coombs and colleagues found that in contrast to clinicians, patients nearing EOL are willing to accept increasing risks and suboptimal living conditions to remain at home.6 What may be intolerable for a younger, healthier patient with a long life expectancy may be acceptable for someone who is approaching EOL. In our framework, a risky home discharge at EOL is considered one in which other adverse events, such as falls or inadequate symptom management, are likely.
Ethical Considerations
Unsafe discharges are challenging in part because some of the pillars of medical ethics can conflict. Prior articles have analyzed the ethical concerns of unsafe discharges in detail.9-11 Briefly, when patients wish to return home against initial medical recommendations, treatment teams may focus on the principles of beneficence and nonmaleficence, as exemplified by the desire to minimize harm, and justice, in which clinicians consider resource allocation and risks that a home discharge poses to family members, caregivers, and home health professionals. However, autonomy is important to consider as well. The concept of dignity of risk highlights the imperative to respect others’ decisions even when they increase the chance of harm, particularly given the overall shift in medicine from paternalism to shared decision making.12 Accommodating patient choice in how and where health care is received allows patients to regain some control over their lives, thereby enhancing their quality of life and promoting patient dignity, especially in their remaining days.13
Discharge Risk Framework
Our risk assessment framework helps clinicians more objectively identify factors that increase or decrease risk, inform discharge planning, partner with patients and families, give patients a prominent role in EOL decisions, and mitigate the risk of a bad outcome. This concept has been used in psychiatry, in which formal suicide assessment includes identifying risk factors and protective factors to estimate suicide risk and determine interventions.14 Similar to suicide risk estimation, this framework is based on clinical judgment rather than a specific calculation.
While this framework serves as a guide for determining and mitigating risk, we encourage teams to consider legal or ethical consultations in challenging cases, such as those in which patients lack both capacity and an involved HCA.
Step 1: Determine the patient’s capacity regarding disposition planning. Patients at EOL are at a higher risk of impaired decision-making capabilities; therefore, capacity evaluation is a critical step.
Step 2: Identify risk factors and protective factors for discharge home. Risk factors are intrinsic and extrinsic factors that increase risk such as functional or sensory impairments. Protective factors are intrinsic and extrinsic factors that decrease risk, including a good understanding of illness and consistent connection with the health care system (Table 1).
Step 3: Determine discharge to home risk level based on identified risk factors and protective factors. Patients may be at low, moderate, or high risk of having an adverse event, such as a fall or inadequate symptom control (Table 2).
Step 4: Identify risk mitigation strategies. These should be tailored to the patient based on the factors identified in Step 2. Examples include home nursing and therapy, mental health treatment, a medical alert system, and frequent contact between the patient and health care team.
Step 5: Meet with inpatient and outpatient HCP teams. Meetings should include the primary care professional (PCP) or relevant subspecialist, such as an oncologist for patients with cancer. For veterans receiving care solely at a local VA medical center, this can be easier to facilitate, but for veterans who receive care through both VA and non-VA systems, this step may require additional coordination. We also recommend including interdisciplinary team members, such as social workers, case managers, and the relevant home care or hospice agency. Certain agencies may decline admission if they perceive increased risk, such as no 24-hour care, perceived self-neglect, and limited instrumental support. During this meeting, HCPs discuss risk mitigation strategies identified in Step 4 and create a plan to propose to patients and families.
Step 6: Meet with patient, HCA, and family members. In addition to sharing information about prognosis, assessing caregiver capabilities and burden can guide conversations about discharge. The discharge plan should be determined through shared decision making.11 If the patient lacks capacity regarding disposition planning, this should be shared with the HCA. However, even when patients lack capacity, it is important to continue to engage them to understand their goals and preferences.
Step 7: Maximize risk mitigation strategies. If a moderate- or high-risk discharge is requested, the health care team should maximize risk mitigation strategies. For low-risk discharges, risk mitigation strategies can still promote safety, especially since risk increases as patients progress toward EOL. In some instances, patients, their HCAs, or caregivers may decline all risk mitigation strategies despite best efforts to communicate and negotiate options. In such circumstances, we recommend discussing the case with the outpatient team for a warm handoff. HCPs should also document all efforts (helpful from a legal standpoint as well as for the patient’s future treatment teams) and respect the decision to discharge home.
Applying the Framework
Our patient Joe provides a good illustration of how to implement this EOL framework. He was deemed to have the capacity to make decisions regarding discharge (Step 1). We determined his risk factors and protective factors for discharge (Step 2). His poor functional status, limited instrumental support, heavy alcohol use, rejection of home services, and communication barriers due to severe hearing impairment all increased his risk. Protective factors included an appreciation of functional limitations, intact cognition, and an involved HCA. Based on his limited instrumental support and poor function but good insight into limitations, discharge home was deemed to be of moderate risk (Step 3). Although risk factors such as alcohol use and severe hearing impairment could have raised his level to high risk, we felt that his involved HCA maintained him in the moderate-risk category.
We worked with the hospitalist team, PT, and audiology to identify multiple risk mitigation strategies: frequent phone calls between the HCA and outpatient palliative care team, home PT to improve transfers from bed to bedside commode, home nursing services either through a routine agency or hospice, and hearing aids for better communication (Steps 4 and 5). We then proposed these strategies to Joe and his HCA (Step 6). Due to concerns about infringement on his independence, Joe declined all home services but agreed to twice-daily check-ins by his HCA, frequent communication between his HCA and our team, and new hearing aids.
Joe returned home with the agreed-upon risk mitigation strategies in place (Step 7). Despite clinicians’ original reservations about sending Joe home without formal services, his HCA maintained close contact with our team, noting that Joe remained stable and happy to be at home in the months following discharge.
Conclusions
Fortunately, VA HCPs operate in an integrated health care system with access to psychological, social, and at-home medical support that can help mitigate risks. Still, we have benefitted from having a tool to help us evaluate risk systematically. Even if patients, families, and HCPs disagree on ideal discharge plans, this tool helps clinicians approach discharges methodically while maintaining open communication and partnership with patients. In doing so, our framework reflects the shift in medical culture from a patriarchal approach to shared decision-making practices regarding all aspects of medical care. Furthermore, we hope that this can help reduce clinician moral distress stemming from these challenging cases.
Future research on best practices for discharge risk assessment and optimizing home safety are needed. We also hope to evaluate the impact and effectiveness of our framework through interviews with key stakeholders. For Joe and other veterans like him, where to spend their final days may be the last important decision they make in life, and our framework allows for their voices to be better heard throughout the decision-making process.
Acknowledgments
We thank Brooke Lifland, MD, for her theoretical contributions to the concept behind this paper.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
1. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington (DC): National Academies Press (US); March 19, 2015.
2. Casarett D, Pickard A, Amos Bailey F, et al. Important aspects of end-of-life care among veterans: implications for measurement and quality improvement. J Pain Symptom Manage. 2008;35(2):115-125. doi:10.1016/j.jpainsymman.2007.03.008
3. Kolva E, Rosenfeld B, Brescia R, Comfort C. Assessing decision-making capacity at end of life. Gen Hosp Psychiatry. 2014;36(4):392-397. doi:10.1016/j.genhosppsych.2014.02.013
4. Kolva E, Rosenfeld B, Saracino R. Assessing the decision-making capacity of terminally ill patients with cancer. Am J Geriatr Psychiatry. 2018;26(5):523-531. doi:10.1016/j.jagp.2017.11.012
5. Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nurs. 1994;19(2):249-256. doi:10.1111/j.1365-2648.1994.tb01078.x
6. Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients’ and health care professionals’ decision making. Palliat Med. 2017;31(7):617-624. doi:10.1177/0269216316673476
7. Hyslop B. ‘Not safe for discharge’? Words, values, and person-centred care. Age Ageing. 2020;49(3):334-336. doi:10.1093/ageing/afz170
8. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emerg Med J. 2006;23(10):753-755. doi:10.1136/emj.2006.037903
9. Swidler RN, Seastrum T, Shelton W. Difficult hospital inpatient discharge decisions: ethical, legal and clinical practice issues. Am J Bioeth. 2007;7(3):23-28. doi:10.1080/15265160601171739
10. Hill J, Filer W. Safety and ethical considerations in discharging patients to suboptimal living situations. AMA J Ethics. 2015;17(6):506-510. Published 2015 Jun 1. doi:10.1001/journalofethics.2015.17.6.ecas2-1506
11. West JC. What is an ethically informed approach to managing patient safety risk during discharge planning?. AMA J Ethics. 2020;22(11):E919-E923. Published 2020 Nov 1. doi:10.1001/amajethics.2020.919
12. Mukherjee D. Discharge decisions and the dignity of risk. Hastings Cent Rep. 2015;45(3):7-8. doi:10.1002/hast.441
13. Wheatley VJ, Baker JI. “Please, I want to go home”: ethical issues raised when considering choice of place of care in palliative care. Postgrad Med J. 2007;83(984):643-648. doi:10.1136/pgmj.2007.058487
14. Work Group on Suicidal Behaviors. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(suppl 11):1-60.
Where Have All the Future Veterans Gone?
Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.
John F. Kennedy 1
The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.2
For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”3
The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.
The Recruiting Crisis
Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.4 At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.5 But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.6
Challenging Trends
There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.7 For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.8
These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.9 Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.10
Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).11 Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.12 This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.10 That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.12
This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.13 The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.14 Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.
Armed Forces and Veterans Day
This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.1 The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.
