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LGBTQ+ Youth Consult: Let’s talk about PrEP!
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
As pediatricians, almost all of our clinic visits include some anticipatory guidance and recommendations on ways to promote well-being and prevent illness and injury for our patients. Because of minority stress, discrimination, and increased exposure to adverse childhood experiences, LGBTQ+ patients are disproportionately affected by certain health conditions including depression, anxiety, substance use, homelessness, as well as HIV and other sexually transmitted infections (STIs).1 While LGBTQ+ youth could benefit from additional guidance, counseling, and interventions related to these health disparities and have expressed interest in talking about these topics with their providers, sexual and gender minority youth also stress that they want to be treated as any other youth.2 Extending counseling for preventive care measures such as preexposure prophylaxis (PrEP) for HIV to all sexually active youth could help to destigmatize LGBTQ+ youth as being “different” from other youth and also help to increase overall access to HIV prevention services.3
Described by some as the “birth control” for HIV infection, PrEP is taken on an ongoing basis by those who are HIV negative before potential exposures to HIV in order to prevent new HIV infections. PrEP was first approved as a daily pill for adults in 2015 by the Food and Drug Administration with extension in 2018 to all individuals at risk for HIV weighing at least 35 kg after safety and efficacy data showed it could be used routinely for adolescents.4 When taken daily, oral PrEP can decrease the risk of HIV from sexual contact by more than 90% and from injection drug use by around 70%. As PrEP is highly effective with low risk for side effects, the U.S. Preventive Services Task Force (USPSTF) gave PrEP a “Grade A” recommendation for use in those at high risk for HIV infection in 2019.5 Since efficacy is closely tied to adherence, the first injectable PrEP (given at 0, 1, and 2 months with dosing then every 2 months) was also recently FDA approved in late 2021.6
Since HIV infection disproportionately affects LBGTQ+ individuals, and particularly LBGTQ+ youth of color, counseling related to PrEP has been largely targeted to these groups.7 Insurance and financial barriers to PrEP have been greatly reduced over the past several years through changes in insurance coverage (strengthened by the USPSTF recommendation), supplemental insurance programs, and pharmaceutical copay programs. Many states (but not all) also include HIV in the definition of STIs and allow minors to consent to PrEP services without a parent or guardian. Unfortunately, despite the high efficacy of PrEP and efforts to decrease barriers, rates of PrEP use continue to be extremely low, especially in youth, with only 15.6% of those aged 16-24 who are at risk for HIV in the United States actually taking PrEP in 2019.8 Many barriers to PrEP continue to exist including lack of awareness of PrEP, stigma surrounding HIV and PrEP, and lack of PrEP providers.
In order to address these low rates of PrEP uptake, the Centers for Disease Control and Prevention now recommends that medical providers discuss PrEP with all sexually active patients.6 PrEP should not be seen or discussed as something only relevant to LBGTQ+ populations, but rather as another tool in everyone’s “sexual health toolbox” that can allow us to experience human connection and pleasure through sexual activity while also having more control over what happens to our bodies. Not only will this allow more patients to access PrEP directly, it will also decrease the stigma of talking about HIV and PrEP and strengthen youths’ sense of autonomy and control over their own sexual health.
Since PrEP is a relatively new medical service, many providers will need to learn more about PrEP to at least have initial discussions with patients and to feel comfortable prescribing this themselves (See Resources). Below are also some suggestions to incorporate into your practice in order to advocate for the health and well-being of all your patients, including LGBTQ+ youth.
- Once your patients are 13 years and older, spend time with them alone to confidentially discuss more sensitive topics such as sexual health, mental health, and substance use.
- For all patients who are sexually active or considering sexual activity in the near future, discuss topics to help them control what happens to their bodies including consent, condoms, birth control, PrEP, and routine STI screening.
- Recommend PrEP to anyone who is sexually active and may be at increased risk for HIV infection or who is interested in taking PrEP for HIV prevention.
- Learn more about PrEP and start prescribing it to your own patients or become familiar with providers in your area to whom you could refer patients who are interested. While no certification is needed to prescribe PrEP, programs exist to help providers become more familiar with how to prescribe PrEP.
Dr. Warus is an adolescent medicine physician who specializes in care for transgender and gender-nonconforming youth, HIV prevention for adolescents and young adults, and LGBTQ health for youth at Children’s Hospital of Los Angeles. He is an assistant professor of clinical pediatrics and a University of Southern California faculty member.
Resources
CDC PrEP resources for clinicians: www.cdc.gov/hiv/clinicians/prevention/prep.html.Health HIV’s HIV Prevention Certified Provider Certification Program: https://healthhiv.org/programs/hpcp/.PrEP providers in the United States: https://preplocator.org/.Adolescent Health Working Group’s Sexual and Reproductive Health Toolkit for Adolescent Providers: https://ahwg.org/download/sexual-and-reproductive-health-toolkit-for-adolescent-providers/.
References
1. Lund EM and Burgess CM. Prim Care Clin Office Pract. 2021:48:179-89.
2. Hoffman ND et al. J Adolesc Health. 2009;45:222-9.
3. Mayer KH et al. Adv Ther. 2020;37:1778-811.
4. Hosek SG et al. JAMA Pediatr. 2017;171(11):1063-71.
5. U.S. Preventive Services Task Force; Owens DK et al. JAMA. 2019;321(22):2203-13.
6. Centers for Disease Control and Prevention: U.S. Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2021 Update: A Clinical Practice Guideline. Published 2021. Accessed July 10, 2022.
7. Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States, 2015-2019. HIV Surveillance Supplemental Report. 2021;26(1). Published May 2021. Accessed July 10, 2022.
8. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data–United States and 6 Dependent Areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3).
Two congressmen targeting ‘gender transition’ physicians
Two GOP congressmen have introduced legislation aimed at holding doctors who perform gender transition procedures on minors liable for their actions, says a story reported on KATV.com, among other news sites.
The two GOP lawmakers – Rep. Jim Banks (IN) and Sen. Tom Cotton (AR) – introduced the Protecting Minors from Medical Malpractice Act in their respective chambers.
If passed, the House and Senate bills would make doctors liable for any gender transition surgery on a minor that results in injury, whether physical, psychological, emotional, or physiological. Minors who believe they’ve been harmed would have up to 30 years from when they turn 18 to file a claim.
The House proposal would also strip federal funding from states that require health care professionals to provide gender transition procedures, including puberty blockers, cross-sex hormones, and gender reassignment surgeries.
A companion House bill, also sponsored by Banks, targets another issue related to gender transitioning for minors: parental consent.
If passed, the Empower Parents to Protect Their Kids Act of 2022 would deny federal funding to any elementary and secondary schools that initiate a minor’s gender transition without first securing parental consent. (Last October, Sen. Cotton released a similar bill in the Senate.)
The content contained in this article is for informational purposes only and does not constitute legal advice. Reliance on any information provided in this article is solely at your own risk.
A version of this article first appeared on Medscape.com.
Two GOP congressmen have introduced legislation aimed at holding doctors who perform gender transition procedures on minors liable for their actions, says a story reported on KATV.com, among other news sites.
The two GOP lawmakers – Rep. Jim Banks (IN) and Sen. Tom Cotton (AR) – introduced the Protecting Minors from Medical Malpractice Act in their respective chambers.
If passed, the House and Senate bills would make doctors liable for any gender transition surgery on a minor that results in injury, whether physical, psychological, emotional, or physiological. Minors who believe they’ve been harmed would have up to 30 years from when they turn 18 to file a claim.
The House proposal would also strip federal funding from states that require health care professionals to provide gender transition procedures, including puberty blockers, cross-sex hormones, and gender reassignment surgeries.
A companion House bill, also sponsored by Banks, targets another issue related to gender transitioning for minors: parental consent.
If passed, the Empower Parents to Protect Their Kids Act of 2022 would deny federal funding to any elementary and secondary schools that initiate a minor’s gender transition without first securing parental consent. (Last October, Sen. Cotton released a similar bill in the Senate.)
The content contained in this article is for informational purposes only and does not constitute legal advice. Reliance on any information provided in this article is solely at your own risk.
A version of this article first appeared on Medscape.com.
Two GOP congressmen have introduced legislation aimed at holding doctors who perform gender transition procedures on minors liable for their actions, says a story reported on KATV.com, among other news sites.
The two GOP lawmakers – Rep. Jim Banks (IN) and Sen. Tom Cotton (AR) – introduced the Protecting Minors from Medical Malpractice Act in their respective chambers.
If passed, the House and Senate bills would make doctors liable for any gender transition surgery on a minor that results in injury, whether physical, psychological, emotional, or physiological. Minors who believe they’ve been harmed would have up to 30 years from when they turn 18 to file a claim.
The House proposal would also strip federal funding from states that require health care professionals to provide gender transition procedures, including puberty blockers, cross-sex hormones, and gender reassignment surgeries.
A companion House bill, also sponsored by Banks, targets another issue related to gender transitioning for minors: parental consent.
If passed, the Empower Parents to Protect Their Kids Act of 2022 would deny federal funding to any elementary and secondary schools that initiate a minor’s gender transition without first securing parental consent. (Last October, Sen. Cotton released a similar bill in the Senate.)
The content contained in this article is for informational purposes only and does not constitute legal advice. Reliance on any information provided in this article is solely at your own risk.
A version of this article first appeared on Medscape.com.
Depression screens do not reduce suicidal acts in teens: Study
Screening adolescents for signs of depression does not reduce their emergency department visits, hospitalizations, or treatment for suicidal behaviors, according to research published in Preventive Medicine. Adolescents who underwent a depression screening were just as likely to need these services as those who did not.
In 2016, the U.S. Preventive Services Task Force recommended that adolescents aged 12-18 years be screened for major depressive disorder, provided that effective treatment options and follow-up strategies are in place.
“The main goal of depression screening is really to reduce adverse psychiatric outcomes. But I think a collateral hope is that, in reducing these adverse psychiatric outcomes, you would also reduce avoidable health services use,” such as ED visits or hospitalizations, said Kira Riehm, PhD, a postdoctoral fellow in epidemiology at Columbia University, New York, who led the research. Dr. Riehm designed the new study, which was part of her doctoral work at Johns Hopkins University, Baltimore, to test this premise.
Dr. Riehm and colleagues compared 14,433 adolescents aged 12-18 years who were screened for depression at least once during a wellness visit from 2014 to 2017 to 43,299 adolescents who were not screened for depression during such visits. Depression screenings were interspersed among a total of 281,463 adolescent wellness visits from 2014 to 2017, which represented 5% of all visits.
The researchers used diagnostic codes from a database of insurance claims to determine who had undergone depression screening. They then compared use of ED services, inpatient hospitalizations, and the number of treatments for suicidal behaviors between the two groups for the 2 years following the wellness visit.
The average age of the adolescents who underwent screening was 13-14 years, as was the average age of adolescents who were not screened. Both groups were evenly matched with respect to being male or female.
The researchers estimated that a high majority of adolescents in the sample were White (83%). Black persons represented 7% of the sample; Hispanic/Latino, 5%; and Asian, 3%. Insurance claims don’t always include racial and ethnicity data, Dr. Riehm said, so her group statistically imputed these proportions. The claims data also do not include details about which type of screening tool was used or the results of the screening, such as whether a teen exhibited mild or severe depression.
