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‘Ecotrauma’: The effects of climate change on mental health
In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.
In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.
Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.
As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.
The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.
Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?
Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.
Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?
Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.
Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?
Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.
Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.
Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.
Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.
Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?
Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.
On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.
This article was translated from Univadis Spain.
A version of this article first appeared on Medscape.com.
In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.
In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.
Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.
As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.
The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.
Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?
Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.
Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?
Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.
Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?
Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.
Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.
Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.
Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.
Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?
Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.
On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.
This article was translated from Univadis Spain.
A version of this article first appeared on Medscape.com.
In June of this year, the World Health Organization launched a policy report to confront the increasingly strong and lasting impacts that climate change is having directly and indirectly on people’s mental health and psychosocial well-being.
In addition to the increasingly high incidence of mental disorders (for instance, emotional distress, stress, depression, and suicidal behavior) affecting people worldwide This term refers to anxiety in the face of the apocalyptic scenario predicted to result from the transformation of ecosystems by anthropogenic activity.
Two weeks after the release of the policy report, which integrates key policies for countries to address one of the biggest challenges, the WHO published its largest review of global mental health since the turn of the century. The work provides a model for governments, academics, health professionals, and civil society to become key players when dealing with the mental health problems that our society is going through.
As the document highlights, almost 1 billion people, including 14% of the world’s adolescents, were living with a mental health disorder in 2019. Suicide accounted for more than 1 in 100 deaths, and 58% of cases occurred before age 50 years. Mental health disorders are already the leading cause of disability in the world, and people with serious but preventable diseases die on average 10-20 years earlier than the general population.
The COVID-19 crisis has significantly aggravated mental health disorders, especially in populations such as minors. Consequently, many experts refer to this public health phenomenon as the new major pandemic. “I’m not sure it’s correct to call a set of mental health problems a pandemic, but the reality is that many countries are ignoring or largely forgetting this crisis,” Sarah Sheppard, WHO communications officer, told this news organization. According to Ms. Sheppard, “stigma and lack of understanding are key drivers of these problems and have been one of the reasons for the lack of mental health funding for decades. Mental health receives less than 1% of international health aid.” We recently interviewed Ms. Sheppard about these challenges.
Univadis: As the data provided in the recently released Mental Health and Climate Change Policy Brief indicate, there are large gaps in many countries between mental health needs and the services and systems available to address them. Where can we start to change this reality?
Ms. Sheppard: The simplest answer to improve the situation we face begins with a change in people’s priorities when it comes to valuing mental health. This would lead to greater investment in human and financial resources for mental health services and systems. However, the challenge lies in the complexity of the problem. In the report we just published, we provide comprehensive recommendations on how to transform mental health systems for all, such as trying to integrate climate change considerations into policies and programs for mental health or building on existing global commitments, including the Sustainable Development Goals (SDGs) or the Paris Agreement.
Univadis: Is there evidence that mental illnesses and disorders affect some populations more than others, such as women, for example?
Ms. Sheppard: The prevalence of mental disorders varies according to conditions and according to sex and age. In general, I don’t think we can say that mental health conditions or disorders affect women more than men. There are groups at risk, but vulnerability depends on the context and varies a lot. Of course, social determinants such as poverty, unstable housing, and exposure to adversity can significantly increase risk.
Univadis: According to the statistics recently provided by the WHO, changes in the environment are directly and indirectly affecting people’s mental health and psychosocial well-being. The new report highlights the gap between countries when it comes to addressing this complex problem. Is there any country that is carrying out political or innovative initiatives in this regard?
Ms. Sheppard: Yes, there are many case studies in the policy brief that highlight important work in the area. There are strong examples that are highlighted in the summary. One of them is India and its resilient cities program. Focused on the reduction of disaster risk, climate resilience, and mental health and psychosocial support at city level, this project resulted from a collaboration between the United Nations Development Program and the Indian National Institute of Mental Health and Neurosciences, which began in 2017.
Univadis: In addition to its effects on mental health, we are seeing how climate change is causing the appearance and resurgence of zoonoses, such as the pandemic caused by coronavirus and now monkeypox.
Ms. Sheppard: Mike Ryan, head of emergency situations at WHO, stated at the beginning of June that the increase in zoonoses raises the risk of new pandemics. Infections transmitted from animals to humans, such as Ebola, COVID-19, or monkeypox, have multiplied in recent years. Climate change alters the conditions for pathogens and zoonotic disease vectors and their distribution. The intensification of travel, for example, allows them to spread more quickly and in a more uncontrolled way.
Human health, including mental health, is connected to animal health. As various materials available to us from our World Health Day 2022 campaign examine, the links between planetary health and human health are inextricable.
Univadis: How is it possible that while scientific progress advances and more powerful and efficient technologies are developed, we become increasingly vulnerable to environmental phenomena?
Ms. Sheppard: Scientific advancement improves our understanding of the quality and scale of the health impacts of climate change, including the identification of the most vulnerable groups, as well as the adaptation and mitigation measures that would work to reduce the consequences on health. At the same time, climate change is widespread, rapid, and intensifying. Technological advances have a role to play in mitigation, particularly those tools that reduce our dependence on burning fossil fuels, as well as adaptation to climate change. For example, early warning systems for extreme weather events could reduce those vulnerabilities your question mentioned.
On the other hand, the measures proposed by the latest report on mental health and climate change have multiple effects. Some are particularly powerful and are not overly dependent on new technology. These include changing our mode of transport to low-emission, physically active ways to get around (walking, cycling), the benefits of which are already more than proven for both the environment and human health.
This article was translated from Univadis Spain.
A version of this article first appeared on Medscape.com.
Growing evidence gardening cultivates mental health
The results of the small pilot study add to the growing body of evidence supporting the therapeutic value of gardening, study investigator Charles Guy, PhD, professor emeritus, University of Florida Institute of Food and Agricultural Sciences, Gainesville, told this news organization.
“If we can see therapeutic benefits among healthy individuals in a rigorously designed study, where variability was as controlled as you will see in this field, then now is the time to invest in some large-scale multi-institutional studies,” Dr. Guy added.
The study was published online in PLOS ONE.
Horticulture as therapy
Horticulture therapy involves engaging in gardening and plant-based activities facilitated by a trained therapist. Previous studies found that this intervention reduces apathy and improves cognitive function in some populations.
The current study included healthy, nonsmoking, and non–drug-using women, whose average age was about 32.5 years and whose body mass index was less than 32. The participants had no chronic conditions and were not allergic to pollen or plants.
Virtually all previous studies of therapeutic gardening included participants who had been diagnosed with conditions such as depression, chronic pain, or PTSD. “If we can see a therapeutic benefit with perfectly healthy people, then this is likely to have a therapeutic effect with whatever clinical population you might be interested in looking at,” said Dr. Guy.
In addition, including only women reduced variability, which is important in a small study, he said.
The researchers randomly assigned 20 participants to the gardening intervention and 20 to an art intervention. Each intervention consisted of twice-weekly 60-minute sessions for 4 weeks and a single follow-up session.
The art group was asked not to visit art galleries, museums, arts and crafts events, or art-related websites. Those in the gardening group were told not to visit parks or botanical gardens, not to engage in gardening activities, and not to visit gardening websites.
Activities in both groups involved a similar level of physical, cognitive, and social engagement. Gardeners were taught how to plant seeds and transplant and harvest edible crops, such as tomatoes, beans, and basil. Those in the art group learned papermaking and storytelling through drawing, printmaking, and mixed media collage.
At the beginning and end of the study, participants completed six questionnaires: the Profile of Mood States 2-A (POMS) short form, the Perceived Stress Scale (PSS), the Beck Depression Inventory II (BDI-II), the State-Trait Anxiety Inventory for Adults, the Satisfaction With Participation in Discretionary Social Activities, and the 36-item Short-Form Survey.
Participants wore wrist cuff blood pressure and heart rate monitors.
The analysis included 15 persons in the gardening group and 17 in the art group.
Participants in both interventions improved on several scales. For example, the mean preintervention POMS TMD (T score) for gardeners was 53.1, which was reduced to a mean of 46.9 post intervention (P = .018). In the art group, the means score was 53.5 before the intervention and 47.0 after the intervention (P = .009).
For the PSS, mean scores went from 14.9 to 9.4 (P = .002) for gardening and from 15.8 to 10.0 (P = .001) for artmaking.
For the BDI-II, mean scores dropped from 8.2 to 2.8 (P = .001) for gardening and from 9.0 to 5.1 (P = .009) for art.
However, gardening was associated with less trait anxiety than artmaking. “We concluded that both interventions were roughly equally therapeutic, with one glaring exception, and that was with trait anxiety, where the gardening resulted in statistical separation from the art group,” said Dr. Guy.
There appeared to be dose responses for total mood disturbance, perceived stress, and depression symptomatology for both gardening and artmaking.
Neither intervention affected heart rate or blood pressure. A larger sample might be needed to detect treatment differences in healthy women, the investigators noted.
The therapeutic benefit of gardening may lie in the role of plants in human evolution, during which “we relied on plants for shelter; we relied on them for protection; we relied on them obviously for nutrition,” said Dr. Guy.