1. US Department of Defense. Armed Forces Day. Accessed October 17, 2023. https://afd.defense.gov/History
2. Zipkin A. The military draft ended 50 years ago, dividing a generation. The Washington Post. January 27, 2023. Accessed October 17, 2023. https://www.washingtonpost.com/history/2023/01/27/draft-end-conscription-1973
3. Lopez TC. All-volunteer force proves successful for U.S. military. March 2, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3316678/all-volunteer-force-proves-successful-for-us-military
4. Garamone J. Vice-chiefs talk recruiting shortfalls, readiness issues. April 20, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3369472/vice-chiefs-talk-recruiting-shortfalls-readiness-issues
5. Winkie D. Army recruiters at two-thirds of contract goals as the fiscal year closes. Military Times. September 7, 2023. Accessed October 17, 2023. https://www.armytimes.com/news/recruiting/2023/09/07/army-recruiters-at-two-thirds-of-contract-goals-as-fiscal-year-closes
6. Baldor LC. Army misses recruiting goal by 15,000 soldiers. Accessed October 17, 2023. https://www.armytimes.com/news/your-army/2022/10/02/army-misses-recruiting-goal-by-15000-soldiers
7. Younis M. Confidence in U.S. military lowest in over two decades. Accessed October 17, 2023. https://news.gallup.com/poll/509189/confidence-military-lowest-two-decades.aspx
8. Rogin A, Corkery A. Why recruiting and confidence in America’s armed forces is so low right now? Accessed October 17, 2023. https://www.pbs.org/newshour/show/why-recruiting-and-confidence-in-americas-armed-forces-is-so-low-right-now
9. Military Family Advisory Network. 2021 military family support programming survey. Accessed October 17, 2023. https://www.mfan.org/wp-content/uploads/2022/07/Executive-Summary-MFAN-Programming-Survey-Results-2021.pdf
10. Kesling B. The military recruiting crisis: even veterans don’t want their family to join. Wall Street Journal. 30 June 2023. Accessed October 17, 2023. https://www.wsj.com/articles/military-recruiting-crisis-veterans-dont-want-their-children-to-join-510e1a25
11. Pew Research Center. The military-civilian gap: fewer family connections. Accessed October 17, 2023. https://www.pewresearch.org/social-trends/2011/11/23/the-military-civilian-gap-fewer-family-connections
12. Myers M. Is the military too ‘woke’ to recruit? Accessed October 17, 2023. https://www.militarytimes.com/news/your-military/2022/10/13/is-the-military-too-woke-to-recruit
13. Schaeffer K. The changing face of America’s veteran population. Accessed October 17, 2023. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population
14. Phillips D. With few able and fewer willing, U.S. military can’t find recruits. New York Times. July 14, 2023. Accessed October 17, 2023. https://www.nytimes.com/2022/07/14/us/us-military-recruiting-enlistment.html
Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.
John F. Kennedy 1
The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.2
For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”3
The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.
The Recruiting Crisis
Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.4 At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.5 But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.6
Challenging Trends
There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.7 For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.8
These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.9 Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.10
Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).11 Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.12 This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.10 That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.12
This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.13 The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.14 Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.
Armed Forces and Veterans Day
This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.1 The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.
Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.
John F. Kennedy 1
The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.2
For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”3
The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.
The Recruiting Crisis
Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.4 At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.5 But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.6
Challenging Trends
There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.7 For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.8
These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.9 Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.10
Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).11 Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.12 This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.10 That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.12
This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.13 The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.14 Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.
Armed Forces and Veterans Day
This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.1 The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.
1. US Department of Defense. Armed Forces Day. Accessed October 17, 2023. https://afd.defense.gov/History
2. Zipkin A. The military draft ended 50 years ago, dividing a generation. The Washington Post. January 27, 2023. Accessed October 17, 2023. https://www.washingtonpost.com/history/2023/01/27/draft-end-conscription-1973
3. Lopez TC. All-volunteer force proves successful for U.S. military. March 2, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3316678/all-volunteer-force-proves-successful-for-us-military
4. Garamone J. Vice-chiefs talk recruiting shortfalls, readiness issues. April 20, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3369472/vice-chiefs-talk-recruiting-shortfalls-readiness-issues
5. Winkie D. Army recruiters at two-thirds of contract goals as the fiscal year closes. Military Times. September 7, 2023. Accessed October 17, 2023. https://www.armytimes.com/news/recruiting/2023/09/07/army-recruiters-at-two-thirds-of-contract-goals-as-fiscal-year-closes
6. Baldor LC. Army misses recruiting goal by 15,000 soldiers. Accessed October 17, 2023. https://www.armytimes.com/news/your-army/2022/10/02/army-misses-recruiting-goal-by-15000-soldiers
7. Younis M. Confidence in U.S. military lowest in over two decades. Accessed October 17, 2023. https://news.gallup.com/poll/509189/confidence-military-lowest-two-decades.aspx
8. Rogin A, Corkery A. Why recruiting and confidence in America’s armed forces is so low right now? Accessed October 17, 2023. https://www.pbs.org/newshour/show/why-recruiting-and-confidence-in-americas-armed-forces-is-so-low-right-now
9. Military Family Advisory Network. 2021 military family support programming survey. Accessed October 17, 2023. https://www.mfan.org/wp-content/uploads/2022/07/Executive-Summary-MFAN-Programming-Survey-Results-2021.pdf
10. Kesling B. The military recruiting crisis: even veterans don’t want their family to join. Wall Street Journal. 30 June 2023. Accessed October 17, 2023. https://www.wsj.com/articles/military-recruiting-crisis-veterans-dont-want-their-children-to-join-510e1a25
11. Pew Research Center. The military-civilian gap: fewer family connections. Accessed October 17, 2023. https://www.pewresearch.org/social-trends/2011/11/23/the-military-civilian-gap-fewer-family-connections
12. Myers M. Is the military too ‘woke’ to recruit? Accessed October 17, 2023. https://www.militarytimes.com/news/your-military/2022/10/13/is-the-military-too-woke-to-recruit
13. Schaeffer K. The changing face of America’s veteran population. Accessed October 17, 2023. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population
14. Phillips D. With few able and fewer willing, U.S. military can’t find recruits. New York Times. July 14, 2023. Accessed October 17, 2023. https://www.nytimes.com/2022/07/14/us/us-military-recruiting-enlistment.html
1. US Department of Defense. Armed Forces Day. Accessed October 17, 2023. https://afd.defense.gov/History
2. Zipkin A. The military draft ended 50 years ago, dividing a generation. The Washington Post. January 27, 2023. Accessed October 17, 2023. https://www.washingtonpost.com/history/2023/01/27/draft-end-conscription-1973
3. Lopez TC. All-volunteer force proves successful for U.S. military. March 2, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3316678/all-volunteer-force-proves-successful-for-us-military
4. Garamone J. Vice-chiefs talk recruiting shortfalls, readiness issues. April 20, 2023. Accessed October 17, 2023. https://www.defense.gov/News/News-Stories/Article/Article/3369472/vice-chiefs-talk-recruiting-shortfalls-readiness-issues
5. Winkie D. Army recruiters at two-thirds of contract goals as the fiscal year closes. Military Times. September 7, 2023. Accessed October 17, 2023. https://www.armytimes.com/news/recruiting/2023/09/07/army-recruiters-at-two-thirds-of-contract-goals-as-fiscal-year-closes
6. Baldor LC. Army misses recruiting goal by 15,000 soldiers. Accessed October 17, 2023. https://www.armytimes.com/news/your-army/2022/10/02/army-misses-recruiting-goal-by-15000-soldiers
7. Younis M. Confidence in U.S. military lowest in over two decades. Accessed October 17, 2023. https://news.gallup.com/poll/509189/confidence-military-lowest-two-decades.aspx
8. Rogin A, Corkery A. Why recruiting and confidence in America’s armed forces is so low right now? Accessed October 17, 2023. https://www.pbs.org/newshour/show/why-recruiting-and-confidence-in-americas-armed-forces-is-so-low-right-now
9. Military Family Advisory Network. 2021 military family support programming survey. Accessed October 17, 2023. https://www.mfan.org/wp-content/uploads/2022/07/Executive-Summary-MFAN-Programming-Survey-Results-2021.pdf
10. Kesling B. The military recruiting crisis: even veterans don’t want their family to join. Wall Street Journal. 30 June 2023. Accessed October 17, 2023. https://www.wsj.com/articles/military-recruiting-crisis-veterans-dont-want-their-children-to-join-510e1a25
11. Pew Research Center. The military-civilian gap: fewer family connections. Accessed October 17, 2023. https://www.pewresearch.org/social-trends/2011/11/23/the-military-civilian-gap-fewer-family-connections
12. Myers M. Is the military too ‘woke’ to recruit? Accessed October 17, 2023. https://www.militarytimes.com/news/your-military/2022/10/13/is-the-military-too-woke-to-recruit
13. Schaeffer K. The changing face of America’s veteran population. Accessed October 17, 2023. https://www.pewresearch.org/short-reads/2021/04/05/the-changing-face-of-americas-veteran-population
14. Phillips D. With few able and fewer willing, U.S. military can’t find recruits. New York Times. July 14, 2023. Accessed October 17, 2023. https://www.nytimes.com/2022/07/14/us/us-military-recruiting-enlistment.html
How to think about second-line therapy in NSCLC
This transcript has been edited for clarity.
I’ve been thinking lately about treatments after initial therapy for non–small cell lung cancers, what people often call second-line therapy.
I think the first thought is that, for all the regimens that are available and tested, the results are clearly not as good as seen with first-line therapy. I’ll get into some specifics in a second. That being the case, it’s really important to make the best choice for first-line therapy.
The second thing that is absolutely critical is to very carefully assess when that first-line therapy has stopped working and whether there is a need for a new systemic therapy. We very often have these situations where there is an oligoprogression, and by treating a single symptomatic lesion, you may get the patient in a very good place and may continue initial therapy. Very often, there is inconsequential growth of the cancer.
For example, if there is a 21% increase in the size of a primary tumor that is not associated with any symptoms in a person who is living their life and is not having any severe side effects, you have to think long and hard about changing that therapy. I wouldn’t even give a consolidative therapy there if they’re really doing well. Obviously, consolidative therapies are a new therapy, and they have their side effects with them as well.
With second-line therapy, sadly, none of them have a huge benefit anywhere near what we see in first line. All the rates of response are well under 50%. Just getting into it, you’re not going to shrink the cancer by more than 30% in the majority of patients, so you have to think long and hard about making that switch.
Second, our standard still remains docetaxel, and the numbers on docetaxel are really not great. It’s about a 15% rate of response and a median survival of about 5 months. Now, by adding other RET drugs to docetaxel, you can achieve better results. By adding ramucirumab, for example, the response rate just about doubles and the duration of response and progression-free survival both go up by a few months.
For patients who have KRAS G12C, in the randomized trial that has been done so far, over docetaxel, you get, again, a doubling of response. For patients where response is important, you really double that response rate, but also you get an improvement in median progression-free survival by, again, 2-3 months. There is benefit there in terms of response and progression-free survival; however, it’s not huge.
Please remember, if you’re choosing to use docetaxel, to think about using alternative dosages and schedules. When you look at the course of a person treated with docetaxel over, let’s say, a 6-month period, you often see that doses are held. When you look at the total dose, it’s very similar to an every-2-week dose of a lower amount. I routinely give a 60-mg flat dose every 2 weeks.
I urge you to look at the progress of one of your patients over a 6-month period who was given the 75-mg dose. Many of those doses end up getting held. When all is said and done, you give a lower dose over that whole time from that 75-mg dose. Giving 35 mg/m2 or a 60-mg flat dose every 2 weeks, you end up getting almost exactly the same amount of docetaxel. There’s really no convincing evidence that the higher dose is better. It’s clearly harder on the patient.
I’ve shared some thoughts about second-line therapy. We really have to do better. Please make sure that your first-line therapy is the best you can give. Make sure you’ve gotten everything out of that first-line therapy and that it will be continued as long as possible, as long as you and the patient have concluded that there’s benefit. When you do switch, try to give the most effective regimen that you have, which would be docetaxel with ramucirumab, or for patients with KRAS G12C, giving adagrasib or sotorasib at this point.