Adolescents in both groups were just as likely to go to the ED for any reason, be admitted to the hospital for any reason, or undergo treatment for suicidal behaviors. The researchers observed a slight association between being screened for depression and going to the ED specifically for a mental health reason (relative risk, 1.16; 95% confidence interval, 1.00-1.33). The sex of the adolescents had no bearing on whether they used these services.
“I think people think of [depression screening] as one event. But in reality, screening is a series of different events that all have to be happening in order for a screening program to work,” Dr. Riehm told this news organization.
These events could include ensuring that adolescents who exhibit signs of depression receive a proper assessment, receive medications if needed, and have access to psychotherapists who can help them. Without these supports in place, she said, a one-off depression screening may have limited benefit.
“There’s a lot of places where people could drop out of that care continuum,” Dr. Riehm said.
“One-time screening may not be enough,” said Trân Đoàn, PhD, MPH, a postdoctoral researcher in the University of Pittsburgh department of pediatrics.
Dr. Đoàn, who was not involved in the research, noted that the American Academy of Pediatrics recommends annual screening of all adolescents for depressive symptoms. Given that only 5% of the visits in this sample included any kind of depression screening, Dr. Đoàn said, some pediatric practices may not have felt they had the resources to adequately address positive screenings for depression.
Both Dr. Riehm and Dr. Đoàn are focusing on the link between depression screening and health outcomes. In her own doctoral work at the University of Michigan, Dr. Đoàn modeled the effects of universal annual depression screening in primary care settings on the health status of people aged 12-22 years. She is currently preparing this work for publication.
“I did find that, over the long term, there is improvement in health outcomes if we were to screen on an annual basis,” provided improved screening is coupled with comprehensive treatment plans, Dr. Đoàn said. The model’s health outcomes measures included an increase in life expectancy as well as a greater proportion of depression-free days among adolescents who receive appropriate treatment.
Dr. Riehm and Dr. Đoàn disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Screening adolescents for signs of depression does not reduce their emergency department visits, hospitalizations, or treatment for suicidal behaviors, according to research published in Preventive Medicine. Adolescents who underwent a depression screening were just as likely to need these services as those who did not.
In 2016, the U.S. Preventive Services Task Force recommended that adolescents aged 12-18 years be screened for major depressive disorder, provided that effective treatment options and follow-up strategies are in place.
“The main goal of depression screening is really to reduce adverse psychiatric outcomes. But I think a collateral hope is that, in reducing these adverse psychiatric outcomes, you would also reduce avoidable health services use,” such as ED visits or hospitalizations, said Kira Riehm, PhD, a postdoctoral fellow in epidemiology at Columbia University, New York, who led the research. Dr. Riehm designed the new study, which was part of her doctoral work at Johns Hopkins University, Baltimore, to test this premise.
Dr. Riehm and colleagues compared 14,433 adolescents aged 12-18 years who were screened for depression at least once during a wellness visit from 2014 to 2017 to 43,299 adolescents who were not screened for depression during such visits. Depression screenings were interspersed among a total of 281,463 adolescent wellness visits from 2014 to 2017, which represented 5% of all visits.
The researchers used diagnostic codes from a database of insurance claims to determine who had undergone depression screening. They then compared use of ED services, inpatient hospitalizations, and the number of treatments for suicidal behaviors between the two groups for the 2 years following the wellness visit.
The average age of the adolescents who underwent screening was 13-14 years, as was the average age of adolescents who were not screened. Both groups were evenly matched with respect to being male or female.
The researchers estimated that a high majority of adolescents in the sample were White (83%). Black persons represented 7% of the sample; Hispanic/Latino, 5%; and Asian, 3%. Insurance claims don’t always include racial and ethnicity data, Dr. Riehm said, so her group statistically imputed these proportions. The claims data also do not include details about which type of screening tool was used or the results of the screening, such as whether a teen exhibited mild or severe depression.
Adolescents in both groups were just as likely to go to the ED for any reason, be admitted to the hospital for any reason, or undergo treatment for suicidal behaviors. The researchers observed a slight association between being screened for depression and going to the ED specifically for a mental health reason (relative risk, 1.16; 95% confidence interval, 1.00-1.33). The sex of the adolescents had no bearing on whether they used these services.
“I think people think of [depression screening] as one event. But in reality, screening is a series of different events that all have to be happening in order for a screening program to work,” Dr. Riehm told this news organization.
These events could include ensuring that adolescents who exhibit signs of depression receive a proper assessment, receive medications if needed, and have access to psychotherapists who can help them. Without these supports in place, she said, a one-off depression screening may have limited benefit.
“There’s a lot of places where people could drop out of that care continuum,” Dr. Riehm said.
“One-time screening may not be enough,” said Trân Đoàn, PhD, MPH, a postdoctoral researcher in the University of Pittsburgh department of pediatrics.
Dr. Đoàn, who was not involved in the research, noted that the American Academy of Pediatrics recommends annual screening of all adolescents for depressive symptoms. Given that only 5% of the visits in this sample included any kind of depression screening, Dr. Đoàn said, some pediatric practices may not have felt they had the resources to adequately address positive screenings for depression.
Both Dr. Riehm and Dr. Đoàn are focusing on the link between depression screening and health outcomes. In her own doctoral work at the University of Michigan, Dr. Đoàn modeled the effects of universal annual depression screening in primary care settings on the health status of people aged 12-22 years. She is currently preparing this work for publication.
“I did find that, over the long term, there is improvement in health outcomes if we were to screen on an annual basis,” provided improved screening is coupled with comprehensive treatment plans, Dr. Đoàn said. The model’s health outcomes measures included an increase in life expectancy as well as a greater proportion of depression-free days among adolescents who receive appropriate treatment.
Dr. Riehm and Dr. Đoàn disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Screening adolescents for signs of depression does not reduce their emergency department visits, hospitalizations, or treatment for suicidal behaviors, according to research published in Preventive Medicine. Adolescents who underwent a depression screening were just as likely to need these services as those who did not.
In 2016, the U.S. Preventive Services Task Force recommended that adolescents aged 12-18 years be screened for major depressive disorder, provided that effective treatment options and follow-up strategies are in place.
“The main goal of depression screening is really to reduce adverse psychiatric outcomes. But I think a collateral hope is that, in reducing these adverse psychiatric outcomes, you would also reduce avoidable health services use,” such as ED visits or hospitalizations, said Kira Riehm, PhD, a postdoctoral fellow in epidemiology at Columbia University, New York, who led the research. Dr. Riehm designed the new study, which was part of her doctoral work at Johns Hopkins University, Baltimore, to test this premise.
Dr. Riehm and colleagues compared 14,433 adolescents aged 12-18 years who were screened for depression at least once during a wellness visit from 2014 to 2017 to 43,299 adolescents who were not screened for depression during such visits. Depression screenings were interspersed among a total of 281,463 adolescent wellness visits from 2014 to 2017, which represented 5% of all visits.
The researchers used diagnostic codes from a database of insurance claims to determine who had undergone depression screening. They then compared use of ED services, inpatient hospitalizations, and the number of treatments for suicidal behaviors between the two groups for the 2 years following the wellness visit.
The average age of the adolescents who underwent screening was 13-14 years, as was the average age of adolescents who were not screened. Both groups were evenly matched with respect to being male or female.
The researchers estimated that a high majority of adolescents in the sample were White (83%). Black persons represented 7% of the sample; Hispanic/Latino, 5%; and Asian, 3%. Insurance claims don’t always include racial and ethnicity data, Dr. Riehm said, so her group statistically imputed these proportions. The claims data also do not include details about which type of screening tool was used or the results of the screening, such as whether a teen exhibited mild or severe depression.
Adolescents in both groups were just as likely to go to the ED for any reason, be admitted to the hospital for any reason, or undergo treatment for suicidal behaviors. The researchers observed a slight association between being screened for depression and going to the ED specifically for a mental health reason (relative risk, 1.16; 95% confidence interval, 1.00-1.33). The sex of the adolescents had no bearing on whether they used these services.
“I think people think of [depression screening] as one event. But in reality, screening is a series of different events that all have to be happening in order for a screening program to work,” Dr. Riehm told this news organization.
These events could include ensuring that adolescents who exhibit signs of depression receive a proper assessment, receive medications if needed, and have access to psychotherapists who can help them. Without these supports in place, she said, a one-off depression screening may have limited benefit.
“There’s a lot of places where people could drop out of that care continuum,” Dr. Riehm said.
“One-time screening may not be enough,” said Trân Đoàn, PhD, MPH, a postdoctoral researcher in the University of Pittsburgh department of pediatrics.
Dr. Đoàn, who was not involved in the research, noted that the American Academy of Pediatrics recommends annual screening of all adolescents for depressive symptoms. Given that only 5% of the visits in this sample included any kind of depression screening, Dr. Đoàn said, some pediatric practices may not have felt they had the resources to adequately address positive screenings for depression.
Both Dr. Riehm and Dr. Đoàn are focusing on the link between depression screening and health outcomes. In her own doctoral work at the University of Michigan, Dr. Đoàn modeled the effects of universal annual depression screening in primary care settings on the health status of people aged 12-22 years. She is currently preparing this work for publication.
“I did find that, over the long term, there is improvement in health outcomes if we were to screen on an annual basis,” provided improved screening is coupled with comprehensive treatment plans, Dr. Đoàn said. The model’s health outcomes measures included an increase in life expectancy as well as a greater proportion of depression-free days among adolescents who receive appropriate treatment.
Dr. Riehm and Dr. Đoàn disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM PREVENTIVE MEDICINE
Transgender youth on hormone therapy risk substantial bone loss
, and this is true regardless of gender assignment at birth.
The problem worsens as the time during which these patients receive sex steroid hormones increases. So far, the “bone mineral density effects of these therapies are understudied,” warned Natalie Nokoff, MD, who presented a cross-sectional study at the annual meeting of the Endocrine Society.
The study of bone density is part of a larger body of research being conducted by Dr. Nokoff and her co-investigators on the long-term health effects of gender-affirming therapy in children and adolescents. In one of several recent studies, transgender youths taking gonadotropin-releasing hormone (GnRH) agonists, which effectively block puberty, were shown to be at greater risk of adverse changes in body composition and markers of cardiometabolic health than youths who were not taking them.
“We need more information on the optimal length of treatment with puberty-delaying medications before either discontinuation or introduction of gender-affirming hormones,” said Dr. Nokoff, an assistant professor of pediatrics and endocrinology at the University of Colorado School of Medicine, Aurora.
In this study, 56 transgender youth underwent total body dual-energy x-ray absorptiometry (DEXA). The patients ranged in age from 10 years to almost 20 years. Just over half (53%) were assigned female sex at birth.
The mean Z scores, signifying deviation from age-matched norms, were lower regardless of current use or past use of GnRH agonists in both transgender males or transgender females, relative to age-matched norms.
Asked to comment, Michele A. O’Connell, MBBCh, department of endocrinology and diabetes, Royal Children’s Hospital, Victoria, Australia, said the risk of bone loss is real.