The study results support carrying out large, well-designed, rigorously designed trials “that will definitively and conclusively demonstrate treatment effects with quantitative descriptions of those treatment effects with respect to dosage,” he said.
Good for the mind
Commenting on the study, Sir Richard Thompson, MD, past president, Royal College of Physicians, London, who has written about the health benefits of gardening, said this new study provides “more evidence that both gardening and art therapy are good for the mind” with mostly equal benefits for the two interventions.
“A much larger study would be needed to strengthen their case, but it fits in with much of the literature,” said Dr. Thompson.
However, he acknowledged the difficulty of carrying out scientifically robust studies in the field of alternative medicine, which “tends to be frowned upon” by some scientists.
Dr. Thompson identified some drawbacks of the study. In trying to measure so many parameters, the authors “may have had to resort to complex statistical analyses,” which may have led to some outcome changes being statistically positive by chance.
He noted that the study was small and that the gardening arm was “artificial” in that it was carried out in a greenhouse. “Maybe being outside would have been more beneficial; it would be interesting to test that hypothesis.”
As well, he pointed out initial differences between the two groups, including income and initial blood pressure, but he doubts these were significant.
He agreed that changes in cardiovascular parameters wouldn’t be expected in healthy young women, “as there’s little room for improvement.
“I wonder whether more improvement might have been seen in participants who were already suffering from anxiety, depression, etc.”
The study was supported by the Horticulture Research Institute, the Gene and Barbara Batson Endowed Nursery Fund, Florida Nursery Growers and Landscape Association, the Institute of Food and Agricultural Sciences, Wilmot Botanical Gardens, the Center for Arts in Medicine, Health Shands Arts in Medicine, and the department of environmental horticulture at the University of Florida. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The results of the small pilot study add to the growing body of evidence supporting the therapeutic value of gardening, study investigator Charles Guy, PhD, professor emeritus, University of Florida Institute of Food and Agricultural Sciences, Gainesville, told this news organization.
“If we can see therapeutic benefits among healthy individuals in a rigorously designed study, where variability was as controlled as you will see in this field, then now is the time to invest in some large-scale multi-institutional studies,” Dr. Guy added.
The study was published online in PLOS ONE.
Horticulture as therapy
Horticulture therapy involves engaging in gardening and plant-based activities facilitated by a trained therapist. Previous studies found that this intervention reduces apathy and improves cognitive function in some populations.
The current study included healthy, nonsmoking, and non–drug-using women, whose average age was about 32.5 years and whose body mass index was less than 32. The participants had no chronic conditions and were not allergic to pollen or plants.
Virtually all previous studies of therapeutic gardening included participants who had been diagnosed with conditions such as depression, chronic pain, or PTSD. “If we can see a therapeutic benefit with perfectly healthy people, then this is likely to have a therapeutic effect with whatever clinical population you might be interested in looking at,” said Dr. Guy.
In addition, including only women reduced variability, which is important in a small study, he said.
The researchers randomly assigned 20 participants to the gardening intervention and 20 to an art intervention. Each intervention consisted of twice-weekly 60-minute sessions for 4 weeks and a single follow-up session.
The art group was asked not to visit art galleries, museums, arts and crafts events, or art-related websites. Those in the gardening group were told not to visit parks or botanical gardens, not to engage in gardening activities, and not to visit gardening websites.
Activities in both groups involved a similar level of physical, cognitive, and social engagement. Gardeners were taught how to plant seeds and transplant and harvest edible crops, such as tomatoes, beans, and basil. Those in the art group learned papermaking and storytelling through drawing, printmaking, and mixed media collage.
At the beginning and end of the study, participants completed six questionnaires: the Profile of Mood States 2-A (POMS) short form, the Perceived Stress Scale (PSS), the Beck Depression Inventory II (BDI-II), the State-Trait Anxiety Inventory for Adults, the Satisfaction With Participation in Discretionary Social Activities, and the 36-item Short-Form Survey.
Participants wore wrist cuff blood pressure and heart rate monitors.
The analysis included 15 persons in the gardening group and 17 in the art group.
Participants in both interventions improved on several scales. For example, the mean preintervention POMS TMD (T score) for gardeners was 53.1, which was reduced to a mean of 46.9 post intervention (P = .018). In the art group, the means score was 53.5 before the intervention and 47.0 after the intervention (P = .009).
For the PSS, mean scores went from 14.9 to 9.4 (P = .002) for gardening and from 15.8 to 10.0 (P = .001) for artmaking.
For the BDI-II, mean scores dropped from 8.2 to 2.8 (P = .001) for gardening and from 9.0 to 5.1 (P = .009) for art.
However, gardening was associated with less trait anxiety than artmaking. “We concluded that both interventions were roughly equally therapeutic, with one glaring exception, and that was with trait anxiety, where the gardening resulted in statistical separation from the art group,” said Dr. Guy.
There appeared to be dose responses for total mood disturbance, perceived stress, and depression symptomatology for both gardening and artmaking.
Neither intervention affected heart rate or blood pressure. A larger sample might be needed to detect treatment differences in healthy women, the investigators noted.
The therapeutic benefit of gardening may lie in the role of plants in human evolution, during which “we relied on plants for shelter; we relied on them for protection; we relied on them obviously for nutrition,” said Dr. Guy.
The study results support carrying out large, well-designed, rigorously designed trials “that will definitively and conclusively demonstrate treatment effects with quantitative descriptions of those treatment effects with respect to dosage,” he said.
Good for the mind
Commenting on the study, Sir Richard Thompson, MD, past president, Royal College of Physicians, London, who has written about the health benefits of gardening, said this new study provides “more evidence that both gardening and art therapy are good for the mind” with mostly equal benefits for the two interventions.
“A much larger study would be needed to strengthen their case, but it fits in with much of the literature,” said Dr. Thompson.
However, he acknowledged the difficulty of carrying out scientifically robust studies in the field of alternative medicine, which “tends to be frowned upon” by some scientists.
Dr. Thompson identified some drawbacks of the study. In trying to measure so many parameters, the authors “may have had to resort to complex statistical analyses,” which may have led to some outcome changes being statistically positive by chance.
He noted that the study was small and that the gardening arm was “artificial” in that it was carried out in a greenhouse. “Maybe being outside would have been more beneficial; it would be interesting to test that hypothesis.”
As well, he pointed out initial differences between the two groups, including income and initial blood pressure, but he doubts these were significant.
He agreed that changes in cardiovascular parameters wouldn’t be expected in healthy young women, “as there’s little room for improvement.
“I wonder whether more improvement might have been seen in participants who were already suffering from anxiety, depression, etc.”
The study was supported by the Horticulture Research Institute, the Gene and Barbara Batson Endowed Nursery Fund, Florida Nursery Growers and Landscape Association, the Institute of Food and Agricultural Sciences, Wilmot Botanical Gardens, the Center for Arts in Medicine, Health Shands Arts in Medicine, and the department of environmental horticulture at the University of Florida. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
The results of the small pilot study add to the growing body of evidence supporting the therapeutic value of gardening, study investigator Charles Guy, PhD, professor emeritus, University of Florida Institute of Food and Agricultural Sciences, Gainesville, told this news organization.
“If we can see therapeutic benefits among healthy individuals in a rigorously designed study, where variability was as controlled as you will see in this field, then now is the time to invest in some large-scale multi-institutional studies,” Dr. Guy added.
The study was published online in PLOS ONE.
Horticulture as therapy
Horticulture therapy involves engaging in gardening and plant-based activities facilitated by a trained therapist. Previous studies found that this intervention reduces apathy and improves cognitive function in some populations.
The current study included healthy, nonsmoking, and non–drug-using women, whose average age was about 32.5 years and whose body mass index was less than 32. The participants had no chronic conditions and were not allergic to pollen or plants.
Virtually all previous studies of therapeutic gardening included participants who had been diagnosed with conditions such as depression, chronic pain, or PTSD. “If we can see a therapeutic benefit with perfectly healthy people, then this is likely to have a therapeutic effect with whatever clinical population you might be interested in looking at,” said Dr. Guy.
In addition, including only women reduced variability, which is important in a small study, he said.
The researchers randomly assigned 20 participants to the gardening intervention and 20 to an art intervention. Each intervention consisted of twice-weekly 60-minute sessions for 4 weeks and a single follow-up session.
The art group was asked not to visit art galleries, museums, arts and crafts events, or art-related websites. Those in the gardening group were told not to visit parks or botanical gardens, not to engage in gardening activities, and not to visit gardening websites.
Activities in both groups involved a similar level of physical, cognitive, and social engagement. Gardeners were taught how to plant seeds and transplant and harvest edible crops, such as tomatoes, beans, and basil. Those in the art group learned papermaking and storytelling through drawing, printmaking, and mixed media collage.
At the beginning and end of the study, participants completed six questionnaires: the Profile of Mood States 2-A (POMS) short form, the Perceived Stress Scale (PSS), the Beck Depression Inventory II (BDI-II), the State-Trait Anxiety Inventory for Adults, the Satisfaction With Participation in Discretionary Social Activities, and the 36-item Short-Form Survey.