Dr. Kris is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York. He reported conflicts of interest with AstraZeneca, Roche/Genentech, Ariad Pharmaceuticals, Pfizer, and PUMA.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
I’ve been thinking lately about treatments after initial therapy for non–small cell lung cancers, what people often call second-line therapy.
I think the first thought is that, for all the regimens that are available and tested, the results are clearly not as good as seen with first-line therapy. I’ll get into some specifics in a second. That being the case, it’s really important to make the best choice for first-line therapy.
The second thing that is absolutely critical is to very carefully assess when that first-line therapy has stopped working and whether there is a need for a new systemic therapy. We very often have these situations where there is an oligoprogression, and by treating a single symptomatic lesion, you may get the patient in a very good place and may continue initial therapy. Very often, there is inconsequential growth of the cancer.
For example, if there is a 21% increase in the size of a primary tumor that is not associated with any symptoms in a person who is living their life and is not having any severe side effects, you have to think long and hard about changing that therapy. I wouldn’t even give a consolidative therapy there if they’re really doing well. Obviously, consolidative therapies are a new therapy, and they have their side effects with them as well.
With second-line therapy, sadly, none of them have a huge benefit anywhere near what we see in first line. All the rates of response are well under 50%. Just getting into it, you’re not going to shrink the cancer by more than 30% in the majority of patients, so you have to think long and hard about making that switch.
Second, our standard still remains docetaxel, and the numbers on docetaxel are really not great. It’s about a 15% rate of response and a median survival of about 5 months. Now, by adding other RET drugs to docetaxel, you can achieve better results. By adding ramucirumab, for example, the response rate just about doubles and the duration of response and progression-free survival both go up by a few months.
For patients who have KRAS G12C, in the randomized trial that has been done so far, over docetaxel, you get, again, a doubling of response. For patients where response is important, you really double that response rate, but also you get an improvement in median progression-free survival by, again, 2-3 months. There is benefit there in terms of response and progression-free survival; however, it’s not huge.
Please remember, if you’re choosing to use docetaxel, to think about using alternative dosages and schedules. When you look at the course of a person treated with docetaxel over, let’s say, a 6-month period, you often see that doses are held. When you look at the total dose, it’s very similar to an every-2-week dose of a lower amount. I routinely give a 60-mg flat dose every 2 weeks.
I urge you to look at the progress of one of your patients over a 6-month period who was given the 75-mg dose. Many of those doses end up getting held. When all is said and done, you give a lower dose over that whole time from that 75-mg dose. Giving 35 mg/m2 or a 60-mg flat dose every 2 weeks, you end up getting almost exactly the same amount of docetaxel. There’s really no convincing evidence that the higher dose is better. It’s clearly harder on the patient.
I’ve shared some thoughts about second-line therapy. We really have to do better. Please make sure that your first-line therapy is the best you can give. Make sure you’ve gotten everything out of that first-line therapy and that it will be continued as long as possible, as long as you and the patient have concluded that there’s benefit. When you do switch, try to give the most effective regimen that you have, which would be docetaxel with ramucirumab, or for patients with KRAS G12C, giving adagrasib or sotorasib at this point.
Dr. Kris is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York. He reported conflicts of interest with AstraZeneca, Roche/Genentech, Ariad Pharmaceuticals, Pfizer, and PUMA.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
I’ve been thinking lately about treatments after initial therapy for non–small cell lung cancers, what people often call second-line therapy.
I think the first thought is that, for all the regimens that are available and tested, the results are clearly not as good as seen with first-line therapy. I’ll get into some specifics in a second. That being the case, it’s really important to make the best choice for first-line therapy.
The second thing that is absolutely critical is to very carefully assess when that first-line therapy has stopped working and whether there is a need for a new systemic therapy. We very often have these situations where there is an oligoprogression, and by treating a single symptomatic lesion, you may get the patient in a very good place and may continue initial therapy. Very often, there is inconsequential growth of the cancer.
For example, if there is a 21% increase in the size of a primary tumor that is not associated with any symptoms in a person who is living their life and is not having any severe side effects, you have to think long and hard about changing that therapy. I wouldn’t even give a consolidative therapy there if they’re really doing well. Obviously, consolidative therapies are a new therapy, and they have their side effects with them as well.
With second-line therapy, sadly, none of them have a huge benefit anywhere near what we see in first line. All the rates of response are well under 50%. Just getting into it, you’re not going to shrink the cancer by more than 30% in the majority of patients, so you have to think long and hard about making that switch.
Second, our standard still remains docetaxel, and the numbers on docetaxel are really not great. It’s about a 15% rate of response and a median survival of about 5 months. Now, by adding other RET drugs to docetaxel, you can achieve better results. By adding ramucirumab, for example, the response rate just about doubles and the duration of response and progression-free survival both go up by a few months.
For patients who have KRAS G12C, in the randomized trial that has been done so far, over docetaxel, you get, again, a doubling of response. For patients where response is important, you really double that response rate, but also you get an improvement in median progression-free survival by, again, 2-3 months. There is benefit there in terms of response and progression-free survival; however, it’s not huge.
Please remember, if you’re choosing to use docetaxel, to think about using alternative dosages and schedules. When you look at the course of a person treated with docetaxel over, let’s say, a 6-month period, you often see that doses are held. When you look at the total dose, it’s very similar to an every-2-week dose of a lower amount. I routinely give a 60-mg flat dose every 2 weeks.
I urge you to look at the progress of one of your patients over a 6-month period who was given the 75-mg dose. Many of those doses end up getting held. When all is said and done, you give a lower dose over that whole time from that 75-mg dose. Giving 35 mg/m2 or a 60-mg flat dose every 2 weeks, you end up getting almost exactly the same amount of docetaxel. There’s really no convincing evidence that the higher dose is better. It’s clearly harder on the patient.
I’ve shared some thoughts about second-line therapy. We really have to do better. Please make sure that your first-line therapy is the best you can give. Make sure you’ve gotten everything out of that first-line therapy and that it will be continued as long as possible, as long as you and the patient have concluded that there’s benefit. When you do switch, try to give the most effective regimen that you have, which would be docetaxel with ramucirumab, or for patients with KRAS G12C, giving adagrasib or sotorasib at this point.
Dr. Kris is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York. He reported conflicts of interest with AstraZeneca, Roche/Genentech, Ariad Pharmaceuticals, Pfizer, and PUMA.
A version of this article first appeared on Medscape.com.
Perinatal depression rarely stands alone
Mental health conditions are the leading cause of pregnancy-related death in Illinois (40%) and across the United States (21%).1,2 Funding bodies, such as the Agency for Healthcare Research and Quality3 and the Health Resources and Service Administration,4 have spotlights on improving screening and access to care for depression and substance use disorders (SUDs). However, the needs of individuals with multiple mental health conditions still often go unrecognized and unaddressed in perinatal health settings.
The U.S. Preventive Services Task Force recommends that all adults be screened for depression, alcohol use, and drug use, and will be recommending screening for anxiety.5,6 The American College of Obstetrics and Gynecology recommends screening for perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and suicidality; however, despite these recommendations, screening and treatment for comorbid mental health disorders during pregnancy and the postpartum is not standard practice.7
Addressing perinatal mental health is critical because untreated mental health conditions during the perinatal period can cause long-term adverse psychiatric and medical outcomes for the birthing person, the baby, and the family.8 This commentary highlights the importance of recognizing and screening for perinatal mental health comorbidities, improving referral rates for mental health treatment, and raising awareness of the importance of addressing rural perinatal mental health.
Perinatal mental health comorbidities
Major depressive disorder is the most common mental health condition during the perinatal period9 and is often comorbid.10-12 In “Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities,” Craemer et al.13 reported that nearly half of the perinatal patients who screened positive for MDD also screened positive for at least one other mental health condition, among them general anxiety disorder (GAD), SUD, posttraumatic stress disorder (PTSD), and suicidality.
Many (9%) of the perinatal patients with MDD had a severe comorbidity profile characterized by four diagnoses – MDD, GAD, SUD, and PTSD. In routine medical care these comorbidities often go undetected even though the risk to mothers and babies increases with more severe mental health symptoms.8
The high frequency of perinatal mental health comorbidities Craemer et al.13 found demonstrates a compelling need for comorbid mental health screening during the perinatal period, particularly for low-income Black, Hispanic, and rural birthing persons. Positive screens for perinatal mental health disorders may reflect the onset of these disorders in pregnancy or the postpartum, or preexisting disorders that have gone undetected or untreated before pregnancy.
For many patients, the perinatal period is the first time they are screened for any mental health disorder; typically, they are screened solely for depression. Screening alone can have a positive impact on perinatal mental health. In fact, the USPSTF found that programs to screen perinatal patients, with or without treatment-related support, resulted in a 2%-9% absolute reduction in depression prevalence.14 However, screening for MDD is too infrequent for many reasons, including the logistics of integrating screening into the clinic workflow and limited provider availability, time, and training in mental health.
We recommend screening perinatal patients for mental health comorbidities. This recommendation may seem impractical given the lack of screening tools for comorbid mental health conditions; however, the Computerized Adaptive Test for Mental Health (CAT-MH), the validated tool15-17 used in this study, is an ideal option. CAT-MH is uniquely capable of screening for MDD, GAD, PTSD, SUD, and suicidality in one platform and is routinely used in diverse settings including the Veterans Administration,18 foster care,19 and universities.20 The main limitation of this more comprehensive screening is that it takes about 10 minutes per patient. However, CAT-MH is self-administered and can be done in the waiting room or on a mobile device prior to a clinic visit.
CAT-MH can also be easily integrated into clinical workflow when added to the Electronic Medical Record21, and is a more comprehensive tool than existing perinatal depression tools such as the Perinatal Health Questionaire-9 (PHQ-9) and Edinburgh Perinatal Depression Scale (EPDS).22 Another limitation is cost – currently $5.00 per assessment – however, this is less than routine blood work.23 If CAT-MH is not an option, we recommend a stepped approach of screening for GAD when perinatal patients screen positive for MDD, as this is the most common comorbidity profile. The GAD-7 is a free and widely available tool.24
Barriers to care
In Craemer et al,13 nearly two-thirds (64.9%) of perinatal patients with a positive screen did not receive a referral to follow-up care or a medication prescription. These low referral rates may reflect a variety of widely recognized barriers to care, including lack of referral options, provider and/or patient reluctance to pursue referrals, barriers to insurance coverage, or inadequate behavioral health infrastructure to ensure referral and diagnostic follow-up.