“Monitoring of bone health is recommended for all transgender-diverse adolescents treated with gonadotropin-releasing hormone agonists,” said Dr. O’Connell. He referred to multiple guidelines, including those issued by the World Professional Association of Transgender Health in 2012 and those from the Endocrine Society that were issued in 2017.
Inverse correlation between duration of GnRH agonist therapy and Z scores
In Dr. Nokoff’s study, for transgender males, the BMD Z score was reduced 0.2 relative to male norms and by 0.4 relative to female norms. For transgender females, the scores were reduced by 0.4 relative to male norms and by 0.2 relative to female norms.
Among transgender males who were taking testosterone and who had previously been exposed to GnRH agonists, the Z score was significantly lower than those taking testosterone alone (P = .004). There were no differences in Z score for transgender females taking estradiol alone relative to estradiol with current or past use of GnRH agonists.
There was a significant inverse correlation for duration of GnRH agonist therapy and Z scores for transgender females relative to male norms (P = .005) or female norms (P = .029). However, Z scores were unrelated to length of time receiving testosterone or estradiol therapy or to sex steroid concentrations.
The number of children and adolescents taking puberty-delaying or gender-affirming therapies is increasing. Although reliable data are limited, the exploration of gender identify appears to have become more common with the growing social acceptance of gender dysphoria. That term refers to a sense of unease among individuals who feel that their biological sex does not match their gender identity, according to Dr. Nokoff.
“It is now estimated that 2% of youths identify as transgender,” she said.
Findings from studies investigating the relationship between gender-affirming therapy and bone loss among adults have not been consistent. In a single-center study that followed 543 transgender men and 711 transgender women who had undergone DEXA scanning at baseline prior to starting hormone therapy, there did not appear to be any substantial negative effects on lumbar bone density over time (J Bone Min Res. 2018 Dec;34:447-54).
For adolescents, there is growing evidence of the risk of bone loss in relation to gender-affirming therapy, but there is limited agreement on clinical risks and how they can be avoided. Relevant variables include genetics and diet, as well as the types, doses, and length of time receiving gender-affirming therapy.
Monitor bone in transgender youth; Use vitamin D and weight-bearing exercise
Dr. O’Connell is the first author of a recent summary of the pharmacologic management of trans and gender-diverse adolescents. That summary covered multiple topics in addition to risk of bone loss, including the impact on growth, cognition, and mental health (J Clin Endocrinol Metab. 2022 Jan;107:241-257).
Overall, she believes that bone health should be monitored for children receiving puberty-delaying or gender-affirming therapies but agrees with Dr. Nokoff that the clinical impact remains poorly defined.
“Long-term follow-up studies will be required to assess the impact, if any, on functional outcomes such as fracture risk,” she reported. Still, she encouraged use of standard ways of improving bone health, including adequate vitamin D intake and weight-bearing exercise.
Dr. Nokoff and Dr. O’Connell have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, and this is true regardless of gender assignment at birth.
The problem worsens as the time during which these patients receive sex steroid hormones increases. So far, the “bone mineral density effects of these therapies are understudied,” warned Natalie Nokoff, MD, who presented a cross-sectional study at the annual meeting of the Endocrine Society.
The study of bone density is part of a larger body of research being conducted by Dr. Nokoff and her co-investigators on the long-term health effects of gender-affirming therapy in children and adolescents. In one of several recent studies, transgender youths taking gonadotropin-releasing hormone (GnRH) agonists, which effectively block puberty, were shown to be at greater risk of adverse changes in body composition and markers of cardiometabolic health than youths who were not taking them.
“We need more information on the optimal length of treatment with puberty-delaying medications before either discontinuation or introduction of gender-affirming hormones,” said Dr. Nokoff, an assistant professor of pediatrics and endocrinology at the University of Colorado School of Medicine, Aurora.
In this study, 56 transgender youth underwent total body dual-energy x-ray absorptiometry (DEXA). The patients ranged in age from 10 years to almost 20 years. Just over half (53%) were assigned female sex at birth.
The mean Z scores, signifying deviation from age-matched norms, were lower regardless of current use or past use of GnRH agonists in both transgender males or transgender females, relative to age-matched norms.
Asked to comment, Michele A. O’Connell, MBBCh, department of endocrinology and diabetes, Royal Children’s Hospital, Victoria, Australia, said the risk of bone loss is real.
“Monitoring of bone health is recommended for all transgender-diverse adolescents treated with gonadotropin-releasing hormone agonists,” said Dr. O’Connell. He referred to multiple guidelines, including those issued by the World Professional Association of Transgender Health in 2012 and those from the Endocrine Society that were issued in 2017.
Inverse correlation between duration of GnRH agonist therapy and Z scores
In Dr. Nokoff’s study, for transgender males, the BMD Z score was reduced 0.2 relative to male norms and by 0.4 relative to female norms. For transgender females, the scores were reduced by 0.4 relative to male norms and by 0.2 relative to female norms.
Among transgender males who were taking testosterone and who had previously been exposed to GnRH agonists, the Z score was significantly lower than those taking testosterone alone (P = .004). There were no differences in Z score for transgender females taking estradiol alone relative to estradiol with current or past use of GnRH agonists.
There was a significant inverse correlation for duration of GnRH agonist therapy and Z scores for transgender females relative to male norms (P = .005) or female norms (P = .029). However, Z scores were unrelated to length of time receiving testosterone or estradiol therapy or to sex steroid concentrations.
The number of children and adolescents taking puberty-delaying or gender-affirming therapies is increasing. Although reliable data are limited, the exploration of gender identify appears to have become more common with the growing social acceptance of gender dysphoria. That term refers to a sense of unease among individuals who feel that their biological sex does not match their gender identity, according to Dr. Nokoff.
“It is now estimated that 2% of youths identify as transgender,” she said.
Findings from studies investigating the relationship between gender-affirming therapy and bone loss among adults have not been consistent. In a single-center study that followed 543 transgender men and 711 transgender women who had undergone DEXA scanning at baseline prior to starting hormone therapy, there did not appear to be any substantial negative effects on lumbar bone density over time (J Bone Min Res. 2018 Dec;34:447-54).
For adolescents, there is growing evidence of the risk of bone loss in relation to gender-affirming therapy, but there is limited agreement on clinical risks and how they can be avoided. Relevant variables include genetics and diet, as well as the types, doses, and length of time receiving gender-affirming therapy.
Monitor bone in transgender youth; Use vitamin D and weight-bearing exercise
Dr. O’Connell is the first author of a recent summary of the pharmacologic management of trans and gender-diverse adolescents. That summary covered multiple topics in addition to risk of bone loss, including the impact on growth, cognition, and mental health (J Clin Endocrinol Metab. 2022 Jan;107:241-257).
Overall, she believes that bone health should be monitored for children receiving puberty-delaying or gender-affirming therapies but agrees with Dr. Nokoff that the clinical impact remains poorly defined.
“Long-term follow-up studies will be required to assess the impact, if any, on functional outcomes such as fracture risk,” she reported. Still, she encouraged use of standard ways of improving bone health, including adequate vitamin D intake and weight-bearing exercise.
Dr. Nokoff and Dr. O’Connell have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, and this is true regardless of gender assignment at birth.
The problem worsens as the time during which these patients receive sex steroid hormones increases. So far, the “bone mineral density effects of these therapies are understudied,” warned Natalie Nokoff, MD, who presented a cross-sectional study at the annual meeting of the Endocrine Society.
The study of bone density is part of a larger body of research being conducted by Dr. Nokoff and her co-investigators on the long-term health effects of gender-affirming therapy in children and adolescents. In one of several recent studies, transgender youths taking gonadotropin-releasing hormone (GnRH) agonists, which effectively block puberty, were shown to be at greater risk of adverse changes in body composition and markers of cardiometabolic health than youths who were not taking them.
“We need more information on the optimal length of treatment with puberty-delaying medications before either discontinuation or introduction of gender-affirming hormones,” said Dr. Nokoff, an assistant professor of pediatrics and endocrinology at the University of Colorado School of Medicine, Aurora.
In this study, 56 transgender youth underwent total body dual-energy x-ray absorptiometry (DEXA). The patients ranged in age from 10 years to almost 20 years. Just over half (53%) were assigned female sex at birth.
The mean Z scores, signifying deviation from age-matched norms, were lower regardless of current use or past use of GnRH agonists in both transgender males or transgender females, relative to age-matched norms.
Asked to comment, Michele A. O’Connell, MBBCh, department of endocrinology and diabetes, Royal Children’s Hospital, Victoria, Australia, said the risk of bone loss is real.
“Monitoring of bone health is recommended for all transgender-diverse adolescents treated with gonadotropin-releasing hormone agonists,” said Dr. O’Connell. He referred to multiple guidelines, including those issued by the World Professional Association of Transgender Health in 2012 and those from the Endocrine Society that were issued in 2017.
Inverse correlation between duration of GnRH agonist therapy and Z scores
In Dr. Nokoff’s study, for transgender males, the BMD Z score was reduced 0.2 relative to male norms and by 0.4 relative to female norms. For transgender females, the scores were reduced by 0.4 relative to male norms and by 0.2 relative to female norms.
Among transgender males who were taking testosterone and who had previously been exposed to GnRH agonists, the Z score was significantly lower than those taking testosterone alone (P = .004). There were no differences in Z score for transgender females taking estradiol alone relative to estradiol with current or past use of GnRH agonists.
There was a significant inverse correlation for duration of GnRH agonist therapy and Z scores for transgender females relative to male norms (P = .005) or female norms (P = .029). However, Z scores were unrelated to length of time receiving testosterone or estradiol therapy or to sex steroid concentrations.
The number of children and adolescents taking puberty-delaying or gender-affirming therapies is increasing. Although reliable data are limited, the exploration of gender identify appears to have become more common with the growing social acceptance of gender dysphoria. That term refers to a sense of unease among individuals who feel that their biological sex does not match their gender identity, according to Dr. Nokoff.
“It is now estimated that 2% of youths identify as transgender,” she said.
Findings from studies investigating the relationship between gender-affirming therapy and bone loss among adults have not been consistent. In a single-center study that followed 543 transgender men and 711 transgender women who had undergone DEXA scanning at baseline prior to starting hormone therapy, there did not appear to be any substantial negative effects on lumbar bone density over time (J Bone Min Res. 2018 Dec;34:447-54).
For adolescents, there is growing evidence of the risk of bone loss in relation to gender-affirming therapy, but there is limited agreement on clinical risks and how they can be avoided. Relevant variables include genetics and diet, as well as the types, doses, and length of time receiving gender-affirming therapy.
Monitor bone in transgender youth; Use vitamin D and weight-bearing exercise
Dr. O’Connell is the first author of a recent summary of the pharmacologic management of trans and gender-diverse adolescents. That summary covered multiple topics in addition to risk of bone loss, including the impact on growth, cognition, and mental health (J Clin Endocrinol Metab. 2022 Jan;107:241-257).
Overall, she believes that bone health should be monitored for children receiving puberty-delaying or gender-affirming therapies but agrees with Dr. Nokoff that the clinical impact remains poorly defined.