Participants wore wrist cuff blood pressure and heart rate monitors.
The analysis included 15 persons in the gardening group and 17 in the art group.
Participants in both interventions improved on several scales. For example, the mean preintervention POMS TMD (T score) for gardeners was 53.1, which was reduced to a mean of 46.9 post intervention (P = .018). In the art group, the means score was 53.5 before the intervention and 47.0 after the intervention (P = .009).
For the PSS, mean scores went from 14.9 to 9.4 (P = .002) for gardening and from 15.8 to 10.0 (P = .001) for artmaking.
For the BDI-II, mean scores dropped from 8.2 to 2.8 (P = .001) for gardening and from 9.0 to 5.1 (P = .009) for art.
However, gardening was associated with less trait anxiety than artmaking. “We concluded that both interventions were roughly equally therapeutic, with one glaring exception, and that was with trait anxiety, where the gardening resulted in statistical separation from the art group,” said Dr. Guy.
There appeared to be dose responses for total mood disturbance, perceived stress, and depression symptomatology for both gardening and artmaking.
Neither intervention affected heart rate or blood pressure. A larger sample might be needed to detect treatment differences in healthy women, the investigators noted.
The therapeutic benefit of gardening may lie in the role of plants in human evolution, during which “we relied on plants for shelter; we relied on them for protection; we relied on them obviously for nutrition,” said Dr. Guy.
The study results support carrying out large, well-designed, rigorously designed trials “that will definitively and conclusively demonstrate treatment effects with quantitative descriptions of those treatment effects with respect to dosage,” he said.
Good for the mind
Commenting on the study, Sir Richard Thompson, MD, past president, Royal College of Physicians, London, who has written about the health benefits of gardening, said this new study provides “more evidence that both gardening and art therapy are good for the mind” with mostly equal benefits for the two interventions.
“A much larger study would be needed to strengthen their case, but it fits in with much of the literature,” said Dr. Thompson.
However, he acknowledged the difficulty of carrying out scientifically robust studies in the field of alternative medicine, which “tends to be frowned upon” by some scientists.
Dr. Thompson identified some drawbacks of the study. In trying to measure so many parameters, the authors “may have had to resort to complex statistical analyses,” which may have led to some outcome changes being statistically positive by chance.
He noted that the study was small and that the gardening arm was “artificial” in that it was carried out in a greenhouse. “Maybe being outside would have been more beneficial; it would be interesting to test that hypothesis.”
As well, he pointed out initial differences between the two groups, including income and initial blood pressure, but he doubts these were significant.
He agreed that changes in cardiovascular parameters wouldn’t be expected in healthy young women, “as there’s little room for improvement.
“I wonder whether more improvement might have been seen in participants who were already suffering from anxiety, depression, etc.”
The study was supported by the Horticulture Research Institute, the Gene and Barbara Batson Endowed Nursery Fund, Florida Nursery Growers and Landscape Association, the Institute of Food and Agricultural Sciences, Wilmot Botanical Gardens, the Center for Arts in Medicine, Health Shands Arts in Medicine, and the department of environmental horticulture at the University of Florida. The authors disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM PLOS ONE
Religious fundamentalism and later-life anxiety
I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.
“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist.
Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.
Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.
Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:
It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.
This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.
That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.
I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.
Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.
It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God.
Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.
He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.
Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.
He goes on to describe how powerful the process was for him and his healing.
Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.
Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).
It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.
“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist.
Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.
Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.
Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:
It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.
This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.
That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.
I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.
Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.
It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God.
Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.
He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.
Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.
He goes on to describe how powerful the process was for him and his healing.
Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.
Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).
It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
I was a resident, young and naive, when I bumped into my neighbor in the hospital hallway as he walked out of a psychiatrist’s office.
“Why are you here?” I asked, thinking that my neighbor, a theology professor, had some professional reason to be meeting with a psychiatrist, perhaps some type of community project. As the question escaped from my lips, however, I had an instant sense of regret and made a “note to self” in bold, all capital letters with a few exclamation points: Don’t ever ask friends or neighbors why they are visiting a psychiatrist.
Fast-forward a number of decades, and I received an email from that neighbor. Charles Marsh, is now a professor of religious studies at the University of Virginia, Charlottesville, director of the Lived Theology Project, and author of several books. He sent me a link to an article he’d written about his treatment for an anxiety disorder and let me know he was working on a book on the topic. I later received the galleys for his manuscript, Evangelical Anxiety: A Memoir, which was released last month by HarperOne.
Professor Marsh opens his story as he’s sitting with his family in church, listening to his pastor’s sermon. It is a quiet April day, and as they are throughout this memoir, his descriptions are so vivid that the reader is sitting next to him in his familiar pew, there in that church on that Sunday, seeing what he sees, smelling what he smells, and feeling what he feels. The pastor confers a wish on his congregants: He’d like them all to have a nervous breakdown in their youth. He goes on to say that if Martin Luther had lived in the days of Prozac, his inner torment would have been quelled, and there would have been no Protestant reformation. Professor Marsh then treats us to the first of many humorous moments – he rushes home and swallows a tablet of Ativan.
Professor Marsh focuses on a single dividing point for his life, a day in the fall of 1981. He was resting on his bed in his dorm room at Harvard Divinity School at the ripe age of 23 years, 6 months, and 3 days (but who’s counting), when all of who he was changed. He described what he went through that night:
It was then that a high pandemonium ripped away everything protecting me from the world outside. I was no longer a person alone in his room. In an instant, I could hear all things inside my body in their deepest repercussions. My heart and its soft aortic murmur, my breath’s every exhalation and inhalation, the downward silences, the laborious intake – would this one be the last? How much noise the body makes when amped up on fear! I could hear the hiss of molecules colliding. And outside in the yellow night, the compressors harrumphing atop the nearby physics building, the sound of car engines and slamming doors. All these things I heard as tormenting assault, a soundscape I could not mute. I’d become a thought thinking about thinking itself and nothing else, metaphysics’ ancient curse. A cogitation cycling through every autonomous body function, placing on each a question mark like flowers for the dead.
This moment in time – this “breakdown,” as Professor Marsh repeatedly refers to it – bifurcated his life. He went from being a person who lived “disguised to myself as unaghast and free” to someone who could no longer find escape in his reading, who struggled in his own skin and his own mind, and who, for lack of a better description, was tortured. The “breakdown” passed, and Professor Marsh diagnosed himself with generalized anxiety disorder.
That night, he did not go to an emergency department nor did he seek help from services that were available to Harvard students. There was no psychiatrist, no therapy, no medication. It was, for him, with his fundamentalist Christian background, a religious event of sorts.
I counted it all joy if I should suffer. My sorrow, my soul’s sin-sickness, was not unintelligible – it was a kind of blessing, something that might draw me, like a medieval saint, to the suffering of my Lord, something that would testify wordlessly to my heroic exertion to attain purity. And, at least during those late days of autumn 1981, the heavens above and the earth below, spirit and flesh, felt miraculously aligned. Though suffering, this was the life I had craved.
Charles Marsh grew up as a Baptist pastor’s son in the Deep South during a time when the civil rights movement came to a head, and life was marked by fear and change. The memoir is not simply about one man’s struggle with an anxiety disorder, but a beautifully written account of life as an evangelical Christian during a tumultuous time of racial tensions and horrible violence. He details his life as a lonely only child in a God-fearing world cast in dark shadows, one where he struggled to belong and called out to his mother in the nights. Inside this world, Professor Marsh searched for his own religious identity, with the pride of being a high school “Jesus freak,” running alongside his repressed and frustrated sexual longings.
It was a world of good and bad, of heaven and hell, only the two became so confused as he talked about his existence full of fears: The windows were barred; violence and fear were central in his Alabama hometown, “the epicenter of white terrorism,” and then later when his family moved to Mississippi. He feared the barking dogs that guarded the houses, the bullies who tormented him, and the bullying in which, he too, joined in. He feared the switch-wielding adults – his mother, his principals, his coaches, and his youth pastor, all set on “breaking the will of the child,” a term he explains to be a Christian concept in which the child’s own will is broken so that he will be submissive to his parents and to God.
Professor Marsh wanted so much to be good. And we’re not sure he even knew what that was as he battled his desire to conform and belong, and his ever-present sexual impulses. Even as an adult, he was certain his mother would know if he had premarital sex and he would have to kill himself. Sex outside of marriage was the one unpardonable sin.
He suffered in silence and shame. It was not until a few years later that he entered psychotherapy as a doctoral student. When he moved to Baltimore, he again looked for a therapist and eventually found himself with a psychiatrist who was training to be a psychoanalyst in the hospital where I was a resident. This psychoanalysis proved to be transformative and healing, but first, Professor Marsh needed to reconcile his treatment with his religious beliefs, as therapy and fundamental religion travel different roads.