Further, rural residing perinatal patients are an underserved population that need more resources and screening. Despite an on-site behavioral specialist at the rural clinic, Craemer et al13 found a stark disparity in referral rates: referrals to treatment for a positive diagnosis was over two times less at the rural clinic (23.9%), compared with the urban clinics (51.6%). The most common treatment offered at the rural clinic was a prescription for medication (17.4%), while referral to follow-up care was the most common at the urban clinics (35.5%). Rural areas not only have a shortage of health care providers, but community members seeking mental health care often encounter greater stigma, compared with urban residents.25,26
These data highlight an unmet need for referrals to treatment for patients in rural communities, particularly in Illinois where the pregnancy-related mortality ratio attributable to mental health conditions is three times greater in rural areas, compared with those residing in urban Cook County (Chicago).2 Increasing access and availability to mental health treatment and prevention resources in Illinois, especially in rural areas, is an opportunity to prevent pregnancy-related mortality attributable to mental health conditions.
Overall, there is a critical need for screening for perinatal mental health comorbidities, increased attention to low rates of referral to mental health treatment, and investing in rural perinatal mental health. Addressing perinatal mental health disorders is key to decreasing the burden of maternal mortality, particularly in Illinois.
Ms. Craemer and Ms. Sayah are senior research specialists at the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Duffecy is a professor of clinical psychiatry at the University of Illinois at Chicago. Dr. Geller is a professor of obstetrics & gynecology and director of the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Maki is a professor of psychiatry, psychology, and obstetrics & gynecology at the University of Illinois at Chicago.
References
1. Trost S et al. Pregnancy-related deaths: Data from maternal mortality review committees in 36 states, 2017-2019. Atlanta: Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, 2022.
2. Illinois Department of Public Health. Illinois maternal morbidity and mortality report 2016-2017. 2021.
3. AHRQ. Funding opportunities to address opioid and other substance use disorders. Updated 2023.
4. HRSA. Screening and treatment for maternal mental health and substance use disorders.
5. U.S. Preventive Services Task Force. Recommendations for primary care practice. Accessed May 26, 2023.
6. U.S. Preventive Services Task Force. Draft recommendation statement: Anxiety in adults: Screening. 2022.
7. ACOG. Screening and diagnosis of mental health conditions during pregnancy and postpartum. Clinical Practice Guideline. Number 4. 2023 June.
8. Meltzer-Brody S and Stuebe A. The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol. 2014 Jan. doi: 10.1016/j.bpobgyn.2013.08.009.
9. Van Niel MS and Payne JL. Perinatal depression: A review. Cleve Clin J Med. 2020 May. doi: 10.3949/ccjm.87a.19054.
10. Wisner KL et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. 2013 May. doi: 10.1001/jamapsychiatry.2013.87.
11. Falah-Hassani K et al. The prevalence of antenatal and postnatal co-morbid anxiety and depression: A meta-analysis. Psychol Med. 2017 Sep. doi: 10.1017/S0033291717000617.
12. Pentecost R et al. Scoping review of the associations between perinatal substance use and perinatal depression and anxiety. J Obstet Gynecol Neonatal Nurs. 2021 Jul. doi: 10.1016/j.jogn.2021.02.008.
13. Craemer KA et al. Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities. Gen Hosp Psychiatry. 2023 Jul-Aug. doi: 10.1016/j.genhosppsych.2023.05.007.
14. O’Connor E et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016 Jan 26. doi: 10.1001/jama.2015.18948.
15. Kozhimannil KB et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011 Jun. doi: 10.1176/ps.62.6.pss6206_0619.
16. Wenzel ES et al. Depression and anxiety symptoms across pregnancy and the postpartum in low-income Black and Latina women. Arch Womens Ment Health. 2021 Dec. doi: 10.1007/s00737-021-01139-y.
17. Gibbons RD et al. Development of a computerized adaptive substance use disorder scale for screening and measurement: The CAT‐SUD. Addiction. 2020 Jul. doi: 10.1111/add.14938.
18. Brenner LA et al. Validation of a computerized adaptive test suicide scale (CAT-SS) among united states military veterans. PloS One. 2022 Jan 21. doi: 10.1371/journal.pone.0261920.
19. The Center for State Child Welfare Data. Using technology to diagnose and report on behavioral health challenges facing foster youth. 2018.
20. Kim JJ et al. The experience of depression, anxiety, and mania among perinatal women. Arch Womens Ment Health. 2016 Oct. doi: 10.1007/s00737-016-0632-6.
21. Tepper MC et al. Toward population health: Using a learning behavioral health system and measurement-based care to improve access, care, outcomes, and disparities. Community Ment Health J. 2022 Nov. doi: 10.1007/s10597-022-00957-3.
22. Wenzel E et al. Using computerised adaptive tests to screen for perinatal depression in underserved women of colour. Evid Based Ment Health. 2022 Feb. doi: 10.1136/ebmental-2021-300262.
23. Sanger-Katz M. They want it to be secret: How a common blood test can cost $11 or almost $1,000. New York Times. 2019 Apr 19.
24. Spitzer RL et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006 May 22. doi: 10.1001/archinte.166.10.1092.
25. Mollard E et al. An integrative review of postpartum depression in rural US communities. Arch Psychiatr Nurs. 2016 Jun. doi: 10.1016/j.apnu.2015.12.003.
26. Anglim AJ and Radke SM. Rural maternal health care outcomes, drivers, and patient perspectives. Clin Obstet Gynecol. 2022 Dec 1. doi: 10.1097/GRF.0000000000000753.
Mental health conditions are the leading cause of pregnancy-related death in Illinois (40%) and across the United States (21%).1,2 Funding bodies, such as the Agency for Healthcare Research and Quality3 and the Health Resources and Service Administration,4 have spotlights on improving screening and access to care for depression and substance use disorders (SUDs). However, the needs of individuals with multiple mental health conditions still often go unrecognized and unaddressed in perinatal health settings.
The U.S. Preventive Services Task Force recommends that all adults be screened for depression, alcohol use, and drug use, and will be recommending screening for anxiety.5,6 The American College of Obstetrics and Gynecology recommends screening for perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and suicidality; however, despite these recommendations, screening and treatment for comorbid mental health disorders during pregnancy and the postpartum is not standard practice.7
Addressing perinatal mental health is critical because untreated mental health conditions during the perinatal period can cause long-term adverse psychiatric and medical outcomes for the birthing person, the baby, and the family.8 This commentary highlights the importance of recognizing and screening for perinatal mental health comorbidities, improving referral rates for mental health treatment, and raising awareness of the importance of addressing rural perinatal mental health.
Perinatal mental health comorbidities
Major depressive disorder is the most common mental health condition during the perinatal period9 and is often comorbid.10-12 In “Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities,” Craemer et al.13 reported that nearly half of the perinatal patients who screened positive for MDD also screened positive for at least one other mental health condition, among them general anxiety disorder (GAD), SUD, posttraumatic stress disorder (PTSD), and suicidality.
Many (9%) of the perinatal patients with MDD had a severe comorbidity profile characterized by four diagnoses – MDD, GAD, SUD, and PTSD. In routine medical care these comorbidities often go undetected even though the risk to mothers and babies increases with more severe mental health symptoms.8
The high frequency of perinatal mental health comorbidities Craemer et al.13 found demonstrates a compelling need for comorbid mental health screening during the perinatal period, particularly for low-income Black, Hispanic, and rural birthing persons. Positive screens for perinatal mental health disorders may reflect the onset of these disorders in pregnancy or the postpartum, or preexisting disorders that have gone undetected or untreated before pregnancy.
For many patients, the perinatal period is the first time they are screened for any mental health disorder; typically, they are screened solely for depression. Screening alone can have a positive impact on perinatal mental health. In fact, the USPSTF found that programs to screen perinatal patients, with or without treatment-related support, resulted in a 2%-9% absolute reduction in depression prevalence.14 However, screening for MDD is too infrequent for many reasons, including the logistics of integrating screening into the clinic workflow and limited provider availability, time, and training in mental health.
We recommend screening perinatal patients for mental health comorbidities. This recommendation may seem impractical given the lack of screening tools for comorbid mental health conditions; however, the Computerized Adaptive Test for Mental Health (CAT-MH), the validated tool15-17 used in this study, is an ideal option. CAT-MH is uniquely capable of screening for MDD, GAD, PTSD, SUD, and suicidality in one platform and is routinely used in diverse settings including the Veterans Administration,18 foster care,19 and universities.20 The main limitation of this more comprehensive screening is that it takes about 10 minutes per patient. However, CAT-MH is self-administered and can be done in the waiting room or on a mobile device prior to a clinic visit.
CAT-MH can also be easily integrated into clinical workflow when added to the Electronic Medical Record21, and is a more comprehensive tool than existing perinatal depression tools such as the Perinatal Health Questionaire-9 (PHQ-9) and Edinburgh Perinatal Depression Scale (EPDS).22 Another limitation is cost – currently $5.00 per assessment – however, this is less than routine blood work.23 If CAT-MH is not an option, we recommend a stepped approach of screening for GAD when perinatal patients screen positive for MDD, as this is the most common comorbidity profile. The GAD-7 is a free and widely available tool.24
Barriers to care
In Craemer et al,13 nearly two-thirds (64.9%) of perinatal patients with a positive screen did not receive a referral to follow-up care or a medication prescription. These low referral rates may reflect a variety of widely recognized barriers to care, including lack of referral options, provider and/or patient reluctance to pursue referrals, barriers to insurance coverage, or inadequate behavioral health infrastructure to ensure referral and diagnostic follow-up.
Further, rural residing perinatal patients are an underserved population that need more resources and screening. Despite an on-site behavioral specialist at the rural clinic, Craemer et al13 found a stark disparity in referral rates: referrals to treatment for a positive diagnosis was over two times less at the rural clinic (23.9%), compared with the urban clinics (51.6%). The most common treatment offered at the rural clinic was a prescription for medication (17.4%), while referral to follow-up care was the most common at the urban clinics (35.5%). Rural areas not only have a shortage of health care providers, but community members seeking mental health care often encounter greater stigma, compared with urban residents.25,26
These data highlight an unmet need for referrals to treatment for patients in rural communities, particularly in Illinois where the pregnancy-related mortality ratio attributable to mental health conditions is three times greater in rural areas, compared with those residing in urban Cook County (Chicago).2 Increasing access and availability to mental health treatment and prevention resources in Illinois, especially in rural areas, is an opportunity to prevent pregnancy-related mortality attributable to mental health conditions.
Overall, there is a critical need for screening for perinatal mental health comorbidities, increased attention to low rates of referral to mental health treatment, and investing in rural perinatal mental health. Addressing perinatal mental health disorders is key to decreasing the burden of maternal mortality, particularly in Illinois.
Ms. Craemer and Ms. Sayah are senior research specialists at the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Duffecy is a professor of clinical psychiatry at the University of Illinois at Chicago. Dr. Geller is a professor of obstetrics & gynecology and director of the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Maki is a professor of psychiatry, psychology, and obstetrics & gynecology at the University of Illinois at Chicago.