“Long-term follow-up studies will be required to assess the impact, if any, on functional outcomes such as fracture risk,” she reported. Still, she encouraged use of standard ways of improving bone health, including adequate vitamin D intake and weight-bearing exercise.
Dr. Nokoff and Dr. O’Connell have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM ENDO 2022
Are social networks threatening adolescents’ mental health?
When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.
In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
‘Facebook depression’
Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?
Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.
“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.
“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
Teens’ fantasy life
There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.
This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.
However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.
The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.
Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).
“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
Language of distress
Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.
The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.
According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
Internet risks and dangers
Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”
Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.
Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.
Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.
A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.
The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.
“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.
But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.
Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).
Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
Support on social networks?
Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.
The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.
Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.
“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.
They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”
An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
Promoting access to care
In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.
“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”
These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.
On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.
The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.
Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
Professionals go digital
France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.
Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”
Dr. Morgiève said she has no conflicts of interest regarding the subject presented.
This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.
When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.
In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
‘Facebook depression’
Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?
Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.
“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.
“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
Teens’ fantasy life
There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.
This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.
However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.
The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.
Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).
“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
Language of distress
Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.
The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.
According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
Internet risks and dangers
Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”
Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.
Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.
Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.
A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.
The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.
“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.
But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.
Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).
Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
Support on social networks?
Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.
The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.
Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.
“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.
They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”
An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
Promoting access to care
In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.
“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”
These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.
On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.
The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.
Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
Professionals go digital
France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.
Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”
Dr. Morgiève said she has no conflicts of interest regarding the subject presented.
This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.
When it comes to the link between mental health and social networks, be careful of jumping to conclusions. This warning came from Margot Morgiève, PhD, sociology researcher at the French National Institute of Health and Medical Research and the Center for Research in Medicine, Science, Health, Mental Health, and Society (Inserm-Cermes 3). She delivered her remarks at the opening session of the Pediatric Societies Congress organized by the French Society of Pediatrics, based on an increasing amount of scientific literature on the subject.
In 2021, 4.2 billion people, or more than half the world’s population, used social networks, and 80.3% of French citizens had a social network account.
‘Facebook depression’
Between those who condemn social networks for causing problems in adolescents and those who, in contrast, view it as a lifeline, what do we really know about their impact on the mental health of young people?
Although several studies have found a significant association between the heavy use of social networks and anxiety, depressive symptoms, and stress, there have also been reports of decreased life satisfaction, as well as reduced general well-being and self-esteem.
“Due to an increased [concurrence] between mood disorders or depression and the use of social networks, researchers wanted to establish a new disorder: ‘Facebook Depression,’ ” commented Dr. Morgiève, who is also a clinical psychologist and coordinator of the chat and social network unit for the French national suicide prevention hotline 3114.
“But they quickly realized that it would be wrong to recognize it as a characterized disorder, because it would appear that the harmful effects of social networks on mental health are not linked to the social network itself, but rather to problematic social network use.”
Teens’ fantasy life
There are three major categories of problematic social network use, the first being social comparison. This refers to the spontaneous tendency of social beings to compare themselves to individuals who appear to be more attractive than them.
This is nothing new, but it is exacerbated on social networks. Users emphasize the positive aspects of their life and present themselves as balanced, popular, and satisfied.
However, this leads to strong normative constraints, which result in a negative self-assessment, thereby lowering self-esteem and promoting the emergence of depressive symptoms. “Thus, it isn’t the social network that creates depression, but rather the phenomenon of comparison, which it pushes to the extreme,” said Dr. Morgiève.
The second problem associated with social networks is their propensity to promote addictive behavior through [observational learning], which can give rise to compulsive and uncontrolled behavior, as illustrated by “FOMO,” or fear of missing out.
Hence the idea of defining a specific entity called “social network addiction,” which was also quickly abandoned. It is the very features of social networks that generate this fear and thus this tendency, just like news feeds (constant updating of a personalized news list).
“Substitutive” use is the third major category. This is when time spent in the online environment replaces that spent offline. Excessive users report a feeling of loneliness and an awareness of a lack of intimate connections.
Language of distress
Initial studies using artificial intelligence and machine learning tend to show that a digital language of distress exists. Authors noticed that themes associated with self-loathing, loneliness, suicide, death, and self-harm correlated with users who exhibited the highest levels of depression.
The very structure of the language (more words, more use of “I,” more references to death, and fewer verbs) correlated with users in distress.
According to the authors, the typical social network practice of vaguebooking – writing a post that may incite worry, such as “better days are coming” – is a significant predictive factor of suicidal ideation. A visual language of distress also reportedly exists – for example, the use of darker shades, like the black-and-white inkwell filter with no enhancements in Instagram.
Internet risks and dangers
Digital environments entail many risks and dangers. Suicide pacts and online suicides (like the suicide of a young girl on Periscope in 2016) remain rare but go viral. The same is true of challenges. In 2015, the Blue Whale Challenge consisted of a list of 50 challenges ranging from the benign to the dramatic, with the final challenge being to “hang yourself.”
Its huge media coverage might well have added to its viral success had the social networks not quickly reacted in a positive manner.
Trolling, for its part, consists of posting provocative content with the intent of either sparking conflict or causing distress.
Cyberbullying, the most common online risk adolescents face, is the repeated spreading of false, embarrassing, or hostile information.
A growing danger is sexting (sending, receiving, or passing on sexually explicit photographs, messages, or images). The serious potential consequences of sexting include revenge porn or cyber rape, which is defined as the distribution of illicit content without consent, the practice of which has been linked to depression and involvement in risky behavior.
The risk of suicide exposure should no longer be overlooked, in view of the hypothesis that some online content relating to suicide may produce a suggestive effect with respect to the idea or the method of suicide, as well as precipitating suicide attempts.
“People who post suicidal comments are in communities that are closely connected by bonds of affiliation (memberships, friendships) and activities (retweets, likes, comments),” explained Dr. Morgiève.
But in these communities, emotionally charged information that spreads rapidly and repetitively could promote corumination, hence the concept of “suicidocosme [suicide world]», developed in 2017 by Charles-Edouard Notredame, MD, of the child and adolescent psychiatry department at Lille (France) University Hospital. This, in turn, can produce and increase the suicide contagion based on the Werther effect model.
Just one of many examples is Marilyn Monroe’s suicide in 1962, which increased the suicide rate by 40% in Los Angeles. The Werther effect is especially significant because two biases are present: the prestige bias (identification with the person one admires) and similarity bias (identification with the person who resembles me).
Similarity bias is the most decisive in adolescence. It should be noted that the positive counterpart to the Werther effect is the Papageno effect. The Belgian singer-songwriter Stromae’s TV appearances earlier this year, in which he spoke about his suicidal ideations, enabling young people to recognize their suffering and seek help, is an example of the Papageno effect.
Support on social networks?
Social networks can increase connectedness, for example, the feeling of being connected to something meaningful outside oneself. Connectedness promotes psychological well-being and quality of life.
The very characteristics of social networks can enhance elements of connectedness, both objectively by increasing users’ social sphere, and subjectively by reinforcing the feeling of social belonging and subjective well-being.
Taking Facebook and its “anniversary” feature as an example, it has been shown that the greater the number of Facebook friends, the more individuals saw themselves as being connected to a community.
“Millennials, or people born between the beginning of the 1980s and the end of the 1990s, are thus more likely to take advantage of the digital social environment to establish a new relationship with psychological suffering and its attempts to ease it,” said Dr. Morgiève.
They are also more likely to naturally turn to the digital space to look for help. More and more of them are searching the Internet for information on mental health and sharing experiences to get support.”
An example is the It Gets Better Project, which is a good illustration of the structure of online peer communities, with stories from LGBTQ+ individuals who describe how they succeeded in coping with adversity during their adolescence. In this way, social media seems to help identify peers and positive resources that are usually unavailable outside of the digital space. As a result, thanks to normative models on extremely strong social networks that are easy to conform to, these online peer-support communities have the potential to facilitate social interactions and reinforce a feeling both of hope and of belonging to a group.”
Promoting access to care
In Dr. Morgiève’s opinion, “access to care, particularly in the area of adolescent mental health, is extremely critical, given the lack of support precisely when they need it the most, as [evidenced] by the number of suicide attempts.
“There are two types of barriers to seeking help which can explain this. The first is structural barriers: help is too expensive or too far away or the wait is too long. The second refers to personal barriers, including denying the need for help, which may involve a self-sufficiency bias, the feeling that one cannot be helped, refusal to bother close friends and family, fear of being stigmatized, and a feeling of shame.”
These types of barriers are particularly difficult to overcome because the beliefs regarding care and caregivers are limiting (doubts about caregiver confidentiality, reliability, and competence). This is observed especially in adolescents because of the desire for emancipation and development of identity. So [the help relationship] may be experienced as subordination or alienation.
On a positive note, it is the very properties of social networks that will enable these obstacles to seeking help to be overcome. The fact that they are available everywhere makes up for young people’s lack of mobility and regional disparities. In addition, it ensures discretion and freedom of use, while reducing inhibitions.
The fact that social networks are free of charge overcomes structural obstacles, such as financial and organizational costs, as well as personal obstacles, thereby facilitating engagement and lessening the motivational cost. The dissociative pseudonymity or anonymity reduces the feeling of vulnerability associated with revealing oneself, as well as fears of a breach of confidentiality.
Dr. Morgiève summed it up by saying: “While offline life is silent because young people don’t talk about their suicidal ideations, online life truly removes inhibitions about speaking, relationships, and sharing experiences. Thus, the internet offers adolescents new opportunities to express themselves, which they’re not doing in real life.”
Professionals go digital
France records one suicide every hour (8,885 deaths a year) and one suicide attempt every 4 minutes. Since the 1950s, government-funded telehealth prevention and assistance programs, such as S.O.S. Amitié, Suicide Écoute, SOS Suicide Phénix, etc., have been developed. Their values and principles are anonymity, nondirectivity, nonjudgment, and neutrality. In addition to these nonprofit offerings, a professional teleprevention program, the confidential suicide prevention hotline 3114 – with professionals who are available to listen 24 hours a day, 7 days a week – was launched by the Ministry of Health and Prevention in October 2021.
Its values and principles include confidentiality, proactivity, concern, and caring for others. To date, 13 of 17 centers have opened. In the space of 6 months, they have received 50,000 calls, with an average of 400-500 calls a day. The dedicated chat application was codesigned with users (suicide attempters). And now social networks are joining in. For example, the hotline number 3114 appears whenever a TikTok user types the word “suicide.”
Dr. Morgiève said she has no conflicts of interest regarding the subject presented.
This article was translated from the Medscape French edition. A version of this article first appeared on Medscape.com.
Caring for the young elite athlete
Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.
A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).
An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.
Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.
Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.
Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.
We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.
When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.
A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).
An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.
Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.
Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.
Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.
We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.
When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Concerns about the potential harm resulting from overzealous training regimens and performance schedules for young elite athletes seems to come in cycles much like the Olympics. But, more recently, the media attention has become more intense fueled by the very visible psychological vulnerabilities of some young gymnasts, tennis players, and figure skaters. Accusations of physical and psychological abuse by team physicians and coaches continue to surface with troubling regularity.