Analysis and faith traverse similar terrain – they understand how language and narrative heal. They may see each other as strangers or competitors, but they need not. Like prayer, the analytic dialogue slows down to ponder, to meander, to piece together, to redeem; both inspire the mind toward hope under the influence of an empathetic listener. Neither needs the other to effectuate its truths, but they follow parallel tracks into the mysteries of being human, where all truth is God’s truth. It’s more than fine that they neither merge nor collide.
He goes on to describe how powerful the process was for him and his healing.
Analysis is the space where one feels – where I felt in an embodied way, in the unhurried hours over months and years – a trust in the beautiful interplay between the center and the extremes. My body and mind would not be raised in resurrected splendor in the course of the treatment. I wish to emphasize the point. It was tempting to think that it would, that I would undergo a miraculous transformation. If not resurrected splendor, then surely I would take on the “new man.” Instead, I received the gift of mortal life: the freedom to be imperfect, to have fears and face them, to accept brokenness, to let go of the will to control all outcomes.
Professor Marsh’s use of language is extraordinary; he has a gift for metaphors and descriptions, and he carries the reader alongside him on a splendid journey. It has to be said, however, that he assumes a lot: He is a sophisticated scholar who mentions religious leaders, philosophers, historical characters, and the occasional rock song, with no patience for those who don’t follow his quick transitions and impressive vocabulary; I could have read this book with a dictionary beside me (but I didn’t).
It’s an illuminating journey, often sad and disturbing, sometimes funny and endearing, and ultimately uplifting. In our skeptical world where psychiatrists are so are often undone, it is refreshing to read a memoir where the psychiatrist is the good guy and the patient emerges healed and whole.
Dr. Miller, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore. She has disclosed no relevant financial relationships. A version of this article first appeared on Medscape.com.
Anxiety spreads from mother to daughter, father to son
The new findings suggest that children learn anxious behavior from their parents, study investigator Barbara Pavlova, PhD, clinical psychologist with Nova Scotia Health Authority, told this news organization.
“This means that transmission of anxiety from parents to children may be preventable,” said Dr. Pavlova, assistant professor, department of psychiatry, Dalhousie University, Halifax, Canada.
“Treating parents’ anxiety is not just important for their own health but also for the health of their children. This may be especially true if the child and the parent are the same sex,” Dr. Pavlova added.
The study was published online in JAMA Network Open.
Parental anxiety a disruptor
Anxiety disorders run in families. Both genes and environment are thought to be at play, but there are few data on sex-specific transmission from parent to child.
To investigate, the researchers conducted a cross-sectional study of 203 girls and 195 boys and their parents. The average age of the children was 11 years, and they had a familial risk for mood disorders.
Anxiety disorder in a same-sex parent was significantly associated with anxiety disorder in offspring (odds ratio, 2.85; 95% confidence interval, 1.52-5.34; P = .001) but not in an opposite-sex parent (OR, 1.51; 95% CI, 0.81-2.81; P = .20).
Living with a same-sex parent without anxiety was associated with lower rates of offspring anxiety (OR, 0.38; 95% CI, 0.22-0.67; P = .001).
Among all 398 children, 108 (27%) had been diagnosed with one or more anxiety disorders, including generalized anxiety disorder (7.8%), social anxiety disorder (6.3%), separation anxiety disorder (8.6%), specific phobia (8%), and anxiety disorder not otherwise specified (5%).
Rates of anxiety disorders in children increased with age, from 14% in those younger than 9 years to 52% in those older than 15 years. Anxiety disorders were similarly common among boys (24%) and girls (30%).
Rates of anxiety disorders were lowest (24%) in children of two parents without anxiety disorders and highest (41%) in cases in which both parents had anxiety disorders.
The findings point to the possible role of environmental factors, “such as modeling and vicarious learning,” in the transmission of anxiety from parents to their children, the researchers note.
“A child receives [a] similar amount of genetic information from each biological parent. A strong same-sex parent effect suggests children learn resilience by modeling the behavior of their same-sex parent. A parent’s anxiety disorder may disrupt this protective learning,” said Dr. Pavlova.
Early diagnosis, treatment essential
Reached for comment, Jill Emanuele, PhD, vice president of clinical training for the Child MIND Institute, New York, said that when it comes to anxiety, it’s important to assess and treat both the parent and the child.
“We know that both environment and genetics play a role in anxiety disorders. From a clinical perspective, if we see a parent with an anxiety disorder, we know that there is a chance that that is also going to affect the child – whether or not the child has an anxiety disorder,” Dr. Emanuele said in an interview.
“Anxiety disorders are the most common psychiatric disorders diagnosed. We also know that anxiety disorders emerge earlier than mood disorders and certainly can emerge in childhood. It’s important to address anxiety early because those same problems can continue into adulthood if left untreated,” Dr. Emanuele added.
The study was supported by the Canada Research Chairs Program, the Canadian Institutes of Health Research, the Brain & Behavior Research Foundation, the Nova Scotia Health Research Foundation, and the Dalhousie Medical Research Foundation. The authors have disclosed no relevant financial relationships. Dr. Emanuele is a board member with the Anxiety and Depression Association of America.
A version of this article first appeared on Medscape.com.
The new findings suggest that children learn anxious behavior from their parents, study investigator Barbara Pavlova, PhD, clinical psychologist with Nova Scotia Health Authority, told this news organization.
“This means that transmission of anxiety from parents to children may be preventable,” said Dr. Pavlova, assistant professor, department of psychiatry, Dalhousie University, Halifax, Canada.
“Treating parents’ anxiety is not just important for their own health but also for the health of their children. This may be especially true if the child and the parent are the same sex,” Dr. Pavlova added.
The study was published online in JAMA Network Open.
Parental anxiety a disruptor
Anxiety disorders run in families. Both genes and environment are thought to be at play, but there are few data on sex-specific transmission from parent to child.
To investigate, the researchers conducted a cross-sectional study of 203 girls and 195 boys and their parents. The average age of the children was 11 years, and they had a familial risk for mood disorders.
Anxiety disorder in a same-sex parent was significantly associated with anxiety disorder in offspring (odds ratio, 2.85; 95% confidence interval, 1.52-5.34; P = .001) but not in an opposite-sex parent (OR, 1.51; 95% CI, 0.81-2.81; P = .20).
Living with a same-sex parent without anxiety was associated with lower rates of offspring anxiety (OR, 0.38; 95% CI, 0.22-0.67; P = .001).
Among all 398 children, 108 (27%) had been diagnosed with one or more anxiety disorders, including generalized anxiety disorder (7.8%), social anxiety disorder (6.3%), separation anxiety disorder (8.6%), specific phobia (8%), and anxiety disorder not otherwise specified (5%).
Rates of anxiety disorders in children increased with age, from 14% in those younger than 9 years to 52% in those older than 15 years. Anxiety disorders were similarly common among boys (24%) and girls (30%).
Rates of anxiety disorders were lowest (24%) in children of two parents without anxiety disorders and highest (41%) in cases in which both parents had anxiety disorders.
The findings point to the possible role of environmental factors, “such as modeling and vicarious learning,” in the transmission of anxiety from parents to their children, the researchers note.
“A child receives [a] similar amount of genetic information from each biological parent. A strong same-sex parent effect suggests children learn resilience by modeling the behavior of their same-sex parent. A parent’s anxiety disorder may disrupt this protective learning,” said Dr. Pavlova.
Early diagnosis, treatment essential
Reached for comment, Jill Emanuele, PhD, vice president of clinical training for the Child MIND Institute, New York, said that when it comes to anxiety, it’s important to assess and treat both the parent and the child.
“We know that both environment and genetics play a role in anxiety disorders. From a clinical perspective, if we see a parent with an anxiety disorder, we know that there is a chance that that is also going to affect the child – whether or not the child has an anxiety disorder,” Dr. Emanuele said in an interview.
“Anxiety disorders are the most common psychiatric disorders diagnosed. We also know that anxiety disorders emerge earlier than mood disorders and certainly can emerge in childhood. It’s important to address anxiety early because those same problems can continue into adulthood if left untreated,” Dr. Emanuele added.
The study was supported by the Canada Research Chairs Program, the Canadian Institutes of Health Research, the Brain & Behavior Research Foundation, the Nova Scotia Health Research Foundation, and the Dalhousie Medical Research Foundation. The authors have disclosed no relevant financial relationships. Dr. Emanuele is a board member with the Anxiety and Depression Association of America.
A version of this article first appeared on Medscape.com.
The new findings suggest that children learn anxious behavior from their parents, study investigator Barbara Pavlova, PhD, clinical psychologist with Nova Scotia Health Authority, told this news organization.
“This means that transmission of anxiety from parents to children may be preventable,” said Dr. Pavlova, assistant professor, department of psychiatry, Dalhousie University, Halifax, Canada.
“Treating parents’ anxiety is not just important for their own health but also for the health of their children. This may be especially true if the child and the parent are the same sex,” Dr. Pavlova added.
The study was published online in JAMA Network Open.
Parental anxiety a disruptor
Anxiety disorders run in families. Both genes and environment are thought to be at play, but there are few data on sex-specific transmission from parent to child.
To investigate, the researchers conducted a cross-sectional study of 203 girls and 195 boys and their parents. The average age of the children was 11 years, and they had a familial risk for mood disorders.