References
1. Trost S et al. Pregnancy-related deaths: Data from maternal mortality review committees in 36 states, 2017-2019. Atlanta: Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, 2022.
2. Illinois Department of Public Health. Illinois maternal morbidity and mortality report 2016-2017. 2021.
3. AHRQ. Funding opportunities to address opioid and other substance use disorders. Updated 2023.
4. HRSA. Screening and treatment for maternal mental health and substance use disorders.
5. U.S. Preventive Services Task Force. Recommendations for primary care practice. Accessed May 26, 2023.
6. U.S. Preventive Services Task Force. Draft recommendation statement: Anxiety in adults: Screening. 2022.
7. ACOG. Screening and diagnosis of mental health conditions during pregnancy and postpartum. Clinical Practice Guideline. Number 4. 2023 June.
8. Meltzer-Brody S and Stuebe A. The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol. 2014 Jan. doi: 10.1016/j.bpobgyn.2013.08.009.
9. Van Niel MS and Payne JL. Perinatal depression: A review. Cleve Clin J Med. 2020 May. doi: 10.3949/ccjm.87a.19054.
10. Wisner KL et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. 2013 May. doi: 10.1001/jamapsychiatry.2013.87.
11. Falah-Hassani K et al. The prevalence of antenatal and postnatal co-morbid anxiety and depression: A meta-analysis. Psychol Med. 2017 Sep. doi: 10.1017/S0033291717000617.
12. Pentecost R et al. Scoping review of the associations between perinatal substance use and perinatal depression and anxiety. J Obstet Gynecol Neonatal Nurs. 2021 Jul. doi: 10.1016/j.jogn.2021.02.008.
13. Craemer KA et al. Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities. Gen Hosp Psychiatry. 2023 Jul-Aug. doi: 10.1016/j.genhosppsych.2023.05.007.
14. O’Connor E et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016 Jan 26. doi: 10.1001/jama.2015.18948.
15. Kozhimannil KB et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011 Jun. doi: 10.1176/ps.62.6.pss6206_0619.
16. Wenzel ES et al. Depression and anxiety symptoms across pregnancy and the postpartum in low-income Black and Latina women. Arch Womens Ment Health. 2021 Dec. doi: 10.1007/s00737-021-01139-y.
17. Gibbons RD et al. Development of a computerized adaptive substance use disorder scale for screening and measurement: The CAT‐SUD. Addiction. 2020 Jul. doi: 10.1111/add.14938.
18. Brenner LA et al. Validation of a computerized adaptive test suicide scale (CAT-SS) among united states military veterans. PloS One. 2022 Jan 21. doi: 10.1371/journal.pone.0261920.
19. The Center for State Child Welfare Data. Using technology to diagnose and report on behavioral health challenges facing foster youth. 2018.
20. Kim JJ et al. The experience of depression, anxiety, and mania among perinatal women. Arch Womens Ment Health. 2016 Oct. doi: 10.1007/s00737-016-0632-6.
21. Tepper MC et al. Toward population health: Using a learning behavioral health system and measurement-based care to improve access, care, outcomes, and disparities. Community Ment Health J. 2022 Nov. doi: 10.1007/s10597-022-00957-3.
22. Wenzel E et al. Using computerised adaptive tests to screen for perinatal depression in underserved women of colour. Evid Based Ment Health. 2022 Feb. doi: 10.1136/ebmental-2021-300262.
23. Sanger-Katz M. They want it to be secret: How a common blood test can cost $11 or almost $1,000. New York Times. 2019 Apr 19.
24. Spitzer RL et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006 May 22. doi: 10.1001/archinte.166.10.1092.
25. Mollard E et al. An integrative review of postpartum depression in rural US communities. Arch Psychiatr Nurs. 2016 Jun. doi: 10.1016/j.apnu.2015.12.003.
26. Anglim AJ and Radke SM. Rural maternal health care outcomes, drivers, and patient perspectives. Clin Obstet Gynecol. 2022 Dec 1. doi: 10.1097/GRF.0000000000000753.
Mental health conditions are the leading cause of pregnancy-related death in Illinois (40%) and across the United States (21%).1,2 Funding bodies, such as the Agency for Healthcare Research and Quality3 and the Health Resources and Service Administration,4 have spotlights on improving screening and access to care for depression and substance use disorders (SUDs). However, the needs of individuals with multiple mental health conditions still often go unrecognized and unaddressed in perinatal health settings.
The U.S. Preventive Services Task Force recommends that all adults be screened for depression, alcohol use, and drug use, and will be recommending screening for anxiety.5,6 The American College of Obstetrics and Gynecology recommends screening for perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and suicidality; however, despite these recommendations, screening and treatment for comorbid mental health disorders during pregnancy and the postpartum is not standard practice.7
Addressing perinatal mental health is critical because untreated mental health conditions during the perinatal period can cause long-term adverse psychiatric and medical outcomes for the birthing person, the baby, and the family.8 This commentary highlights the importance of recognizing and screening for perinatal mental health comorbidities, improving referral rates for mental health treatment, and raising awareness of the importance of addressing rural perinatal mental health.
Perinatal mental health comorbidities
Major depressive disorder is the most common mental health condition during the perinatal period9 and is often comorbid.10-12 In “Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities,” Craemer et al.13 reported that nearly half of the perinatal patients who screened positive for MDD also screened positive for at least one other mental health condition, among them general anxiety disorder (GAD), SUD, posttraumatic stress disorder (PTSD), and suicidality.
Many (9%) of the perinatal patients with MDD had a severe comorbidity profile characterized by four diagnoses – MDD, GAD, SUD, and PTSD. In routine medical care these comorbidities often go undetected even though the risk to mothers and babies increases with more severe mental health symptoms.8
The high frequency of perinatal mental health comorbidities Craemer et al.13 found demonstrates a compelling need for comorbid mental health screening during the perinatal period, particularly for low-income Black, Hispanic, and rural birthing persons. Positive screens for perinatal mental health disorders may reflect the onset of these disorders in pregnancy or the postpartum, or preexisting disorders that have gone undetected or untreated before pregnancy.
For many patients, the perinatal period is the first time they are screened for any mental health disorder; typically, they are screened solely for depression. Screening alone can have a positive impact on perinatal mental health. In fact, the USPSTF found that programs to screen perinatal patients, with or without treatment-related support, resulted in a 2%-9% absolute reduction in depression prevalence.14 However, screening for MDD is too infrequent for many reasons, including the logistics of integrating screening into the clinic workflow and limited provider availability, time, and training in mental health.
We recommend screening perinatal patients for mental health comorbidities. This recommendation may seem impractical given the lack of screening tools for comorbid mental health conditions; however, the Computerized Adaptive Test for Mental Health (CAT-MH), the validated tool15-17 used in this study, is an ideal option. CAT-MH is uniquely capable of screening for MDD, GAD, PTSD, SUD, and suicidality in one platform and is routinely used in diverse settings including the Veterans Administration,18 foster care,19 and universities.20 The main limitation of this more comprehensive screening is that it takes about 10 minutes per patient. However, CAT-MH is self-administered and can be done in the waiting room or on a mobile device prior to a clinic visit.
CAT-MH can also be easily integrated into clinical workflow when added to the Electronic Medical Record21, and is a more comprehensive tool than existing perinatal depression tools such as the Perinatal Health Questionaire-9 (PHQ-9) and Edinburgh Perinatal Depression Scale (EPDS).22 Another limitation is cost – currently $5.00 per assessment – however, this is less than routine blood work.23 If CAT-MH is not an option, we recommend a stepped approach of screening for GAD when perinatal patients screen positive for MDD, as this is the most common comorbidity profile. The GAD-7 is a free and widely available tool.24
Barriers to care
In Craemer et al,13 nearly two-thirds (64.9%) of perinatal patients with a positive screen did not receive a referral to follow-up care or a medication prescription. These low referral rates may reflect a variety of widely recognized barriers to care, including lack of referral options, provider and/or patient reluctance to pursue referrals, barriers to insurance coverage, or inadequate behavioral health infrastructure to ensure referral and diagnostic follow-up.
Further, rural residing perinatal patients are an underserved population that need more resources and screening. Despite an on-site behavioral specialist at the rural clinic, Craemer et al13 found a stark disparity in referral rates: referrals to treatment for a positive diagnosis was over two times less at the rural clinic (23.9%), compared with the urban clinics (51.6%). The most common treatment offered at the rural clinic was a prescription for medication (17.4%), while referral to follow-up care was the most common at the urban clinics (35.5%). Rural areas not only have a shortage of health care providers, but community members seeking mental health care often encounter greater stigma, compared with urban residents.25,26
These data highlight an unmet need for referrals to treatment for patients in rural communities, particularly in Illinois where the pregnancy-related mortality ratio attributable to mental health conditions is three times greater in rural areas, compared with those residing in urban Cook County (Chicago).2 Increasing access and availability to mental health treatment and prevention resources in Illinois, especially in rural areas, is an opportunity to prevent pregnancy-related mortality attributable to mental health conditions.
Overall, there is a critical need for screening for perinatal mental health comorbidities, increased attention to low rates of referral to mental health treatment, and investing in rural perinatal mental health. Addressing perinatal mental health disorders is key to decreasing the burden of maternal mortality, particularly in Illinois.
Ms. Craemer and Ms. Sayah are senior research specialists at the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Duffecy is a professor of clinical psychiatry at the University of Illinois at Chicago. Dr. Geller is a professor of obstetrics & gynecology and director of the Center for Research on Women & Gender, University of Illinois at Chicago. Dr. Maki is a professor of psychiatry, psychology, and obstetrics & gynecology at the University of Illinois at Chicago.
References
1. Trost S et al. Pregnancy-related deaths: Data from maternal mortality review committees in 36 states, 2017-2019. Atlanta: Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, 2022.
2. Illinois Department of Public Health. Illinois maternal morbidity and mortality report 2016-2017. 2021.
3. AHRQ. Funding opportunities to address opioid and other substance use disorders. Updated 2023.
4. HRSA. Screening and treatment for maternal mental health and substance use disorders.
5. U.S. Preventive Services Task Force. Recommendations for primary care practice. Accessed May 26, 2023.
6. U.S. Preventive Services Task Force. Draft recommendation statement: Anxiety in adults: Screening. 2022.
7. ACOG. Screening and diagnosis of mental health conditions during pregnancy and postpartum. Clinical Practice Guideline. Number 4. 2023 June.
8. Meltzer-Brody S and Stuebe A. The long-term psychiatric and medical prognosis of perinatal mental illness. Best Pract Res Clin Obstet Gynaecol. 2014 Jan. doi: 10.1016/j.bpobgyn.2013.08.009.