A recent article in the Wall St. Journal explores a variety of initiatives aimed at redefining the relationship between youth sports and the physical and mental health of its elite athletes. (Louise Radnofsky, The Wall Street Journal, June 9, 2022).
An example of the new awareness is the recent invitation of Peter Donnelly, PhD, an emeritus professor at the University of Toronto and long-time advocate for regulatory protections for youth athletes, to deliver a paper at a global conference in South Africa devoted to the elimination of child labor. Referring to youth sports, Dr. Donnelly observes “What if McDonalds had the same accident rate? ... There would be huge commissions of inquiry, regulations, and policies.” He suggests that the United Nations Convention on the Rights of the Child might be a mechanism to address the problem.
Writing in the Marquette University Sports Law Review in 2015, Kristin Hoffman, a law student at the time, suggested that the federal Fair Labor Standards Act or state child labor laws could be used to restructure sports like gymnastics or figure skating with tarnished histories. California law prohibits child actors from working more than 5 hours a day on school days and 7 hours on nonschool days but says little about child athletes. On paper, the National Collegiate Athletic Association limits college athletes to 20 hours participation per week but teenagers on club teams are not limited and may sometimes practice 30 hours or more.
Regulation in any form is a tough sell in this country. Coaches, parents, and athletes caught up in the myth that more repetitions and more touches on the ball are always the ticket to success will argue that most elite athletes are self-motivated and don’t view the long hours as a hardship.
Exactly how many are self-driven and how many are being pushed by parents and coaches is unknown. Across the street from us lived a young girl who, despite not having the obvious physical gifts, was clearly committed to excel in sports. She begged her parents to set up lights to allow her to practice well into the evening. She went on to have a good college career as a player and a very successful career as a Division I coach. Now in retirement, she is very open about her mental health history that in large part explains her inner drive and her subsequent troubles.
We need to be realistic in our hope for regulating the current state of youth sports out of its current situation. State laws that put reasonable limits on the hourly commitment to sports much like the California child actor laws feel like a reasonable goal. However, as physicians for these young athletes we must take each child – and we must remind ourselves that they are still children – as an individual.
When faced with patients who are clearly on the elite sport pathway, our goal is to protect their health – both physical and mental. If they are having symptoms of overuse we need to help them find alternative activities that will rest their injuries but still allow them to satisfy their competitive zeal. However, we must be ever alert to the risk that what appears to be unusual self-motivation may be instead a warning that pathologic obsession and compulsion lurk below the surface.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Mobile devices ‘addictive by design’: Obesity is one of many health effects
Wireless devices, like smart phones and tablets, appear to induce compulsive or even addictive use in many individuals, leading to adverse health consequences that are likely to be curtailed only through often difficult behavior modification, according to a pediatric endocrinologist’s take on the problem.
While the summary was based in part on the analysis of 234 published papers drawn from the medical literature, the lead author, Nidhi Gupta, MD, said the data reinforce her own clinical experience.
“As a pediatric endocrinologist, the trend in smartphone-associated health disorders, such as obesity, sleep, and behavior issues, worries me,” Dr. Gupta, director of KAP Pediatric Endocrinology, Nashville, Tenn., said at the annual meeting of the Endocrine Society.
Based on her search of the medical literature, the available data raise concern. In one study she cited, for example, each hour per day of screen time was found to translate into a body mass index increase of 0.5 to 0.7 kg/m2 (P < .001).
With this type of progressive rise in BMI comes prediabetes, dyslipidemia, and other metabolic disorders associated with major health risks, including cardiovascular disease. And there are others. Dr. Gupta cited data suggesting screen time before bed disturbs sleep, which has its own set of health risks.
“When I say health, it includes physical health, mental health, and emotional health,” said Dr. Gupta.
In the U.S. and other countries with a growing obesity epidemic, lack of physical activity and unhealthy eating are widely considered the major culprits. Excessive screen time contributes to both.
“When we are engaged with our devices, we are often snacking subconsciously and not very mindful that we are making unhealthy choices,” Dr. Gupta said.
The problem is that there is a vicious circle. Compulsive use of devices follows the same loop as other types of addictive behaviors, according to Dr. Gupta. She traced overuse of wireless devices to the dopaminergic system, which is a powerful neuroendocrine-mediated process of craving, response, and reward.
Like fat, sugar, and salt, which provoke a neuroendocrine reward signal, the chimes and buzzes of a cell phone provide their own cues for reward in the form of a dopamine surge. As a result, these become the “triggers of an irresistible and irrational urge to check our device that makes the dopamine go high in our brain,” Dr. Gupta explained.
Although the vicious cycle can be thwarted by turning off the device, Dr. Gupta characterized this as “impractical” when smartphones are so vital to daily communication. Rather, Dr. Gupta advocated a program of moderation, reserving the phone for useful tasks without succumbing to the siren song of apps that waste time.
The most conspicuous culprit is social media, which Dr. Gupta considers to be among the most Pavlovian triggers of cell phone addiction. However, she acknowledged that participation in social media has its justifications.
“I, myself, use social media for my own branding and marketing,” Dr. Gupta said.
The problem that users have is distinguishing between screen time that does and does not have value, according to Dr. Gupta. She indicated that many of those overusing their smart devices are being driven by the dopaminergic reward system, which is generally divorced from the real goals of life, such as personal satisfaction and activity that is rewarding monetarily or in other ways.
“I am not asking for these devices to be thrown out the window. I am advocating for moderation, balance, and real-life engagement,” Dr. Gupta said at the meeting, held in Atlanta and virtually.
She outlined a long list of practical suggestions, including turning off the alarms, chimes, and messages that engage the user into the vicious dopaminergic-reward system loop. She suggested mindfulness so that the user can distinguish between valuable device use and activity that is simply procrastination.
“The devices are designed to be addictive. They are designed to manipulate our brain,” she said. “Eliminate the reward. Let’s try to make our devices boring, unappealing, or enticing so that they only work as tools.”
The medical literature is filled with data that support the potential harms of excessive screen use, leading many others to make some of the same points. In 2017, Thomas N. Robinson, MD, professor of child health at Stanford (Calif.) University, reviewed data showing an association between screen media exposure and obesity in children and adolescents.
“This is an area crying out for more research,” Dr. Robinson said in an interview. The problem of screen time, sedentary behavior, and weight gain has been an issue since the television was invented, which was the point he made in his 2017 paper, but he agreed that the problem is only getting worse.
“Digital technology has become ubiquitous, touching nearly every aspect of people’s lives,” he said. Yet, as evidence grows that overuse of this technology can be harmful, it is creating a problem without a clear solution.
“There are few data about the efficacy of specific strategies to reduce harmful impacts of digital screen use,” he said.
While some of the solutions that Dr. Gupta described make sense, they are more easily described than executed. The dopaminergic reward system is strong and largely experienced subconsciously. Recruiting patients to recognize that dopaminergic rewards are not rewards in any true sense is already a challenge. Enlisting patients to take the difficult steps to avoid the behavioral cues might be even more difficult.
Dr. Gupta and Dr. Robinson report no potential conflicts of interest.
Wireless devices, like smart phones and tablets, appear to induce compulsive or even addictive use in many individuals, leading to adverse health consequences that are likely to be curtailed only through often difficult behavior modification, according to a pediatric endocrinologist’s take on the problem.
While the summary was based in part on the analysis of 234 published papers drawn from the medical literature, the lead author, Nidhi Gupta, MD, said the data reinforce her own clinical experience.
“As a pediatric endocrinologist, the trend in smartphone-associated health disorders, such as obesity, sleep, and behavior issues, worries me,” Dr. Gupta, director of KAP Pediatric Endocrinology, Nashville, Tenn., said at the annual meeting of the Endocrine Society.
Based on her search of the medical literature, the available data raise concern. In one study she cited, for example, each hour per day of screen time was found to translate into a body mass index increase of 0.5 to 0.7 kg/m2 (P < .001).
With this type of progressive rise in BMI comes prediabetes, dyslipidemia, and other metabolic disorders associated with major health risks, including cardiovascular disease. And there are others. Dr. Gupta cited data suggesting screen time before bed disturbs sleep, which has its own set of health risks.
“When I say health, it includes physical health, mental health, and emotional health,” said Dr. Gupta.
In the U.S. and other countries with a growing obesity epidemic, lack of physical activity and unhealthy eating are widely considered the major culprits. Excessive screen time contributes to both.
“When we are engaged with our devices, we are often snacking subconsciously and not very mindful that we are making unhealthy choices,” Dr. Gupta said.
The problem is that there is a vicious circle. Compulsive use of devices follows the same loop as other types of addictive behaviors, according to Dr. Gupta. She traced overuse of wireless devices to the dopaminergic system, which is a powerful neuroendocrine-mediated process of craving, response, and reward.
Like fat, sugar, and salt, which provoke a neuroendocrine reward signal, the chimes and buzzes of a cell phone provide their own cues for reward in the form of a dopamine surge. As a result, these become the “triggers of an irresistible and irrational urge to check our device that makes the dopamine go high in our brain,” Dr. Gupta explained.
Although the vicious cycle can be thwarted by turning off the device, Dr. Gupta characterized this as “impractical” when smartphones are so vital to daily communication. Rather, Dr. Gupta advocated a program of moderation, reserving the phone for useful tasks without succumbing to the siren song of apps that waste time.
The most conspicuous culprit is social media, which Dr. Gupta considers to be among the most Pavlovian triggers of cell phone addiction. However, she acknowledged that participation in social media has its justifications.
“I, myself, use social media for my own branding and marketing,” Dr. Gupta said.
The problem that users have is distinguishing between screen time that does and does not have value, according to Dr. Gupta. She indicated that many of those overusing their smart devices are being driven by the dopaminergic reward system, which is generally divorced from the real goals of life, such as personal satisfaction and activity that is rewarding monetarily or in other ways.
“I am not asking for these devices to be thrown out the window. I am advocating for moderation, balance, and real-life engagement,” Dr. Gupta said at the meeting, held in Atlanta and virtually.
She outlined a long list of practical suggestions, including turning off the alarms, chimes, and messages that engage the user into the vicious dopaminergic-reward system loop. She suggested mindfulness so that the user can distinguish between valuable device use and activity that is simply procrastination.
“The devices are designed to be addictive. They are designed to manipulate our brain,” she said. “Eliminate the reward. Let’s try to make our devices boring, unappealing, or enticing so that they only work as tools.”
The medical literature is filled with data that support the potential harms of excessive screen use, leading many others to make some of the same points. In 2017, Thomas N. Robinson, MD, professor of child health at Stanford (Calif.) University, reviewed data showing an association between screen media exposure and obesity in children and adolescents.
“This is an area crying out for more research,” Dr. Robinson said in an interview. The problem of screen time, sedentary behavior, and weight gain has been an issue since the television was invented, which was the point he made in his 2017 paper, but he agreed that the problem is only getting worse.
“Digital technology has become ubiquitous, touching nearly every aspect of people’s lives,” he said. Yet, as evidence grows that overuse of this technology can be harmful, it is creating a problem without a clear solution.
“There are few data about the efficacy of specific strategies to reduce harmful impacts of digital screen use,” he said.