Anxiety disorder in a same-sex parent was significantly associated with anxiety disorder in offspring (odds ratio, 2.85; 95% confidence interval, 1.52-5.34; P = .001) but not in an opposite-sex parent (OR, 1.51; 95% CI, 0.81-2.81; P = .20).
Living with a same-sex parent without anxiety was associated with lower rates of offspring anxiety (OR, 0.38; 95% CI, 0.22-0.67; P = .001).
Among all 398 children, 108 (27%) had been diagnosed with one or more anxiety disorders, including generalized anxiety disorder (7.8%), social anxiety disorder (6.3%), separation anxiety disorder (8.6%), specific phobia (8%), and anxiety disorder not otherwise specified (5%).
Rates of anxiety disorders in children increased with age, from 14% in those younger than 9 years to 52% in those older than 15 years. Anxiety disorders were similarly common among boys (24%) and girls (30%).
Rates of anxiety disorders were lowest (24%) in children of two parents without anxiety disorders and highest (41%) in cases in which both parents had anxiety disorders.
The findings point to the possible role of environmental factors, “such as modeling and vicarious learning,” in the transmission of anxiety from parents to their children, the researchers note.
“A child receives [a] similar amount of genetic information from each biological parent. A strong same-sex parent effect suggests children learn resilience by modeling the behavior of their same-sex parent. A parent’s anxiety disorder may disrupt this protective learning,” said Dr. Pavlova.
Early diagnosis, treatment essential
Reached for comment, Jill Emanuele, PhD, vice president of clinical training for the Child MIND Institute, New York, said that when it comes to anxiety, it’s important to assess and treat both the parent and the child.
“We know that both environment and genetics play a role in anxiety disorders. From a clinical perspective, if we see a parent with an anxiety disorder, we know that there is a chance that that is also going to affect the child – whether or not the child has an anxiety disorder,” Dr. Emanuele said in an interview.
“Anxiety disorders are the most common psychiatric disorders diagnosed. We also know that anxiety disorders emerge earlier than mood disorders and certainly can emerge in childhood. It’s important to address anxiety early because those same problems can continue into adulthood if left untreated,” Dr. Emanuele added.
The study was supported by the Canada Research Chairs Program, the Canadian Institutes of Health Research, the Brain & Behavior Research Foundation, the Nova Scotia Health Research Foundation, and the Dalhousie Medical Research Foundation. The authors have disclosed no relevant financial relationships. Dr. Emanuele is a board member with the Anxiety and Depression Association of America.
A version of this article first appeared on Medscape.com.
Americans’ biggest source of anxiety? Hint: It’s not COVID-19
, results from a new national report from the American Psychiatric Association show.
“The economy seems to have supplanted COVID as a major factor in Americans’ day-to-day anxiety,” APA President Rebecca W. Brendel, MD, JD, said in a news release.
“Knowing that so many Americans are concerned about finances is important because it can prepare clinicians to be ready to approach the subject, which is one that people are often reluctant or ashamed to raise on their own,” Dr. Brendel told this news organization.
What’s the best way to bring up the sensitive topic of money?
“In general, it’s best to start with open-ended questions to allow individuals in therapy to share what is on their minds, explore their concerns, and develop strategies to address these issues. Once a patient raises a concern, that is a good time to ask more about the issues they’ve raised and to explore other potential sources of anxiety or stress,” said Dr. Brendel.
The latest APA poll was conducted by Morning Consult, June 18-20, 2022, among a nationally representative sample of 2,210 adults.
In addition to an uptick in worry about inflation, the poll shows that more than half (51%) of adults are worried about a potential loss of income.
Hispanic adults (66%), mothers (65%), millennials (63%), and genZers (62%) are among the groups most likely to be concerned about income loss.
“Stress is not good for health, mental or physical. So, while it’s a reality that Americans are faced with finding ways of making ends meet, it’s more important than ever to make sure that we are all accessing the care that we need,” said Dr. Brendel.
“People should be aware that there may be low- or no-cost options such as community mental health centers or employer-sponsored resources to address mental health concerns,” she added.
Coping with traumatic events
The latest poll also shows that about one-third of adults are worried about gun violence (35% overall, 47% among genZers) or a natural disaster (29%) personally affecting them.
Climate change anxiety is also up slightly in June, compared with May (+4%).
The same goes for mid-term election-related anxiety (+3%) – particularly among Democrats (54% vs. 59%) compared with Republicans (48% vs. 48%).
The latest poll provides insight how Americans would cope after a traumatic event. More adults report they will turn to family and friends for support (60%) than practice self-care (42%), speak openly about their feelings (37%), or seek help from a professional (31%). Nearly one-third (30%) say they will move on from it and not dwell on their feelings.
GenZers are the least likely to say they will speak openly about their feelings (29%) and are less likely than millennials to say they would speak to a health professional (28% vs. 38%).
“While many people show resilience, it’s troubling that most Americans wouldn’t speak openly about their feelings after a traumatic event,” APA CEO and Medical Director Saul Levin, MD, said in the news release.
“In many ways, naming feelings is the most important step toward healing, and this reluctance to air our thoughts may indicate that mental health stigma is still a powerful force in our society,” Dr. Levin said.
After a traumatic current event, 41% of Americans say they consume more news and 30% say they take in more social media, but the majority say this does not impact their mental health, the poll shows.
Two in five adults (43%) say the news of a traumatic event makes them feel more informed, 32% say it makes them feel more anxious, and about one-quarter say it makes them feel overwhelmed (27%) or discouraged (24%).
Dr. Brendel noted that, after a traumatic event, “it’s expected that people may experience anxiety or other symptoms for brief periods of time. However, no two people experience things the same way. If symptoms don’t go away, are overwhelming, or get worse over time, for example, it’s critical to seek help right away.”
The June poll shows that 50% of Americans are anxious about the future of reproductive rights but the poll was conducted before the Dobbs ruling.
Anxiety around COVID-19 continues to ease, with about 47% of Americans saying they are concerned about the pandemic, down 2% among all Americans and 16% among Black Americans since May.
The APA’s Healthy Minds Monthly tracks timely mental health issues throughout the year. The APA also releases its annual Healthy Minds Poll each May in conjunction with Mental Health Awareness Month.
A version of this article first appeared on Medscape.com.
, results from a new national report from the American Psychiatric Association show.
“The economy seems to have supplanted COVID as a major factor in Americans’ day-to-day anxiety,” APA President Rebecca W. Brendel, MD, JD, said in a news release.
“Knowing that so many Americans are concerned about finances is important because it can prepare clinicians to be ready to approach the subject, which is one that people are often reluctant or ashamed to raise on their own,” Dr. Brendel told this news organization.
What’s the best way to bring up the sensitive topic of money?
“In general, it’s best to start with open-ended questions to allow individuals in therapy to share what is on their minds, explore their concerns, and develop strategies to address these issues. Once a patient raises a concern, that is a good time to ask more about the issues they’ve raised and to explore other potential sources of anxiety or stress,” said Dr. Brendel.
The latest APA poll was conducted by Morning Consult, June 18-20, 2022, among a nationally representative sample of 2,210 adults.
In addition to an uptick in worry about inflation, the poll shows that more than half (51%) of adults are worried about a potential loss of income.
Hispanic adults (66%), mothers (65%), millennials (63%), and genZers (62%) are among the groups most likely to be concerned about income loss.
“Stress is not good for health, mental or physical. So, while it’s a reality that Americans are faced with finding ways of making ends meet, it’s more important than ever to make sure that we are all accessing the care that we need,” said Dr. Brendel.
“People should be aware that there may be low- or no-cost options such as community mental health centers or employer-sponsored resources to address mental health concerns,” she added.
Coping with traumatic events
The latest poll also shows that about one-third of adults are worried about gun violence (35% overall, 47% among genZers) or a natural disaster (29%) personally affecting them.
Climate change anxiety is also up slightly in June, compared with May (+4%).
The same goes for mid-term election-related anxiety (+3%) – particularly among Democrats (54% vs. 59%) compared with Republicans (48% vs. 48%).
The latest poll provides insight how Americans would cope after a traumatic event. More adults report they will turn to family and friends for support (60%) than practice self-care (42%), speak openly about their feelings (37%), or seek help from a professional (31%). Nearly one-third (30%) say they will move on from it and not dwell on their feelings.
GenZers are the least likely to say they will speak openly about their feelings (29%) and are less likely than millennials to say they would speak to a health professional (28% vs. 38%).
“While many people show resilience, it’s troubling that most Americans wouldn’t speak openly about their feelings after a traumatic event,” APA CEO and Medical Director Saul Levin, MD, said in the news release.
“In many ways, naming feelings is the most important step toward healing, and this reluctance to air our thoughts may indicate that mental health stigma is still a powerful force in our society,” Dr. Levin said.
After a traumatic current event, 41% of Americans say they consume more news and 30% say they take in more social media, but the majority say this does not impact their mental health, the poll shows.