9. Van Niel MS and Payne JL. Perinatal depression: A review. Cleve Clin J Med. 2020 May. doi: 10.3949/ccjm.87a.19054.
10. Wisner KL et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. 2013 May. doi: 10.1001/jamapsychiatry.2013.87.
11. Falah-Hassani K et al. The prevalence of antenatal and postnatal co-morbid anxiety and depression: A meta-analysis. Psychol Med. 2017 Sep. doi: 10.1017/S0033291717000617.
12. Pentecost R et al. Scoping review of the associations between perinatal substance use and perinatal depression and anxiety. J Obstet Gynecol Neonatal Nurs. 2021 Jul. doi: 10.1016/j.jogn.2021.02.008.
13. Craemer KA et al. Perinatal mental health in low-income urban and rural patients: The importance of screening for comorbidities. Gen Hosp Psychiatry. 2023 Jul-Aug. doi: 10.1016/j.genhosppsych.2023.05.007.
14. O’Connor E et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016 Jan 26. doi: 10.1001/jama.2015.18948.
15. Kozhimannil KB et al. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011 Jun. doi: 10.1176/ps.62.6.pss6206_0619.
16. Wenzel ES et al. Depression and anxiety symptoms across pregnancy and the postpartum in low-income Black and Latina women. Arch Womens Ment Health. 2021 Dec. doi: 10.1007/s00737-021-01139-y.
17. Gibbons RD et al. Development of a computerized adaptive substance use disorder scale for screening and measurement: The CAT‐SUD. Addiction. 2020 Jul. doi: 10.1111/add.14938.
18. Brenner LA et al. Validation of a computerized adaptive test suicide scale (CAT-SS) among united states military veterans. PloS One. 2022 Jan 21. doi: 10.1371/journal.pone.0261920.
19. The Center for State Child Welfare Data. Using technology to diagnose and report on behavioral health challenges facing foster youth. 2018.
20. Kim JJ et al. The experience of depression, anxiety, and mania among perinatal women. Arch Womens Ment Health. 2016 Oct. doi: 10.1007/s00737-016-0632-6.
21. Tepper MC et al. Toward population health: Using a learning behavioral health system and measurement-based care to improve access, care, outcomes, and disparities. Community Ment Health J. 2022 Nov. doi: 10.1007/s10597-022-00957-3.
22. Wenzel E et al. Using computerised adaptive tests to screen for perinatal depression in underserved women of colour. Evid Based Ment Health. 2022 Feb. doi: 10.1136/ebmental-2021-300262.
23. Sanger-Katz M. They want it to be secret: How a common blood test can cost $11 or almost $1,000. New York Times. 2019 Apr 19.
24. Spitzer RL et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006 May 22. doi: 10.1001/archinte.166.10.1092.
25. Mollard E et al. An integrative review of postpartum depression in rural US communities. Arch Psychiatr Nurs. 2016 Jun. doi: 10.1016/j.apnu.2015.12.003.
26. Anglim AJ and Radke SM. Rural maternal health care outcomes, drivers, and patient perspectives. Clin Obstet Gynecol. 2022 Dec 1. doi: 10.1097/GRF.0000000000000753.
More on disruption of the default mode network
In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (
First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al1 regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.
Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.2 Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.3
Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.
Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”4 Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.
1. Whitfield-Gabrieli S, Ford JM. Default mode network activity and connectivity in psychopathology. Annu Rev Clin Psychol. 2012;8:49-76. doi:10.1146/annurev-clinpsy-032511-143049
2. Valkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: an umbrella review of the evidence. Curr Opin Psychol. 2022;44:58-68. doi:10.1016/j.copsyc.2021.08.017
3. Orben A, Przybylski AK. The association between adolescent well-being and digital technology use. Nat Hum Behav. 2019;3(2):173-182. doi:10.1038/s41562-018-0506-1
4. Shore L, Toumbourou JW, Lewis AJ, et al. Review: longitudinal trajectories of child and adolescent depressive symptoms and their predictors - a systematic review and meta-analysis. Child Adolesc Ment Health. 2018;23(2):107-120. doi:10.1111/camh.12220
In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (
First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al1 regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.
Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.2 Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.3
Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.
Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”4 Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.
In a recent editorial, “Is the contemporary mental health crisis among youth due to DMN disruption?” (
First, Dr. Nasrallah referred to the well-cited review by Whitfield-Gabrieli et al1 regarding the relationship between DMN activation and mental health problems. However, this review shows that in mental health problems like “schizophrenia and depression, the DMN is often found to be hyperactivated and hyperconnected.” This stands in contradiction with the theory of decreased DMN activity in youth with mental health problems, and would, according to Dr. Nasrallah’s theory, call for more, not less, social media use.
Second, Dr. Nasrallah’s theory implies a substantial relationship between social media use and mental health problems. The latest umbrella review on the topic included 25 reviews, of which the majority found either “inconsistent” results or only “weak evidence” for a relationship.2 Additionally, a study of 355,358 adolescents found that digital technology use explains only 0.4% of the variance of well-being.3
Third, there are many focused attention tasks other than video games and social media, such as reading, doing math homework, and playing chess. Dr. Nasrallah’s theory suggests that the World Health Organization should refrain from global efforts to get more kids into schools, given that this would increase the amount of focused attention tasks, reduce DMN activation, and increase the amount of mental health problems.
Fourth, youth mental health problems are multifactorial. Identified predictors include “female gender, low socioeconomic status, higher stress reactivity, conduct issues, substance misuse, and problems in peer and parental relationships.”4 Given that these factors are unrelated to the DMN, under-activation of the DMN cannot “explain” the youth mental health crisis, as the editorial suggested.
1. Whitfield-Gabrieli S, Ford JM. Default mode network activity and connectivity in psychopathology. Annu Rev Clin Psychol. 2012;8:49-76. doi:10.1146/annurev-clinpsy-032511-143049
2. Valkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: an umbrella review of the evidence. Curr Opin Psychol. 2022;44:58-68. doi:10.1016/j.copsyc.2021.08.017
3. Orben A, Przybylski AK. The association between adolescent well-being and digital technology use. Nat Hum Behav. 2019;3(2):173-182. doi:10.1038/s41562-018-0506-1
4. Shore L, Toumbourou JW, Lewis AJ, et al. Review: longitudinal trajectories of child and adolescent depressive symptoms and their predictors - a systematic review and meta-analysis. Child Adolesc Ment Health. 2018;23(2):107-120. doi:10.1111/camh.12220
1. Whitfield-Gabrieli S, Ford JM. Default mode network activity and connectivity in psychopathology. Annu Rev Clin Psychol. 2012;8:49-76. doi:10.1146/annurev-clinpsy-032511-143049
2. Valkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: an umbrella review of the evidence. Curr Opin Psychol. 2022;44:58-68. doi:10.1016/j.copsyc.2021.08.017
3. Orben A, Przybylski AK. The association between adolescent well-being and digital technology use. Nat Hum Behav. 2019;3(2):173-182. doi:10.1038/s41562-018-0506-1
4. Shore L, Toumbourou JW, Lewis AJ, et al. Review: longitudinal trajectories of child and adolescent depressive symptoms and their predictors - a systematic review and meta-analysis. Child Adolesc Ment Health. 2018;23(2):107-120. doi:10.1111/camh.12220
Brain structural and cognitive changes during pregnancy
Pregnancy is unquestionably a major milestone in a woman’s life. During gestation, her body shape noticeably changes, but the invisible structural and cognitive changes in her brain are more striking. Some of those neurobiological changes are short-term, while others are long-lasting, well beyond delivery, and even into old age.
Physiological changes during pregnancy are extraordinary. The dramatic increases in estrogen, progesterone, and glucocorticoids help maintain pregnancy, ensure safe delivery of the baby, and trigger maternal behavior. However, other important changes also occur in the mother’s cardiac output, blood volume, renal function, respiratory output, and immune adaptations to accommodate the growth of the fetus. Gene expression also occurs to accomplish those changes, and there are lifelong repercussions from those drastic physiological changes.
During pregnancy, the brain is exposed to escalating levels of hormones released from the placenta, which the woman had never experienced. Those hormones regulate neuroplasticity, neuroinflammation, behavior, and cognition.
Structural brain changes1-6
Brain volume declines during pregnancy, reaching a nadir at the time of parturition. However, recovery occurs within 5 months after delivery. During the postpartum period, gray matter volume increases in the first 3 to 4 weeks, especially in areas involved in maternal behavior, including the amygdala, prefrontal cortex, and hypothalamus. Hippocampal gray matter decreases at 2 months postpartum compared to preconception levels, and reductions can still be observed up to 2 years following delivery. Gray matter reductions occur in multiple brain regions involved in social cognition, including the superior temporal gyrus, medial and inferior frontal cortex, fusiform areas, and hippocampus. Those changes correlate with positive maternal attachment. It is noteworthy that neural activity is highest in areas with reduced gray volume, so a decline in brain volume is associated with enhanced maternal attachment. Interestingly, those changes occur in fathers, too.
Childbearing improves stroke outcomes in middle age, but body weight will increase. The risk of Alzheimer’s disease increases with a higher number of gestations, but longevity is higher if the pregnancy occurs at an older age. Reproduction is also associated with shorter telomeres, which can elevate the risk of cancer, inflammation, diabetes, and dementia.
Cognitive changes7-10
The term “pregnancy brain” refers to cognitive changes during pregnancy and postpartum; these include decreased memory and concentration, absent-mindedness, heightened reactivity to threatening stimuli, and a decrease in motivation and executive functions. After delivery a mother has increased empathy (sometimes referred to as Theory of Mind) and greater activation in brain structures involved in empathy, including the paracingulate cortex, the posterior cingulate, and the insula. Also, the mirror neuron system becomes more activated in response to a woman’s own children compared to unfamiliar children. This incudes the ventral premotor cortex, the inferior frontal gyrus, and the posterior parietal cortex.
Certain forms of memory are impaired during pregnancy and early postpartum, including verbal free recall and working memory, as well as executive functions. Those are believed to correlate with glucocorticoids and estrogen levels.
Continue to: The following cognitive functions...
The following cognitive functions increase between the first and second trimester: verbal memory, attention, executive functions processing speed, verbal, and visuospatial abilities. Interestingly, mothers of a male fetus outperformed mothers of a female fetus on working memory and spatial ability.
Other changes11-16
- Cells from the fetus can traffic to the mother’s body and create microchimeric cells, which have short-term benefits (healing some of the other’s organs as stem cells do) but long-term downsides include future brain disorders such as Parkinson’s disease or Alzheimer’s disease, as well as autoimmune diseases and various types of cancer. The reverse also occurs with cells transferring from the mother to the fetus, persisting into infancy and childhood.