While some of the solutions that Dr. Gupta described make sense, they are more easily described than executed. The dopaminergic reward system is strong and largely experienced subconsciously. Recruiting patients to recognize that dopaminergic rewards are not rewards in any true sense is already a challenge. Enlisting patients to take the difficult steps to avoid the behavioral cues might be even more difficult.
Dr. Gupta and Dr. Robinson report no potential conflicts of interest.
Wireless devices, like smart phones and tablets, appear to induce compulsive or even addictive use in many individuals, leading to adverse health consequences that are likely to be curtailed only through often difficult behavior modification, according to a pediatric endocrinologist’s take on the problem.
While the summary was based in part on the analysis of 234 published papers drawn from the medical literature, the lead author, Nidhi Gupta, MD, said the data reinforce her own clinical experience.
“As a pediatric endocrinologist, the trend in smartphone-associated health disorders, such as obesity, sleep, and behavior issues, worries me,” Dr. Gupta, director of KAP Pediatric Endocrinology, Nashville, Tenn., said at the annual meeting of the Endocrine Society.
Based on her search of the medical literature, the available data raise concern. In one study she cited, for example, each hour per day of screen time was found to translate into a body mass index increase of 0.5 to 0.7 kg/m2 (P < .001).
With this type of progressive rise in BMI comes prediabetes, dyslipidemia, and other metabolic disorders associated with major health risks, including cardiovascular disease. And there are others. Dr. Gupta cited data suggesting screen time before bed disturbs sleep, which has its own set of health risks.
“When I say health, it includes physical health, mental health, and emotional health,” said Dr. Gupta.
In the U.S. and other countries with a growing obesity epidemic, lack of physical activity and unhealthy eating are widely considered the major culprits. Excessive screen time contributes to both.
“When we are engaged with our devices, we are often snacking subconsciously and not very mindful that we are making unhealthy choices,” Dr. Gupta said.
The problem is that there is a vicious circle. Compulsive use of devices follows the same loop as other types of addictive behaviors, according to Dr. Gupta. She traced overuse of wireless devices to the dopaminergic system, which is a powerful neuroendocrine-mediated process of craving, response, and reward.
Like fat, sugar, and salt, which provoke a neuroendocrine reward signal, the chimes and buzzes of a cell phone provide their own cues for reward in the form of a dopamine surge. As a result, these become the “triggers of an irresistible and irrational urge to check our device that makes the dopamine go high in our brain,” Dr. Gupta explained.
Although the vicious cycle can be thwarted by turning off the device, Dr. Gupta characterized this as “impractical” when smartphones are so vital to daily communication. Rather, Dr. Gupta advocated a program of moderation, reserving the phone for useful tasks without succumbing to the siren song of apps that waste time.
The most conspicuous culprit is social media, which Dr. Gupta considers to be among the most Pavlovian triggers of cell phone addiction. However, she acknowledged that participation in social media has its justifications.
“I, myself, use social media for my own branding and marketing,” Dr. Gupta said.
The problem that users have is distinguishing between screen time that does and does not have value, according to Dr. Gupta. She indicated that many of those overusing their smart devices are being driven by the dopaminergic reward system, which is generally divorced from the real goals of life, such as personal satisfaction and activity that is rewarding monetarily or in other ways.
“I am not asking for these devices to be thrown out the window. I am advocating for moderation, balance, and real-life engagement,” Dr. Gupta said at the meeting, held in Atlanta and virtually.
She outlined a long list of practical suggestions, including turning off the alarms, chimes, and messages that engage the user into the vicious dopaminergic-reward system loop. She suggested mindfulness so that the user can distinguish between valuable device use and activity that is simply procrastination.
“The devices are designed to be addictive. They are designed to manipulate our brain,” she said. “Eliminate the reward. Let’s try to make our devices boring, unappealing, or enticing so that they only work as tools.”
The medical literature is filled with data that support the potential harms of excessive screen use, leading many others to make some of the same points. In 2017, Thomas N. Robinson, MD, professor of child health at Stanford (Calif.) University, reviewed data showing an association between screen media exposure and obesity in children and adolescents.
“This is an area crying out for more research,” Dr. Robinson said in an interview. The problem of screen time, sedentary behavior, and weight gain has been an issue since the television was invented, which was the point he made in his 2017 paper, but he agreed that the problem is only getting worse.
“Digital technology has become ubiquitous, touching nearly every aspect of people’s lives,” he said. Yet, as evidence grows that overuse of this technology can be harmful, it is creating a problem without a clear solution.
“There are few data about the efficacy of specific strategies to reduce harmful impacts of digital screen use,” he said.
While some of the solutions that Dr. Gupta described make sense, they are more easily described than executed. The dopaminergic reward system is strong and largely experienced subconsciously. Recruiting patients to recognize that dopaminergic rewards are not rewards in any true sense is already a challenge. Enlisting patients to take the difficult steps to avoid the behavioral cues might be even more difficult.
Dr. Gupta and Dr. Robinson report no potential conflicts of interest.
FROM ENDO 2022
Anorexia linked to notable shrinkage of key brain structures
, a new brain imaging study shows.
The reductions of cortical thickness, subcortical volumes, and cortical surface area were “very pronounced in acutely underweight anorexia,” Stefan Ehrlich, MD, PhD, head of the Eating Disorder Treatment and Research Center, Technical University, Dresden, Germany, told this news organization.
Yet even a “partial weight gain brings some normalization of these shrinkages. From this it can be deduced that a fast/early normalization of weight is also very important for brain health,” said Dr. Ehrlich.
The study was published online in Biological Psychiatry.
‘A wake-up call’
Researchers with the international ENIGMA Eating Disorders Working Group analyzed T1-weighted structural magnetic resonance imaging scans for nearly 2,000 people with AN (including those in recovery) and healthy controls across 22 sites worldwide.
In the AN sample, reductions in cortical thickness, subcortical volumes, and, to a lesser extent, cortical surface area, were “sizable (Cohen’s d up to 0.95), widespread, and co-localized with hub regions,” they report.
These reductions were two and four times larger than the abnormalities in brain size and shape seen in patients with other mental illnesses, the researchers note.
Noting the harmful impact of anorexia-related undernutrition on the brain, these deficits were associated with lower body mass index in the AN sample and were less severe in partially weight-restored patients – implying that, with appropriate early treatment and support, the brain might be able to repair itself, the investigators note.
“This really is a wake-up call, showing the need for early interventions for people with eating disorders,” Paul Thompson, PhD, author and lead scientist for the ENIGMA Consortium, said in a news release.
“The international scale of this work is extraordinary. Scientists from 22 centers worldwide pooled their brain scans to create the most detailed picture to date of how anorexia affects the brain,” Dr. Thompson added.
“The brain changes in anorexia were more severe than in other any psychiatric condition we have studied. Effects of treatments and interventions can now be evaluated, using these new brain maps as a reference,” he noted.
Immediate clinical implications
Reached for comment, Allison Eliscu, MD, chief of the division of adolescent medicine, department of pediatrics, at Stony Brook (N.Y.) University, said the findings have immediate implications for clinical care.
“When we talk to our patients and the parents, a lot of them focus on things that they can see, such as the way they look. It adds a lot to the conversation to be able to say: You’re obviously not seeing these changes in the brain, but they’re happening and could be potentially long term if you don’t start weight restoring, or if you weight restore and then continue to drop again,” Dr. Eliscu said in an interview.
The findings, she said, really do highlight what anorexia can do to the brain.
“Adolescents need to know, anorexia can absolutely decrease the size of your brain in different areas; you’re not just losing weight in your belly and your thighs, you’re losing weight in the brain as well and that’s really concerning,” said Dr. Eliscu.
The study had no commercial funding. The authors and Dr. Eliscu report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
, a new brain imaging study shows.
The reductions of cortical thickness, subcortical volumes, and cortical surface area were “very pronounced in acutely underweight anorexia,” Stefan Ehrlich, MD, PhD, head of the Eating Disorder Treatment and Research Center, Technical University, Dresden, Germany, told this news organization.
Yet even a “partial weight gain brings some normalization of these shrinkages. From this it can be deduced that a fast/early normalization of weight is also very important for brain health,” said Dr. Ehrlich.
The study was published online in Biological Psychiatry.
‘A wake-up call’
Researchers with the international ENIGMA Eating Disorders Working Group analyzed T1-weighted structural magnetic resonance imaging scans for nearly 2,000 people with AN (including those in recovery) and healthy controls across 22 sites worldwide.
In the AN sample, reductions in cortical thickness, subcortical volumes, and, to a lesser extent, cortical surface area, were “sizable (Cohen’s d up to 0.95), widespread, and co-localized with hub regions,” they report.
These reductions were two and four times larger than the abnormalities in brain size and shape seen in patients with other mental illnesses, the researchers note.
Noting the harmful impact of anorexia-related undernutrition on the brain, these deficits were associated with lower body mass index in the AN sample and were less severe in partially weight-restored patients – implying that, with appropriate early treatment and support, the brain might be able to repair itself, the investigators note.
“This really is a wake-up call, showing the need for early interventions for people with eating disorders,” Paul Thompson, PhD, author and lead scientist for the ENIGMA Consortium, said in a news release.
“The international scale of this work is extraordinary. Scientists from 22 centers worldwide pooled their brain scans to create the most detailed picture to date of how anorexia affects the brain,” Dr. Thompson added.
“The brain changes in anorexia were more severe than in other any psychiatric condition we have studied. Effects of treatments and interventions can now be evaluated, using these new brain maps as a reference,” he noted.
Immediate clinical implications
Reached for comment, Allison Eliscu, MD, chief of the division of adolescent medicine, department of pediatrics, at Stony Brook (N.Y.) University, said the findings have immediate implications for clinical care.
“When we talk to our patients and the parents, a lot of them focus on things that they can see, such as the way they look. It adds a lot to the conversation to be able to say: You’re obviously not seeing these changes in the brain, but they’re happening and could be potentially long term if you don’t start weight restoring, or if you weight restore and then continue to drop again,” Dr. Eliscu said in an interview.
The findings, she said, really do highlight what anorexia can do to the brain.
“Adolescents need to know, anorexia can absolutely decrease the size of your brain in different areas; you’re not just losing weight in your belly and your thighs, you’re losing weight in the brain as well and that’s really concerning,” said Dr. Eliscu.
The study had no commercial funding. The authors and Dr. Eliscu report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
, a new brain imaging study shows.
The reductions of cortical thickness, subcortical volumes, and cortical surface area were “very pronounced in acutely underweight anorexia,” Stefan Ehrlich, MD, PhD, head of the Eating Disorder Treatment and Research Center, Technical University, Dresden, Germany, told this news organization.
Yet even a “partial weight gain brings some normalization of these shrinkages. From this it can be deduced that a fast/early normalization of weight is also very important for brain health,” said Dr. Ehrlich.
The study was published online in Biological Psychiatry.
‘A wake-up call’
Researchers with the international ENIGMA Eating Disorders Working Group analyzed T1-weighted structural magnetic resonance imaging scans for nearly 2,000 people with AN (including those in recovery) and healthy controls across 22 sites worldwide.