Two in five adults (43%) say the news of a traumatic event makes them feel more informed, 32% say it makes them feel more anxious, and about one-quarter say it makes them feel overwhelmed (27%) or discouraged (24%).
Dr. Brendel noted that, after a traumatic event, “it’s expected that people may experience anxiety or other symptoms for brief periods of time. However, no two people experience things the same way. If symptoms don’t go away, are overwhelming, or get worse over time, for example, it’s critical to seek help right away.”
The June poll shows that 50% of Americans are anxious about the future of reproductive rights but the poll was conducted before the Dobbs ruling.
Anxiety around COVID-19 continues to ease, with about 47% of Americans saying they are concerned about the pandemic, down 2% among all Americans and 16% among Black Americans since May.
The APA’s Healthy Minds Monthly tracks timely mental health issues throughout the year. The APA also releases its annual Healthy Minds Poll each May in conjunction with Mental Health Awareness Month.
A version of this article first appeared on Medscape.com.
, results from a new national report from the American Psychiatric Association show.
“The economy seems to have supplanted COVID as a major factor in Americans’ day-to-day anxiety,” APA President Rebecca W. Brendel, MD, JD, said in a news release.
“Knowing that so many Americans are concerned about finances is important because it can prepare clinicians to be ready to approach the subject, which is one that people are often reluctant or ashamed to raise on their own,” Dr. Brendel told this news organization.
What’s the best way to bring up the sensitive topic of money?
“In general, it’s best to start with open-ended questions to allow individuals in therapy to share what is on their minds, explore their concerns, and develop strategies to address these issues. Once a patient raises a concern, that is a good time to ask more about the issues they’ve raised and to explore other potential sources of anxiety or stress,” said Dr. Brendel.
The latest APA poll was conducted by Morning Consult, June 18-20, 2022, among a nationally representative sample of 2,210 adults.
In addition to an uptick in worry about inflation, the poll shows that more than half (51%) of adults are worried about a potential loss of income.
Hispanic adults (66%), mothers (65%), millennials (63%), and genZers (62%) are among the groups most likely to be concerned about income loss.
“Stress is not good for health, mental or physical. So, while it’s a reality that Americans are faced with finding ways of making ends meet, it’s more important than ever to make sure that we are all accessing the care that we need,” said Dr. Brendel.
“People should be aware that there may be low- or no-cost options such as community mental health centers or employer-sponsored resources to address mental health concerns,” she added.
Coping with traumatic events
The latest poll also shows that about one-third of adults are worried about gun violence (35% overall, 47% among genZers) or a natural disaster (29%) personally affecting them.
Climate change anxiety is also up slightly in June, compared with May (+4%).
The same goes for mid-term election-related anxiety (+3%) – particularly among Democrats (54% vs. 59%) compared with Republicans (48% vs. 48%).
The latest poll provides insight how Americans would cope after a traumatic event. More adults report they will turn to family and friends for support (60%) than practice self-care (42%), speak openly about their feelings (37%), or seek help from a professional (31%). Nearly one-third (30%) say they will move on from it and not dwell on their feelings.
GenZers are the least likely to say they will speak openly about their feelings (29%) and are less likely than millennials to say they would speak to a health professional (28% vs. 38%).
“While many people show resilience, it’s troubling that most Americans wouldn’t speak openly about their feelings after a traumatic event,” APA CEO and Medical Director Saul Levin, MD, said in the news release.
“In many ways, naming feelings is the most important step toward healing, and this reluctance to air our thoughts may indicate that mental health stigma is still a powerful force in our society,” Dr. Levin said.
After a traumatic current event, 41% of Americans say they consume more news and 30% say they take in more social media, but the majority say this does not impact their mental health, the poll shows.
Two in five adults (43%) say the news of a traumatic event makes them feel more informed, 32% say it makes them feel more anxious, and about one-quarter say it makes them feel overwhelmed (27%) or discouraged (24%).
Dr. Brendel noted that, after a traumatic event, “it’s expected that people may experience anxiety or other symptoms for brief periods of time. However, no two people experience things the same way. If symptoms don’t go away, are overwhelming, or get worse over time, for example, it’s critical to seek help right away.”
The June poll shows that 50% of Americans are anxious about the future of reproductive rights but the poll was conducted before the Dobbs ruling.
Anxiety around COVID-19 continues to ease, with about 47% of Americans saying they are concerned about the pandemic, down 2% among all Americans and 16% among Black Americans since May.
The APA’s Healthy Minds Monthly tracks timely mental health issues throughout the year. The APA also releases its annual Healthy Minds Poll each May in conjunction with Mental Health Awareness Month.
A version of this article first appeared on Medscape.com.
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.
The mother’s double jeopardy
Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”
Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.
Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.
Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
Internalized sexism
As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.
Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.1 This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?
Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.
An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.
At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.
Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.
“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.2
Intensive mothering
When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”
Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”3 Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.
Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”3 She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.3 Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.
In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.4
There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].
References
1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.
2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.
3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.
4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.
Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”
Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.
Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.
Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
Internalized sexism
As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.
Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.1 This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?
Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.
An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.
At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.
Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.
“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.2
Intensive mothering
When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”
Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”3 Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.
Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”3 She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.3 Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.
In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.4
There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].
References
1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.
2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.
3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.
4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.
Jamestown, Colo., is a small mountain town several miles up through Lefthand Canyon out of Boulder, in the Rocky Mountains. The canyon roads are steep, winding, and narrow, and peopled by brightly clad cyclists struggling up the hill and flying down faster than the cars. The road through Jamestown is dusty in the summer with brightly colored oil barrels strategically placed in the middle of the single road through town. Slashed across their sides: “SLOW DOWN! Watch out for our feral children!”
Wild child or hothouse child? What is the best choice? Women bear the brunt of this deciding, whether they are working outside of the home, or stay-at-home caregivers, or both. Women know they will be blamed if they get it wrong.
Society has exacted a tall order on women who choose to have children. Patriarchal norms ask (White) women who choose both to work and have children, if they are really a “stay-at-home” mother who must work, or a “working” mother who prefers work over their children. The underlying attitude can be read as: “Are you someone who prioritizes paid work over caregiving, or are you someone who prioritizes caregiving over work?” You may be seen as a bad mother if you prioritize work over the welfare of your child. If you prioritize your child over your work, then you are not a reliable, dedicated worker. The working mother can’t win.
Woman’s central question is what kind of mother should I be? Mothers struggle with this question all their lives; when their child has difficulties, society’s question is what did you do wrong with your child? Mothers internalize the standard of the “good mother” and are aware of each minor transgression that depicts them as the “bad mother.” It is hard to escape the impossible perfectionistic standard of the good mother. But perhaps it has come time to push back on the moral imbalance.
Internalized sexism
As women move out of the home into the workplace, the societal pressures to maintain the status quo bear down on women, trying to keep them in their place.
Social pressures employ subtle “technologies of the self,” so that women – as any oppressed group – learn to internalize these technologies, and monitor themselves.1 This is now widely accepted as internalized sexism, whereby women feel that they are not good enough, do not have the right qualifications, and are “less” than the dominant group (men). This phenomenon is also recognized when racial and ethnic biases are assimilated unconsciously, as internalized racism. Should we also have internalized “momism”?
Women are caught between trying to claim their individualism as well as feeling the responsibility to be the self-denying mother. Everyone has an opinion about the place of women. Conservative activist Phyllis Schlafly considered “women’s lib” to be un-American, citing women in the military and the establishment of federal day care centers as actions of a communist state. A similar ideology helped form the antifeminist organization Concerned Women for America, which self-reports that it is the largest American public policy women’s organization. Formed in opposition to the National Organization for Women, CWA is focused on maintaining the traditional family, as understood by (White) evangelical Christians.
An example similar to CWA is the Council of Biblical Manhood and Womanhood. It was established to help evangelical Christian churches defend themselves against an accommodation of secular feminism and also against evangelical feminism (which pushes for more equality in the church). It promotes complementarianism – the idea that masculinity and femininity are ordained by God and that men and women are created to complement each other.
At the other extreme, the most radical of feminists believe in the need to create a women-only society where women would be free from the patriarchy. Less angry but decidedly weirder are the feminists called “FEMEN” who once staged a protest at the Vatican where topless women feigned intercourse with crucifixes, chanting slogans against the pope and religion.
Most women tread a path between extremes, a path which is difficult and lonely. Without a firm ideology, this path is strewn with doubts and pitfalls. Some career-oriented women who have delayed motherhood, knowing that they will soon be biologically past their peak and possibly also without a partner, wonder if they should become single mothers using sperm donation. For many women, the workplace does not offer much help with maternity leave or childcare. Even when maternity leave is available, there is a still a lack of understanding about what is needed.
“Think of it as caregiver bias. If you just extend maternity leave, what is implied is that you’re still expecting me to be the primary source of care for my child, when in fact my partner wants to share the load and will need support to do so as well,” said Pamela Culpepper, an expert in corporate diversity and inclusion.2
Intensive mothering
When the glamor of the workplace wears off and/or when the misogyny and the harassment become too much, women who have the financial stability may decide to return to the role of the stay-at-home mother. Perhaps, in the home, she can feel fulfilled. Yet, young American urban and suburban mothers now parent under a new name – “intensive mothering.”