- Postpartum psychosis is associated with reductions in the volumes of the anterior cingulate, left parahippocampal gyrus, and superior temporal gyrus.
- A woman’s white matter increases during pregnancy compared to preconception. This is attributed to the high levels of prolactin, which proliferates oligodendrocytes, the glial cells that continuously manufacture myelin.
- The pituitary gland increases by 200% to 300% during pregnancy and returns to pre-pregnancy levels approximately 8 months following delivery. Prolactin also mediates the production of brain cells in the hippocampus (ie, neurogenesis).
- Sexual activity, even without pregnancy, increases neurogenesis. Plasma levels of prolactin increase significantly following an orgasm in both men and women, which indicates that sexual activity has beneficial brain effects.
- With pregnancy, the immune system shifts from proinflammatory to anti-inflammatory signaling. This protects the fetus from being attacked and rejected as foreign tissue. However, at the end of pregnancy, there is a “burst” of proinflammatory signaling, which serves as a major trigger to induce uterine contractions and initiate labor (to expel the foreign tissue).
- Brain levels of the anti-inflammatory cytokine interleukin-6 increase in the postpartum period, which represents a significant modification in the neuroimmune environment, and the maternal brain assumes an inflammatory-resistant state, which has cognitive and neuroplasticity implications. However, this neuroimmune dysregulation is implicated in postpartum depression and anxiety.
- Older females who were never pregnant or only had 1 pregnancy had better overall cognitive functioning than females who became pregnant at an young age.
- In animal studies, reproduction alleviates the negative effects of aging on several hippocampal functions, especially neurogenesis. Dendritic spine density in the CA1 region of the hippocampus is higher in pregnancy and early postpartum period compared to nulliparous females (based on animal studies).
Pregnancy is indispensable for the perpetuation of the species. Its hormonal, physiologic, neurobiological, and cognitive correlates are extensive. The cognitive changes in the postpartum period are designed by evolution to prepare a woman to care for her newborn and to ensure its survival. But the biological sequelae of pregnancy extend to the rest of a woman’s life and may predispose her to immune and brain disorders as she ages.
1. Barba-Müller E, Craddock S, Carmona S, et al. Brain plasticity in pregnancy and the postpartum period: links to maternal caregiving and mental health. Arch Womens Ment Health. 2019;22(2):289-299.
2. Pawluski JL, Hoekzema E, Leuner B, et al. Less can be more: fine tuning the maternal brain. Neurosci Biobehav Rev. 2022;133:104475. doi:10.1016/j.neubiorev.2021.11.045
3. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
4. Cárdenas EF, Kujawa A, Humphreys KL. Neurobiological changes during the peripartum period: implications for health and behavior. Soc Cogn Affect Neurosci. 2020;15(10):1097-1110.
5. Eid RS, Chaiton JA, Lieblich SE, et al. Early and late effects of maternal experience on hippocampal neurogenesis, microglia, and the circulating cytokine milieu. Neurobiol Aging. 2019;78:1-17.
6. Galea LA, Leuner B, Slattery DA. Hippocampal plasticity during the peripartum period: influence of sex steroids, stress and ageing. J Neuroendocrinol. 2014;26(10):641-648.
7. Henry JF, Sherwin BB. Hormones and cognitive functioning during late pregnancy and postpartum: a longitudinal study. Behav Neurosci. 2012;126(1):73-85.
8. Barda G, Mizrachi Y, Borokchovich I, et al. The effect of pregnancy on maternal cognition. Sci Rep. 2011;11(1)12187. doi:10.1038/s41598-021-91504-9
9. Davies SJ, Lum JA, Skouteris H, et al. Cognitive impairment during pregnancy: a meta-analysis. Med J Aust. 2018;208(1):35-40.
10. Pownall M, Hutter RRC, Rockliffe L, et al. Memory and mood changes in pregnancy: a qualitative content analysis of women’s first-hand accounts. J Reprod Infant Psychol. 2023;41(5):516-527.
11. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
12. Duarte-Guterman P, Leuner B, Galea LAM. The long and short term effects of motherhood on the brain. Front Neuroendocrinol. 2019;53:100740. doi:10.1016/j.yfrne.2019.02.004
13. Haim A, Julian D, Albin-Brooks C, et al. A survey of neuroimmune changes in pregnant and postpartum female rats. Brain Behav Immun. 2017;59:67-78.
14. Benson JC, Malyuk DF, Madhavan A, et al. Pituitary volume changes in pregnancy and the post-partum period. Neuroradiol J. 2023. doi:10.1177/19714009231196470
15. Schepanski S, Chini M, Sternemann V, et al. Pregnancy-induced maternal microchimerism shapes neurodevelopment and behavior in mice. Nat Commun. 2022;13(1):4571. doi:10.1038/s41467-022-32230-2
16. Larsen CM, Grattan DR. Prolactin, neurogenesis, and maternal behaviors. Brain Behav Immun. 2012;26(2):201-209.
Pregnancy is unquestionably a major milestone in a woman’s life. During gestation, her body shape noticeably changes, but the invisible structural and cognitive changes in her brain are more striking. Some of those neurobiological changes are short-term, while others are long-lasting, well beyond delivery, and even into old age.
Physiological changes during pregnancy are extraordinary. The dramatic increases in estrogen, progesterone, and glucocorticoids help maintain pregnancy, ensure safe delivery of the baby, and trigger maternal behavior. However, other important changes also occur in the mother’s cardiac output, blood volume, renal function, respiratory output, and immune adaptations to accommodate the growth of the fetus. Gene expression also occurs to accomplish those changes, and there are lifelong repercussions from those drastic physiological changes.
During pregnancy, the brain is exposed to escalating levels of hormones released from the placenta, which the woman had never experienced. Those hormones regulate neuroplasticity, neuroinflammation, behavior, and cognition.
Structural brain changes1-6
Brain volume declines during pregnancy, reaching a nadir at the time of parturition. However, recovery occurs within 5 months after delivery. During the postpartum period, gray matter volume increases in the first 3 to 4 weeks, especially in areas involved in maternal behavior, including the amygdala, prefrontal cortex, and hypothalamus. Hippocampal gray matter decreases at 2 months postpartum compared to preconception levels, and reductions can still be observed up to 2 years following delivery. Gray matter reductions occur in multiple brain regions involved in social cognition, including the superior temporal gyrus, medial and inferior frontal cortex, fusiform areas, and hippocampus. Those changes correlate with positive maternal attachment. It is noteworthy that neural activity is highest in areas with reduced gray volume, so a decline in brain volume is associated with enhanced maternal attachment. Interestingly, those changes occur in fathers, too.
Childbearing improves stroke outcomes in middle age, but body weight will increase. The risk of Alzheimer’s disease increases with a higher number of gestations, but longevity is higher if the pregnancy occurs at an older age. Reproduction is also associated with shorter telomeres, which can elevate the risk of cancer, inflammation, diabetes, and dementia.
Cognitive changes7-10
The term “pregnancy brain” refers to cognitive changes during pregnancy and postpartum; these include decreased memory and concentration, absent-mindedness, heightened reactivity to threatening stimuli, and a decrease in motivation and executive functions. After delivery a mother has increased empathy (sometimes referred to as Theory of Mind) and greater activation in brain structures involved in empathy, including the paracingulate cortex, the posterior cingulate, and the insula. Also, the mirror neuron system becomes more activated in response to a woman’s own children compared to unfamiliar children. This incudes the ventral premotor cortex, the inferior frontal gyrus, and the posterior parietal cortex.
Certain forms of memory are impaired during pregnancy and early postpartum, including verbal free recall and working memory, as well as executive functions. Those are believed to correlate with glucocorticoids and estrogen levels.
Continue to: The following cognitive functions...
The following cognitive functions increase between the first and second trimester: verbal memory, attention, executive functions processing speed, verbal, and visuospatial abilities. Interestingly, mothers of a male fetus outperformed mothers of a female fetus on working memory and spatial ability.
Other changes11-16
- Cells from the fetus can traffic to the mother’s body and create microchimeric cells, which have short-term benefits (healing some of the other’s organs as stem cells do) but long-term downsides include future brain disorders such as Parkinson’s disease or Alzheimer’s disease, as well as autoimmune diseases and various types of cancer. The reverse also occurs with cells transferring from the mother to the fetus, persisting into infancy and childhood.
- Postpartum psychosis is associated with reductions in the volumes of the anterior cingulate, left parahippocampal gyrus, and superior temporal gyrus.
- A woman’s white matter increases during pregnancy compared to preconception. This is attributed to the high levels of prolactin, which proliferates oligodendrocytes, the glial cells that continuously manufacture myelin.
- The pituitary gland increases by 200% to 300% during pregnancy and returns to pre-pregnancy levels approximately 8 months following delivery. Prolactin also mediates the production of brain cells in the hippocampus (ie, neurogenesis).
- Sexual activity, even without pregnancy, increases neurogenesis. Plasma levels of prolactin increase significantly following an orgasm in both men and women, which indicates that sexual activity has beneficial brain effects.
- With pregnancy, the immune system shifts from proinflammatory to anti-inflammatory signaling. This protects the fetus from being attacked and rejected as foreign tissue. However, at the end of pregnancy, there is a “burst” of proinflammatory signaling, which serves as a major trigger to induce uterine contractions and initiate labor (to expel the foreign tissue).
- Brain levels of the anti-inflammatory cytokine interleukin-6 increase in the postpartum period, which represents a significant modification in the neuroimmune environment, and the maternal brain assumes an inflammatory-resistant state, which has cognitive and neuroplasticity implications. However, this neuroimmune dysregulation is implicated in postpartum depression and anxiety.
- Older females who were never pregnant or only had 1 pregnancy had better overall cognitive functioning than females who became pregnant at an young age.
- In animal studies, reproduction alleviates the negative effects of aging on several hippocampal functions, especially neurogenesis. Dendritic spine density in the CA1 region of the hippocampus is higher in pregnancy and early postpartum period compared to nulliparous females (based on animal studies).
Pregnancy is indispensable for the perpetuation of the species. Its hormonal, physiologic, neurobiological, and cognitive correlates are extensive. The cognitive changes in the postpartum period are designed by evolution to prepare a woman to care for her newborn and to ensure its survival. But the biological sequelae of pregnancy extend to the rest of a woman’s life and may predispose her to immune and brain disorders as she ages.
Pregnancy is unquestionably a major milestone in a woman’s life. During gestation, her body shape noticeably changes, but the invisible structural and cognitive changes in her brain are more striking. Some of those neurobiological changes are short-term, while others are long-lasting, well beyond delivery, and even into old age.
Physiological changes during pregnancy are extraordinary. The dramatic increases in estrogen, progesterone, and glucocorticoids help maintain pregnancy, ensure safe delivery of the baby, and trigger maternal behavior. However, other important changes also occur in the mother’s cardiac output, blood volume, renal function, respiratory output, and immune adaptations to accommodate the growth of the fetus. Gene expression also occurs to accomplish those changes, and there are lifelong repercussions from those drastic physiological changes.