In the AN sample, reductions in cortical thickness, subcortical volumes, and, to a lesser extent, cortical surface area, were “sizable (Cohen’s d up to 0.95), widespread, and co-localized with hub regions,” they report.
These reductions were two and four times larger than the abnormalities in brain size and shape seen in patients with other mental illnesses, the researchers note.
Noting the harmful impact of anorexia-related undernutrition on the brain, these deficits were associated with lower body mass index in the AN sample and were less severe in partially weight-restored patients – implying that, with appropriate early treatment and support, the brain might be able to repair itself, the investigators note.
“This really is a wake-up call, showing the need for early interventions for people with eating disorders,” Paul Thompson, PhD, author and lead scientist for the ENIGMA Consortium, said in a news release.
“The international scale of this work is extraordinary. Scientists from 22 centers worldwide pooled their brain scans to create the most detailed picture to date of how anorexia affects the brain,” Dr. Thompson added.
“The brain changes in anorexia were more severe than in other any psychiatric condition we have studied. Effects of treatments and interventions can now be evaluated, using these new brain maps as a reference,” he noted.
Immediate clinical implications
Reached for comment, Allison Eliscu, MD, chief of the division of adolescent medicine, department of pediatrics, at Stony Brook (N.Y.) University, said the findings have immediate implications for clinical care.
“When we talk to our patients and the parents, a lot of them focus on things that they can see, such as the way they look. It adds a lot to the conversation to be able to say: You’re obviously not seeing these changes in the brain, but they’re happening and could be potentially long term if you don’t start weight restoring, or if you weight restore and then continue to drop again,” Dr. Eliscu said in an interview.
The findings, she said, really do highlight what anorexia can do to the brain.
“Adolescents need to know, anorexia can absolutely decrease the size of your brain in different areas; you’re not just losing weight in your belly and your thighs, you’re losing weight in the brain as well and that’s really concerning,” said Dr. Eliscu.
The study had no commercial funding. The authors and Dr. Eliscu report no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
FROM BIOLOGICAL PSYCHIATRY
Pandemic stress tied to increased headache burden in teens
Contrary to previous research findings, the stress of the COVID-19 pandemic has been linked to an increased headache burden in teens.
Investigators found factors contributing to headache for preteens and teens during the pandemic included increased screen time for online learning, depression, anxiety, female sex, and weight gain.
“The stressors and pressures of the pandemic may have eventually taken their toll,” lead author Ayşe Nur Özdağ Acarli, MD, Ermenek State Hospital, department of neurology, Karaman, Turkey, told this news organization.
“Limiting screen time and providing more psychosocial supports would help lessen the burden of the COVID-19 pandemic on adolescents with headache.”
The findings were presented at the Congress of the European Academy of Neurology (EAN) 2022.
Most common neurological problem in kids
Headache is the most common neurological problem in children and adolescents. Potential factors contributing to headache in this population include lack of sleep and physical activity, mental health problems, and socioeconomic conditions.
The COVID-19 pandemic has had a “striking” impact on every aspect of life for young people, said Dr. Acarli.
Some studies reported an improvement in headache prevalence among adolescents during COVID-19, which was attributed to less school-related stress. However, said Dr. Acarli in her personal clinical experience, young patients suffered more frequent and severe headaches during the pandemic.
She noted previous research examining the impact of the pandemic on headache in youth was conducted only in the early days of the pandemic and examined shorter-term effects. Research examining the long-term effects of the pandemic on headache in this patient population has been “lacking,” she said.
The study included 851 participants aged 10-18 years (mean age 14.9 years and 62% female) who were seen at a neurology or pediatric outpatient clinic from August-December 2021. The study excluded subjects with neurological problems, intellectual deficits, autism spectrum disorder, and epilepsy.
Participants completed detailed questionnaires providing data on demographics, exposure to COVID-19, and electronics, as well as information on depressive symptoms as assessed by the Patient Health Questionnaire-9 and anxiety symptoms using the Generalized Anxiety Disorder-7 and COVID-related anxiety.
“We used two distinct scales for anxiety: one for generalized anxiety and the other for COVID-related anxiety,” said Dr. Acarli.
Of the total study population, 756 (89%) reported headaches. This headache prevalence in children and adolescents is like that found in other studies.
Dr. Acarli noted several differences in the headache group versus the non-headache group. The female/male ratio was 2:1 versus 1:1, the mean age was 15.0 versus 14.4, and depression and generalized anxiety scores were significantly higher. There was no significant difference in COVID-19 history in those with and without headache.
Researchers categorized those with headache into four groups: worsening headaches (27%), improved headaches (3%), new onset headaches (10%), and stable headaches (61%).
Compared with the other groups, the worsened headache group included significantly more females and older individuals with more severe and frequent headaches. This group also had more participants reporting at least 15 headache attacks a month and using painkillers at least once a month.
The study showed headache severity was significantly increased with age, headache duration, depression, generalized anxiety (all P < .001), and COVID-19 anxiety (P < .01). Headache frequency, measured as attacks per month, was significantly increased with age, depression, and generalized anxiety (all P < .001).
Worsening headache outcomes during the pandemic were associated with longer exposure to computer screens (odds ratio, 1.7; 95% confidence interval, 1.2-2.3; P < .01), lack of suitable conditions for online learning (OR, 2.6; 95% CI, 1.8-3.8; P < .001), depression (OR, 2.0; 95% CI, 1.4-2.8; P < .001); and COVID-19 anxiety (OR, 3.2; 95% CI, 1.3-8.0; P < .01). Other contributing factors included school exams, living in a city, female sex, and weight gain.
There may be a link between COVID-related headaches and anxiety or depression, but it’s unclear what’s causing what. “We don’t know which is the chicken and which is the egg,” said Dr. Acarli.
Headache triggers
Commenting for this news organization, Raquel Gil-Gouveia, MD, PhD, head of the neurology department, Hospital da Luz, Lisbon, Portugal, who co-chaired the session where the research was presented, said the information collected for the study was “extensive.”
Some results were expected, including the fact that patients with headaches were more anxious and depressed, said Dr. Gil-Gouveia.
“Anxiety and depression are frequent comorbidities of headache and can act as a triggering factor for headache attacks but can also be a consequence of intense or chronic pain,” she said.
She agreed the new results differ from those of studies carried out during the first pandemic lockdown, which showed an improvement in headache, but noted online learning was not fully implemented at that time, “so it was much like being on vacation.”
In addition to isolation, anxiety, and prolonged screen exposure, the lack of peer contact and fewer sports and leisure activities may also have contributed to worsening headaches during the COVID lockdown, but these were not explored in this study, said Dr. Gil-Gouveia.
The study was supported by the Global Migraine and Pain Society. The investigators and Dr. Gil-Gouveia report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Contrary to previous research findings, the stress of the COVID-19 pandemic has been linked to an increased headache burden in teens.
Investigators found factors contributing to headache for preteens and teens during the pandemic included increased screen time for online learning, depression, anxiety, female sex, and weight gain.
“The stressors and pressures of the pandemic may have eventually taken their toll,” lead author Ayşe Nur Özdağ Acarli, MD, Ermenek State Hospital, department of neurology, Karaman, Turkey, told this news organization.
“Limiting screen time and providing more psychosocial supports would help lessen the burden of the COVID-19 pandemic on adolescents with headache.”
The findings were presented at the Congress of the European Academy of Neurology (EAN) 2022.
Most common neurological problem in kids
Headache is the most common neurological problem in children and adolescents. Potential factors contributing to headache in this population include lack of sleep and physical activity, mental health problems, and socioeconomic conditions.
The COVID-19 pandemic has had a “striking” impact on every aspect of life for young people, said Dr. Acarli.
Some studies reported an improvement in headache prevalence among adolescents during COVID-19, which was attributed to less school-related stress. However, said Dr. Acarli in her personal clinical experience, young patients suffered more frequent and severe headaches during the pandemic.
She noted previous research examining the impact of the pandemic on headache in youth was conducted only in the early days of the pandemic and examined shorter-term effects. Research examining the long-term effects of the pandemic on headache in this patient population has been “lacking,” she said.
The study included 851 participants aged 10-18 years (mean age 14.9 years and 62% female) who were seen at a neurology or pediatric outpatient clinic from August-December 2021. The study excluded subjects with neurological problems, intellectual deficits, autism spectrum disorder, and epilepsy.
Participants completed detailed questionnaires providing data on demographics, exposure to COVID-19, and electronics, as well as information on depressive symptoms as assessed by the Patient Health Questionnaire-9 and anxiety symptoms using the Generalized Anxiety Disorder-7 and COVID-related anxiety.
“We used two distinct scales for anxiety: one for generalized anxiety and the other for COVID-related anxiety,” said Dr. Acarli.
Of the total study population, 756 (89%) reported headaches. This headache prevalence in children and adolescents is like that found in other studies.
Dr. Acarli noted several differences in the headache group versus the non-headache group. The female/male ratio was 2:1 versus 1:1, the mean age was 15.0 versus 14.4, and depression and generalized anxiety scores were significantly higher. There was no significant difference in COVID-19 history in those with and without headache.
Researchers categorized those with headache into four groups: worsening headaches (27%), improved headaches (3%), new onset headaches (10%), and stable headaches (61%).
Compared with the other groups, the worsened headache group included significantly more females and older individuals with more severe and frequent headaches. This group also had more participants reporting at least 15 headache attacks a month and using painkillers at least once a month.
The study showed headache severity was significantly increased with age, headache duration, depression, generalized anxiety (all P < .001), and COVID-19 anxiety (P < .01). Headache frequency, measured as attacks per month, was significantly increased with age, depression, and generalized anxiety (all P < .001).
Worsening headache outcomes during the pandemic were associated with longer exposure to computer screens (odds ratio, 1.7; 95% confidence interval, 1.2-2.3; P < .01), lack of suitable conditions for online learning (OR, 2.6; 95% CI, 1.8-3.8; P < .001), depression (OR, 2.0; 95% CI, 1.4-2.8; P < .001); and COVID-19 anxiety (OR, 3.2; 95% CI, 1.3-8.0; P < .01). Other contributing factors included school exams, living in a city, female sex, and weight gain.
There may be a link between COVID-related headaches and anxiety or depression, but it’s unclear what’s causing what. “We don’t know which is the chicken and which is the egg,” said Dr. Acarli.
Headache triggers
Commenting for this news organization, Raquel Gil-Gouveia, MD, PhD, head of the neurology department, Hospital da Luz, Lisbon, Portugal, who co-chaired the session where the research was presented, said the information collected for the study was “extensive.”
Some results were expected, including the fact that patients with headaches were more anxious and depressed, said Dr. Gil-Gouveia.
“Anxiety and depression are frequent comorbidities of headache and can act as a triggering factor for headache attacks but can also be a consequence of intense or chronic pain,” she said.
She agreed the new results differ from those of studies carried out during the first pandemic lockdown, which showed an improvement in headache, but noted online learning was not fully implemented at that time, “so it was much like being on vacation.”
In addition to isolation, anxiety, and prolonged screen exposure, the lack of peer contact and fewer sports and leisure activities may also have contributed to worsening headaches during the COVID lockdown, but these were not explored in this study, said Dr. Gil-Gouveia.