Conducting in-depth interviews of 38 women of diverse backgrounds in the United States, Sharon Hays found women describing their 2- to 4-year-old children as innocent and priceless, and believing that they – the mothers – should be primarily responsible for rearing their children, using “child-rearing methods that are child centered, expert guided, emotionally absorbing, labor intensive, and financially expensive.”3 Ms. Hays clarified four beliefs that were common to all the women in the study: mothers are more suitable caregivers than fathers; mothering should be child centered; parenting consists of a set of skills that need to be learned; and parenting is labor-intensive but an emotionally fulfilling activity.
Hays wondered if this type of mothering developed as the last defense against “the impoverishment of social ties, communal obligations and unremunerated commitments.”3 She suggested that women succumbing to social pressures to return to the home is yet another example of how society is set up to benefit men, capitalism, political leaders, and those who try to maintain a “traditional” form of family life.3 Ms. Hays concluded that the practice of intensive mothering is a class-based practice of privileged white women, entangled with capitalism in that the buying of “essential” baby products is equated with good mothering. She found this ideology to be oppressive of all women, regardless of their social class, ethnic background, household composition, and financial situation. Ms. Hays noted that many women experience guilt for not matching up to these ideals.
In “Dead End Feminism,” Elisabeth Badinter asks if the upheaval in the role of women has caused so much uncertainty that it is easier for women to regress to a time when they were in the home and knew themselves as mothers. They ask if this has been reinforced by the movement to embrace all things natural, eschewing the falseness of chemicals and other things that threaten Mother Earth.4
There is no escaping the power of the mother: she will continue to symbolize all that is good and bad as the embodiment of the Mother Archetype. All of this is the background against which you will see the new mother in the family. She will not articulate her dilemma, that is your role as the family psychiatrist.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at [email protected].
References
1. Martin LH et al (eds.). Technologies of the Self: A Seminar with Michel Foucault. University of Massachusetts Press: Amherst, Mass.: University of Massachusetts Press, 2022.
2. How Pamela Culpepper Is Changing The Narrative Of Women In The Workplace. Huffpost. 2020 Mar 6. https://www.huffpost.com/entry/pamela-culpepper-diversity-inclusion-empowerment_n_5e56b6ffc5b62e9dc7dbc307.
3. Hays S. Cultural Contradictions of Motherhood. Yale University Press: New Haven, Conn.: Yale University Press, 1996.
4. Badinter E. (translated by Borossa J). Dead End Feminism. Malden, Mass.: Polity Press, 2006.
Generalized anxiety disorder: 8 studies of biological interventions
Generalized anxiety disorder (GAD) typically begins in early adulthood and persists throughout life. Many individuals with GAD report they have felt anxious their entire lives. The essential symptom of GAD is excessive anxiety and worry about numerous events or activities. The intensity, duration, and/or frequency of the anxiety and worry are out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control their worry and prevent worrisome thoughts from interfering with attention to everyday tasks.1
Treatment of GAD typically consists of psychotherapy and pharmacotherapy. Several studies have suggested that concurrent psychotherapy amplifies the benefits of pharmacotherapy.2-5 Additionally, combined treatment may differentially target specific symptoms (eg, cognitive vs somatic). The addition of psychotherapy may also increase treatment adherence and decrease potential adverse effects of pharmacotherapy.
Multiple classes of medications are available for treating GAD. Current guidelines and evidence suggest that selective serotonin reuptake inhibitors (SSRIs) should be considered a first-line intervention, followed by serotonin-norepinephrine reuptake inhibitors.6-11 While the evidence supporting pharmacotherapy for GAD continues to expand, many patients with GAD do not respond to first-line treatment. There is limited data regarding second-line or augmentation strategies for treating these patients. Because current treatment options for GAD are commonly associated with suboptimal treatment outcomes, researchers are investigating the use of nonpharmacologic biological interventions, such as repetitive transcranial magnetic stimulation (rTMS), which was first cleared by the FDA to treat major depressive disorder (MDD) in 2008.
In Part 1 of this 2-part article, we review 8 randomized controlled trials (RCTs) of biological interventions for GAD that have been published within the last 5 years (Table12-19).
1. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
GAD is highly prevalent in adolescents, and SSRIs are often used as first-line agents. However, treatment response is often variable, and clinicians often use trial-and-error to identify an appropriate medication and dose that will result in meaningful improvement. Understanding an individual’s pharmacokinetic response may help predict response and guide therapy. Adult studies have shown cytochrome P450 (CYP) 2C19 metabolizes several SSRIs, including escitalopram, with faster CYP2C19 metabolism leading to decreased plasma concentrations. Strawn et al12 studied the effects of escitalopram in adolescents with GAD as well as the effects of CYP2C19 metabolism.
Study design
- A double-blind, placebo-controlled trial evaluated 51 adolescents (age 12 to 17) who met DSM-IV-TR criteria for GAD. They had a baseline Pediatric Anxiety Rating Scale (PARS) score ≥15 and a Clinical Global Impressions–Severity (CGI-S) Scale score ≥4.
- Participants were randomized to escitalopram (n = 26; scheduled titration to 15 mg/d, then flexible to 20 mg/d), or placebo (n = 25) and monitored for 8 weeks.
- Patients with panic disorder, agoraphobia, or social anxiety disorder were also enrolled, but GAD was the primary diagnosis.
- The primary outcome was change in PARS score and change from baseline in CGI-S and Clinical Global Impressions–Improvement (CGI-I) scale scores, with assessments completed at Week 1, Week 2, Week 4, Week 6, and Week 8, or at early termination.
- Genomic DNA was obtained via buccal swab to assess 9 alleles of CYP2C19. Plasma concentrations of escitalopram and its major metabolite, desmethylescitalopram, were collected to assess plasma escitalopram and desmethylescitalopram area under the curve for 24 hours (AUC0-24) and maximum plasma concentration (CMAX).
Outcomes
- Escitalopram was superior to placebo, evident by statistically significantly greater changes in PARS and CGI scores.
- Greater improvement over time on PARS was correlated with intermediate CYP2C19 metabolizers, and greater response as measured by CGI-I was associated with having at least 1 long allele of SLC6A4 and being an intermediate CYP2C19 metabolizer.
- While plasma escitalopram exposure (AUC0-24) significantly decreased and desmethylcitalopram-to-escitalopram ratios increased with faster CYP2C19 metabolism at 15 mg/d, escitalopram exposure at the 15 mg/d dose and escitalopram-to-desmethylcitalopram ratios did not differ at Week 8 between responders and nonresponders. Patients with activation symptoms had higher CMAX and AUC0-24.
- Changes in vital signs, corrected QT interval, and adverse events were similar in both groups.
Conclusions/limitations
- For adolescents with GAD, escitalopram showed a benefit compared to placebo.
- Allelic differences in CYP2C19 metabolism may lead to variations in pharmacokinetics, and understanding a patient’s CYP2C19 phenotype may help guide dosing escitalopram and predicting adverse effects.
- This study enrolled a small, predominantly female, White, treatment-naïve sample, which may limit conclusions on allelic differences. Additionally, the sample included adolescents with severe anxiety and comorbid anxiety conditions, which may limit generalizability.
Continue to: #2
2. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
Vortioxetine, an FDA-approved antidepressant, has been shown to improve anxiety symptoms in patients with GAD. Additionally, vortioxetine has shown positive effects in patients with MDD, with greater improvement seen in the working and professional population. Due to the overlap between MDD and GAD, Christensen et al13 assessed the effectiveness of vortioxetine on anxiety symptoms in individuals who were working.
Study design
- Researchers conducted a post-hoc analysis of a previously completed randomized, placebo-controlled trial of 301 patients as well as a previously completed randomized, placebo-controlled relapse prevention study of 687 patients. Patients in both groups met DSM-IV-TR criteria for GAD.
- Inclusion criteria included a Hamilton Anxiety Rating Scale (HAM-A) score ≥20 with HAM-A scores ≥2 on items 1 (anxious mood), and 2 (tension), and a Montgomery-Åsberg Depression Rating Scale (MADRS) score ≤16 at screening and baseline.
- Researchers compared participants who were working or pursuing an education vs the full study sample.
Outcomes
- Vortioxetine was significantly associated with benefits in anxiety symptoms, functioning, and quality of life in both working participants and the total population, with the greatest effects seen in professional (ie, managers, administrators) and associate professional (ie, technical, nursing, clerical workers, or secretarial) positions. Working participants who received placebo were more likely to relapse compared to those receiving vortioxetine.
- There did not appear to be a statistically significant benefit or increase in relapse among the skilled labor group (ie, building, electrical/factory worker, or services/sales) while receiving vortioxetine.
Conclusions/limitations
- Vortioxetine may have a more pronounced effect in patients who are working or pursuing an education vs the full GAD population, which suggests that targeting this medication at particular patient demographics may be beneficial.
- Working patients with GAD may also differ from nonworking patients by factors other than work, such as education, support system, motivation, and other personal factors.