During pregnancy, the brain is exposed to escalating levels of hormones released from the placenta, which the woman had never experienced. Those hormones regulate neuroplasticity, neuroinflammation, behavior, and cognition.
Structural brain changes1-6
Brain volume declines during pregnancy, reaching a nadir at the time of parturition. However, recovery occurs within 5 months after delivery. During the postpartum period, gray matter volume increases in the first 3 to 4 weeks, especially in areas involved in maternal behavior, including the amygdala, prefrontal cortex, and hypothalamus. Hippocampal gray matter decreases at 2 months postpartum compared to preconception levels, and reductions can still be observed up to 2 years following delivery. Gray matter reductions occur in multiple brain regions involved in social cognition, including the superior temporal gyrus, medial and inferior frontal cortex, fusiform areas, and hippocampus. Those changes correlate with positive maternal attachment. It is noteworthy that neural activity is highest in areas with reduced gray volume, so a decline in brain volume is associated with enhanced maternal attachment. Interestingly, those changes occur in fathers, too.
Childbearing improves stroke outcomes in middle age, but body weight will increase. The risk of Alzheimer’s disease increases with a higher number of gestations, but longevity is higher if the pregnancy occurs at an older age. Reproduction is also associated with shorter telomeres, which can elevate the risk of cancer, inflammation, diabetes, and dementia.
Cognitive changes7-10
The term “pregnancy brain” refers to cognitive changes during pregnancy and postpartum; these include decreased memory and concentration, absent-mindedness, heightened reactivity to threatening stimuli, and a decrease in motivation and executive functions. After delivery a mother has increased empathy (sometimes referred to as Theory of Mind) and greater activation in brain structures involved in empathy, including the paracingulate cortex, the posterior cingulate, and the insula. Also, the mirror neuron system becomes more activated in response to a woman’s own children compared to unfamiliar children. This incudes the ventral premotor cortex, the inferior frontal gyrus, and the posterior parietal cortex.
Certain forms of memory are impaired during pregnancy and early postpartum, including verbal free recall and working memory, as well as executive functions. Those are believed to correlate with glucocorticoids and estrogen levels.
Continue to: The following cognitive functions...
The following cognitive functions increase between the first and second trimester: verbal memory, attention, executive functions processing speed, verbal, and visuospatial abilities. Interestingly, mothers of a male fetus outperformed mothers of a female fetus on working memory and spatial ability.
Other changes11-16
- Cells from the fetus can traffic to the mother’s body and create microchimeric cells, which have short-term benefits (healing some of the other’s organs as stem cells do) but long-term downsides include future brain disorders such as Parkinson’s disease or Alzheimer’s disease, as well as autoimmune diseases and various types of cancer. The reverse also occurs with cells transferring from the mother to the fetus, persisting into infancy and childhood.
- Postpartum psychosis is associated with reductions in the volumes of the anterior cingulate, left parahippocampal gyrus, and superior temporal gyrus.
- A woman’s white matter increases during pregnancy compared to preconception. This is attributed to the high levels of prolactin, which proliferates oligodendrocytes, the glial cells that continuously manufacture myelin.
- The pituitary gland increases by 200% to 300% during pregnancy and returns to pre-pregnancy levels approximately 8 months following delivery. Prolactin also mediates the production of brain cells in the hippocampus (ie, neurogenesis).
- Sexual activity, even without pregnancy, increases neurogenesis. Plasma levels of prolactin increase significantly following an orgasm in both men and women, which indicates that sexual activity has beneficial brain effects.
- With pregnancy, the immune system shifts from proinflammatory to anti-inflammatory signaling. This protects the fetus from being attacked and rejected as foreign tissue. However, at the end of pregnancy, there is a “burst” of proinflammatory signaling, which serves as a major trigger to induce uterine contractions and initiate labor (to expel the foreign tissue).
- Brain levels of the anti-inflammatory cytokine interleukin-6 increase in the postpartum period, which represents a significant modification in the neuroimmune environment, and the maternal brain assumes an inflammatory-resistant state, which has cognitive and neuroplasticity implications. However, this neuroimmune dysregulation is implicated in postpartum depression and anxiety.
- Older females who were never pregnant or only had 1 pregnancy had better overall cognitive functioning than females who became pregnant at an young age.
- In animal studies, reproduction alleviates the negative effects of aging on several hippocampal functions, especially neurogenesis. Dendritic spine density in the CA1 region of the hippocampus is higher in pregnancy and early postpartum period compared to nulliparous females (based on animal studies).
Pregnancy is indispensable for the perpetuation of the species. Its hormonal, physiologic, neurobiological, and cognitive correlates are extensive. The cognitive changes in the postpartum period are designed by evolution to prepare a woman to care for her newborn and to ensure its survival. But the biological sequelae of pregnancy extend to the rest of a woman’s life and may predispose her to immune and brain disorders as she ages.
1. Barba-Müller E, Craddock S, Carmona S, et al. Brain plasticity in pregnancy and the postpartum period: links to maternal caregiving and mental health. Arch Womens Ment Health. 2019;22(2):289-299.
2. Pawluski JL, Hoekzema E, Leuner B, et al. Less can be more: fine tuning the maternal brain. Neurosci Biobehav Rev. 2022;133:104475. doi:10.1016/j.neubiorev.2021.11.045
3. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
4. Cárdenas EF, Kujawa A, Humphreys KL. Neurobiological changes during the peripartum period: implications for health and behavior. Soc Cogn Affect Neurosci. 2020;15(10):1097-1110.
5. Eid RS, Chaiton JA, Lieblich SE, et al. Early and late effects of maternal experience on hippocampal neurogenesis, microglia, and the circulating cytokine milieu. Neurobiol Aging. 2019;78:1-17.
6. Galea LA, Leuner B, Slattery DA. Hippocampal plasticity during the peripartum period: influence of sex steroids, stress and ageing. J Neuroendocrinol. 2014;26(10):641-648.
7. Henry JF, Sherwin BB. Hormones and cognitive functioning during late pregnancy and postpartum: a longitudinal study. Behav Neurosci. 2012;126(1):73-85.
8. Barda G, Mizrachi Y, Borokchovich I, et al. The effect of pregnancy on maternal cognition. Sci Rep. 2011;11(1)12187. doi:10.1038/s41598-021-91504-9
9. Davies SJ, Lum JA, Skouteris H, et al. Cognitive impairment during pregnancy: a meta-analysis. Med J Aust. 2018;208(1):35-40.
10. Pownall M, Hutter RRC, Rockliffe L, et al. Memory and mood changes in pregnancy: a qualitative content analysis of women’s first-hand accounts. J Reprod Infant Psychol. 2023;41(5):516-527.
11. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
12. Duarte-Guterman P, Leuner B, Galea LAM. The long and short term effects of motherhood on the brain. Front Neuroendocrinol. 2019;53:100740. doi:10.1016/j.yfrne.2019.02.004
13. Haim A, Julian D, Albin-Brooks C, et al. A survey of neuroimmune changes in pregnant and postpartum female rats. Brain Behav Immun. 2017;59:67-78.
14. Benson JC, Malyuk DF, Madhavan A, et al. Pituitary volume changes in pregnancy and the post-partum period. Neuroradiol J. 2023. doi:10.1177/19714009231196470
15. Schepanski S, Chini M, Sternemann V, et al. Pregnancy-induced maternal microchimerism shapes neurodevelopment and behavior in mice. Nat Commun. 2022;13(1):4571. doi:10.1038/s41467-022-32230-2
16. Larsen CM, Grattan DR. Prolactin, neurogenesis, and maternal behaviors. Brain Behav Immun. 2012;26(2):201-209.
1. Barba-Müller E, Craddock S, Carmona S, et al. Brain plasticity in pregnancy and the postpartum period: links to maternal caregiving and mental health. Arch Womens Ment Health. 2019;22(2):289-299.
2. Pawluski JL, Hoekzema E, Leuner B, et al. Less can be more: fine tuning the maternal brain. Neurosci Biobehav Rev. 2022;133:104475. doi:10.1016/j.neubiorev.2021.11.045
3. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
4. Cárdenas EF, Kujawa A, Humphreys KL. Neurobiological changes during the peripartum period: implications for health and behavior. Soc Cogn Affect Neurosci. 2020;15(10):1097-1110.
5. Eid RS, Chaiton JA, Lieblich SE, et al. Early and late effects of maternal experience on hippocampal neurogenesis, microglia, and the circulating cytokine milieu. Neurobiol Aging. 2019;78:1-17.
6. Galea LA, Leuner B, Slattery DA. Hippocampal plasticity during the peripartum period: influence of sex steroids, stress and ageing. J Neuroendocrinol. 2014;26(10):641-648.
7. Henry JF, Sherwin BB. Hormones and cognitive functioning during late pregnancy and postpartum: a longitudinal study. Behav Neurosci. 2012;126(1):73-85.
8. Barda G, Mizrachi Y, Borokchovich I, et al. The effect of pregnancy on maternal cognition. Sci Rep. 2011;11(1)12187. doi:10.1038/s41598-021-91504-9
9. Davies SJ, Lum JA, Skouteris H, et al. Cognitive impairment during pregnancy: a meta-analysis. Med J Aust. 2018;208(1):35-40.
10. Pownall M, Hutter RRC, Rockliffe L, et al. Memory and mood changes in pregnancy: a qualitative content analysis of women’s first-hand accounts. J Reprod Infant Psychol. 2023;41(5):516-527.
11. Hoekzema E, Barba-Müller E, Pozzobon C, et al. Pregnancy leads to long-lasting changes in human brain structure. Nat Neurosci. 2017;20(2):287-296.
12. Duarte-Guterman P, Leuner B, Galea LAM. The long and short term effects of motherhood on the brain. Front Neuroendocrinol. 2019;53:100740. doi:10.1016/j.yfrne.2019.02.004
13. Haim A, Julian D, Albin-Brooks C, et al. A survey of neuroimmune changes in pregnant and postpartum female rats. Brain Behav Immun. 2017;59:67-78.
14. Benson JC, Malyuk DF, Madhavan A, et al. Pituitary volume changes in pregnancy and the post-partum period. Neuroradiol J. 2023. doi:10.1177/19714009231196470
15. Schepanski S, Chini M, Sternemann V, et al. Pregnancy-induced maternal microchimerism shapes neurodevelopment and behavior in mice. Nat Commun. 2022;13(1):4571. doi:10.1038/s41467-022-32230-2
16. Larsen CM, Grattan DR. Prolactin, neurogenesis, and maternal behaviors. Brain Behav Immun. 2012;26(2):201-209.