The study was supported by the Global Migraine and Pain Society. The investigators and Dr. Gil-Gouveia report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Contrary to previous research findings, the stress of the COVID-19 pandemic has been linked to an increased headache burden in teens.
Investigators found factors contributing to headache for preteens and teens during the pandemic included increased screen time for online learning, depression, anxiety, female sex, and weight gain.
“The stressors and pressures of the pandemic may have eventually taken their toll,” lead author Ayşe Nur Özdağ Acarli, MD, Ermenek State Hospital, department of neurology, Karaman, Turkey, told this news organization.
“Limiting screen time and providing more psychosocial supports would help lessen the burden of the COVID-19 pandemic on adolescents with headache.”
The findings were presented at the Congress of the European Academy of Neurology (EAN) 2022.
Most common neurological problem in kids
Headache is the most common neurological problem in children and adolescents. Potential factors contributing to headache in this population include lack of sleep and physical activity, mental health problems, and socioeconomic conditions.
The COVID-19 pandemic has had a “striking” impact on every aspect of life for young people, said Dr. Acarli.
Some studies reported an improvement in headache prevalence among adolescents during COVID-19, which was attributed to less school-related stress. However, said Dr. Acarli in her personal clinical experience, young patients suffered more frequent and severe headaches during the pandemic.
She noted previous research examining the impact of the pandemic on headache in youth was conducted only in the early days of the pandemic and examined shorter-term effects. Research examining the long-term effects of the pandemic on headache in this patient population has been “lacking,” she said.
The study included 851 participants aged 10-18 years (mean age 14.9 years and 62% female) who were seen at a neurology or pediatric outpatient clinic from August-December 2021. The study excluded subjects with neurological problems, intellectual deficits, autism spectrum disorder, and epilepsy.
Participants completed detailed questionnaires providing data on demographics, exposure to COVID-19, and electronics, as well as information on depressive symptoms as assessed by the Patient Health Questionnaire-9 and anxiety symptoms using the Generalized Anxiety Disorder-7 and COVID-related anxiety.
“We used two distinct scales for anxiety: one for generalized anxiety and the other for COVID-related anxiety,” said Dr. Acarli.
Of the total study population, 756 (89%) reported headaches. This headache prevalence in children and adolescents is like that found in other studies.
Dr. Acarli noted several differences in the headache group versus the non-headache group. The female/male ratio was 2:1 versus 1:1, the mean age was 15.0 versus 14.4, and depression and generalized anxiety scores were significantly higher. There was no significant difference in COVID-19 history in those with and without headache.
Researchers categorized those with headache into four groups: worsening headaches (27%), improved headaches (3%), new onset headaches (10%), and stable headaches (61%).
Compared with the other groups, the worsened headache group included significantly more females and older individuals with more severe and frequent headaches. This group also had more participants reporting at least 15 headache attacks a month and using painkillers at least once a month.
The study showed headache severity was significantly increased with age, headache duration, depression, generalized anxiety (all P < .001), and COVID-19 anxiety (P < .01). Headache frequency, measured as attacks per month, was significantly increased with age, depression, and generalized anxiety (all P < .001).
Worsening headache outcomes during the pandemic were associated with longer exposure to computer screens (odds ratio, 1.7; 95% confidence interval, 1.2-2.3; P < .01), lack of suitable conditions for online learning (OR, 2.6; 95% CI, 1.8-3.8; P < .001), depression (OR, 2.0; 95% CI, 1.4-2.8; P < .001); and COVID-19 anxiety (OR, 3.2; 95% CI, 1.3-8.0; P < .01). Other contributing factors included school exams, living in a city, female sex, and weight gain.
There may be a link between COVID-related headaches and anxiety or depression, but it’s unclear what’s causing what. “We don’t know which is the chicken and which is the egg,” said Dr. Acarli.
Headache triggers
Commenting for this news organization, Raquel Gil-Gouveia, MD, PhD, head of the neurology department, Hospital da Luz, Lisbon, Portugal, who co-chaired the session where the research was presented, said the information collected for the study was “extensive.”
Some results were expected, including the fact that patients with headaches were more anxious and depressed, said Dr. Gil-Gouveia.
“Anxiety and depression are frequent comorbidities of headache and can act as a triggering factor for headache attacks but can also be a consequence of intense or chronic pain,” she said.
She agreed the new results differ from those of studies carried out during the first pandemic lockdown, which showed an improvement in headache, but noted online learning was not fully implemented at that time, “so it was much like being on vacation.”
In addition to isolation, anxiety, and prolonged screen exposure, the lack of peer contact and fewer sports and leisure activities may also have contributed to worsening headaches during the COVID lockdown, but these were not explored in this study, said Dr. Gil-Gouveia.
The study was supported by the Global Migraine and Pain Society. The investigators and Dr. Gil-Gouveia report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM EAN 2022
FDA approves Qsymia for treating teens with obesity
The indication is for use as additional therapy along with a reduced-calorie diet and increased physical activity in youth with obesity, defined as a body mass index of the 95th percentile or greater when standardized for age and sex.
Qsymia was first approved in July 2012 for chronic weight management in adults with an initial BMI of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) with one or more weight-related comorbidities, as an adjunct to lifestyle modification.
About 1 in 5 adolescents in the United States has obesity, according to the FDA.
The drug is the fourth to be approved for treating obesity in youth, along with liraglutide (Saxenda) and orlistat (Alli, Xenical), both approved down to age 12, and phentermine for those aged 16 and older.
The Qsymia approval was based on data from a phase 4 double-blind, placebo-controlled trial of 223 youth aged 12-16 with obesity who had not lost weight with lifestyle modifications. They were randomly assigned to Qsymia in doses of 7.5 mg phentermine/46 mg topiramate, 15 mg phentermine/92 mg topiramate, or placebo once daily, along with lifestyle counseling for all.
At 56 weeks, those taking the lower Qsymia dose lost an average of 4.8% of their BMI, and those on the higher dose lost 7.1%. In contrast, the placebo group gained about 3.3% of their BMI.
Because Qsymia increases the risk for oral clefts (lip and palate) in a fetus if taken during pregnancy, female patients should obtain negative pregnancy tests before starting the drug, take monthly pregnancy tests while on the drug, and use effective contraception throughout. Also because of the oral cleft risk, Qsymia is available only through an FDA program called a Risk Evaluation and Mitigation Strategy.
Additional potential adverse effects with Qsymia include increased heart rate and suicidal behavior/ideation. Patients should be advised to monitor for mood changes and discontinue the drug if depression or suicidal thoughts develop. The drug has also been linked to slowing of linear growth, so growth should be monitored in adolescents taking the drug, according to the FDA.
Qsymia is also associated with acute myopia, secondary angle closure glaucoma, visual problems, sleep disorders, cognitive impairment, metabolic acidosis, and decreased renal function.
The most common adverse reactions reported in the pediatric clinical trial included depression, dizziness, joint pain, fever, flu, and ankle sprain.
A version of this article first appeared on Medscape.com.
The indication is for use as additional therapy along with a reduced-calorie diet and increased physical activity in youth with obesity, defined as a body mass index of the 95th percentile or greater when standardized for age and sex.
Qsymia was first approved in July 2012 for chronic weight management in adults with an initial BMI of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) with one or more weight-related comorbidities, as an adjunct to lifestyle modification.
About 1 in 5 adolescents in the United States has obesity, according to the FDA.
The drug is the fourth to be approved for treating obesity in youth, along with liraglutide (Saxenda) and orlistat (Alli, Xenical), both approved down to age 12, and phentermine for those aged 16 and older.
The Qsymia approval was based on data from a phase 4 double-blind, placebo-controlled trial of 223 youth aged 12-16 with obesity who had not lost weight with lifestyle modifications. They were randomly assigned to Qsymia in doses of 7.5 mg phentermine/46 mg topiramate, 15 mg phentermine/92 mg topiramate, or placebo once daily, along with lifestyle counseling for all.
At 56 weeks, those taking the lower Qsymia dose lost an average of 4.8% of their BMI, and those on the higher dose lost 7.1%. In contrast, the placebo group gained about 3.3% of their BMI.
Because Qsymia increases the risk for oral clefts (lip and palate) in a fetus if taken during pregnancy, female patients should obtain negative pregnancy tests before starting the drug, take monthly pregnancy tests while on the drug, and use effective contraception throughout. Also because of the oral cleft risk, Qsymia is available only through an FDA program called a Risk Evaluation and Mitigation Strategy.
Additional potential adverse effects with Qsymia include increased heart rate and suicidal behavior/ideation. Patients should be advised to monitor for mood changes and discontinue the drug if depression or suicidal thoughts develop. The drug has also been linked to slowing of linear growth, so growth should be monitored in adolescents taking the drug, according to the FDA.
Qsymia is also associated with acute myopia, secondary angle closure glaucoma, visual problems, sleep disorders, cognitive impairment, metabolic acidosis, and decreased renal function.
The most common adverse reactions reported in the pediatric clinical trial included depression, dizziness, joint pain, fever, flu, and ankle sprain.
A version of this article first appeared on Medscape.com.
The indication is for use as additional therapy along with a reduced-calorie diet and increased physical activity in youth with obesity, defined as a body mass index of the 95th percentile or greater when standardized for age and sex.
Qsymia was first approved in July 2012 for chronic weight management in adults with an initial BMI of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) with one or more weight-related comorbidities, as an adjunct to lifestyle modification.
About 1 in 5 adolescents in the United States has obesity, according to the FDA.
The drug is the fourth to be approved for treating obesity in youth, along with liraglutide (Saxenda) and orlistat (Alli, Xenical), both approved down to age 12, and phentermine for those aged 16 and older.
The Qsymia approval was based on data from a phase 4 double-blind, placebo-controlled trial of 223 youth aged 12-16 with obesity who had not lost weight with lifestyle modifications. They were randomly assigned to Qsymia in doses of 7.5 mg phentermine/46 mg topiramate, 15 mg phentermine/92 mg topiramate, or placebo once daily, along with lifestyle counseling for all.
At 56 weeks, those taking the lower Qsymia dose lost an average of 4.8% of their BMI, and those on the higher dose lost 7.1%. In contrast, the placebo group gained about 3.3% of their BMI.
Because Qsymia increases the risk for oral clefts (lip and palate) in a fetus if taken during pregnancy, female patients should obtain negative pregnancy tests before starting the drug, take monthly pregnancy tests while on the drug, and use effective contraception throughout. Also because of the oral cleft risk, Qsymia is available only through an FDA program called a Risk Evaluation and Mitigation Strategy.
Additional potential adverse effects with Qsymia include increased heart rate and suicidal behavior/ideation. Patients should be advised to monitor for mood changes and discontinue the drug if depression or suicidal thoughts develop. The drug has also been linked to slowing of linear growth, so growth should be monitored in adolescents taking the drug, according to the FDA.
Qsymia is also associated with acute myopia, secondary angle closure glaucoma, visual problems, sleep disorders, cognitive impairment, metabolic acidosis, and decreased renal function.
The most common adverse reactions reported in the pediatric clinical trial included depression, dizziness, joint pain, fever, flu, and ankle sprain.
A version of this article first appeared on Medscape.com.