- This study was a post-hoc analysis, which limits definitive conclusions but may help guide future studies.
Continue to: #3
3. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
Treatment of GAD should include nonmedication options such as psychotherapy to help enhance efficacy. Few studies have evaluated whether combined cognitive-behavioral therapy (CBT) plus medication has more benefit than medication monotherapy, specifically in patients with GAD. In this randomized trial, Xie et al14 examined how a study population undergoing CBT and receiving duloxetine differed from those receiving duloxetine monotherapy for GAD.
Study design
- In this randomized, open-label trial, adults who met DSM-IV criteria for GAD and had a HAM-A score >14 were randomized to group CBT plus duloxetine (n = 89) or duloxetine only (n = 81), with follow-up at Week 4, Week 8, and Month 3.
- The primary outcomes included response and remission rates based on HAM-A score. Secondary outcomes included HAM-A total score reductions, psychic anxiety (HAMA-PA) and somatic anxiety (HAMA-SA) subscale score reductions, Hamilton Depression Rating Scale score reductions, and reductions in overall illness severity as measured by CGI-S, the Global Assessment of Functioning Scale, and the 12-item Short-Form Health Survey.
Outcomes
- At Week 4, combined therapy was superior to duloxetine alone as evident by the primary and most secondary outcomes, with continued benefits but smaller effect size at Week 8.
- At Month 3, combined therapy was significantly better only in HAM-A total score and HAMA-PA score reductions.
Conclusions/limitations
- Patients who received group CBT plus duloxetine treatment experienced faster improvement of GAD symptoms compared to patients who received duloxetine monotherapy, though the difference reduced over time.
- The most benefit appeared to be for psychic anxiety symptoms, which suggests that group CBT can help change cognition style.
- This study had a short follow-up period, high dropout rates, and recruited patients from only 1 institution.
4. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
Insomnia and anxiety often present together. rTMS has demonstrated efficacy in various psychiatric illnesses, but there is limited research regarding its effectiveness in GAD. Additionally, little is known regarding the benefits of rTMS for patients with comorbid insomnia and GAD. Huang et al15 examined the therapeutic effects of rTMS in patients with comorbid insomnia and GAD.
Continue to: Study design
Study design
- Adults who met DSM-IV criteria for GAD and insomnia were randomized to receive 10 days of low-intensity rTMS on the right parietal lobe (n = 18) or a sham procedure (n = 18). Inclusion criteria also included a score ≥14 on HAM-A, ≥7 on the Pittsburgh Sleep Quality Index (PSQI), and <20 on the 24-item Hamilton Depression Rating Scale (HAM-D).
- rTMS settings included a frequency of 1 Hz, 90% intensity of the resting motor threshold, 3 trains of 500 pulses, and an intertrain interval of 10 minutes.
- Study measurements included HAM-A, PSQI, and HAM-D at baseline, posttreatment at Day 10, Week 2 follow-up, and Month 1 follow-up.
Outcomes
- Significantly more patients in the rTMS group had a meaningful response as measured by change in HAM-A score at posttreatment and both follow-up sessions.
- The rTMS group had significant remission compared to the sham group at posttreatment and Week 2 follow-up, but showed no significant difference at Month 1.
- There were significant improvements in insomnia symptoms in the rTMS group at the posttreatment and follow-up time points.
Conclusions/limitations
- Low-frequency rTMS over the right parietal cortex is an effective treatment option for patients with comorbid GAD and insomnia.
- This study had a small sample size consisting of participants from only 1 institution.
5. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
GAD often presents with comorbid depression. While antidepressants are the standard approach to treatment of both conditions, patients may seek alternative therapies. In previous studies,20Matricaria chamomilla L. (chamomile) has been shown to reduce GAD symptoms, and post-hoc analyses21 have shown its benefits in treating depression. Amsterdam et al16 assessed the effects of chamomile on patients with GAD with and without comorbid depression.
Study design
- As part of an RCT, 179 adults who met DSM-IV-TR criteria for GAD underwent an 8-week open-label phase of chamomile extract therapy (1,500 mg/d). Participants who responded were enrolled in a randomized, double-blind, placebo-control trial. Amsterdam et al16 specifically analyzed the 8-week open label portion of the study.
- Participants were divided into 2 groups: GAD without comorbid depression (n = 100), and GAD with comorbid depression (n = 79).
- Outcome measures included the 7-item generalized anxiety disorder scale (GAD-7), HAM-A, Beck Anxiety Inventory, 17-item HAM-D, 6-item HAM-D, and the Beck Depression Inventory (BDI).
Continue to: Outcomes
Outcomes
- Patients with comorbid depression experienced a greater, statistically significant reduction in HAM-D core symptom scores (depressed mood, guilt, suicide ideation, work and interest, retardation, and somatic symptoms general).
- The comorbid depression group experienced a trend (but not significant) reduction in total HAM-D and BDI scores.
Conclusions/limitations
- Chamomile extract may help reduce depressive symptoms in patients with GAD who also have depression.
- This study was not powered to detect significant differences in depression outcome ratings between groups, was exploratory, and was not a controlled trial.
6. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
Nonpharmacologic modalities, including rTMS, may be effective alternatives for treating GAD. Dilkov et al17 examined whether excitatory rTMS is an effective treatment option for GAD.
Study design
- In this double-blind, sham-controlled trial, adults who met DSM-IV criteria for GAD were randomized to excitatory rTMS of the right dorsolateral prefrontal cortex therapy (n = 15) or a sham procedure (n = 25).
- rTMS settings included a frequency of 20 Hz, 110% intensity of resting motor threshold, 20 trains, 9 seconds/train, and 51-second intertrain intervals.
- Outcomes were measured by HAM-A, CGI, and 21-item HAM-D.
Outcomes
- At the conclusion of 25 treatments, the rTMS group experienced a statistically significant reduction in GAD symptoms as measured by HAM-A.
- Improvements were also noted in the CGI and HAM-D scores in the rTMS group compared to the sham group.
- The benefits continued at the Week 4 follow-up visit.
Conclusions/limitations
- Participants in the rTMS group experienced a significant decrease in anxiety symptoms, which suggests that rTMS may be an effective treatment for GAD.
- The benefits appear sustainable even after the conclusion of the rTMS sessions.
- This study had a small sample size and excluded patients with comorbid psychiatric conditions.
Continue to: #7
7. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
Dysregulated stress response has been proposed as a mechanism for anxiety.22,23 Patients with GAD have been reported to have alterations in cortisol levels, specifically lower morning cortisol levels and a less steep diurnal cortisol slope; however, it is not clear how treatment affects these levels. Keefe et al18 examined whether chamomile therapy in patients with GAD affects cortisol levels.
Study design
- In an 8-week, open-label study, 45 adults who met DSM-IV criteria for GAD received chamomile extract capsules 1,500 mg/d.
- Participants used at-home kits to collect their saliva so cortisol levels could be assessed at 8
am , 12pm , 4pm , and 8pm . - The GAD-7 was used to assess anxiety symptoms.
Outcomes
- Participants who experienced greater improvements in GAD symptoms had relative increases in morning cortisol levels compared to their baseline levels.
- Participants who experienced greater improvements in GAD symptoms had a greater decrease in cortisol levels throughout the day (ie, greater diurnal slope).
Conclusions/limitations
- Greater improvement in GAD symptoms after treatment with chamomile extract appeared to be correlated with increased morning cortisol levels and a steeper diurnal cortisol slope after awakening, which suggests that treatment of GAD may help improve dysregulated stress biology.
- This study had a small sample size and was not placebo-controlled.
Continue to: #8
8. Stein DJ, Khoo JP, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
Compared to the medications that are FDA-approved for GAD, agomelatine has a different mechanism of action, and has shown to be efficacious and tolerable in previous studies.24-26 In this study, Stein et al19 compared agomelatine vs escitalopram for patients with severe GAD.
Study design
- In a 12-week, double-blind study, adults who met DSM-IV-TR criteria for GAD were randomized to agomelatine 25 to 50 mg/d (n = 261) or escitalopram 10 to 20 mg/d (n = 262).
- Participants had to meet specific criteria for severe anxiety, including a HAM-A total score ≥25.
- The primary outcome measure was the change in HAM-A score from baseline to Week 12. Secondary outcome measures included the rate of response as determined by change in scores on the HAM-PA, HAM-SA, CGI, Toronto Hospital Alertness Test, Snaith-Hamilton Pleasure Scale, and Leeds Sleep Evaluation Questionnaire.
Outcomes
- Participants in both the agomelatine and escitalopram groups reported similar, clinically significant mean reductions in HAM-A scores at Week 12.
- There were no significant differences in secondary measures between the 2 groups, and both groups experienced improvement in psychic and somatic symptoms, alertness, and sleep.
- Overall, the agomelatine group experienced fewer adverse events compared to the escitalopram group.
Conclusions/limitations
- Agomelatine may be an efficacious and well-tolerated treatment option for severe GAD.
- This study excluded individuals with comorbid conditions.
Bottom Line
Recent research suggests that escitalopram; vortioxetine; agomelatine; duloxetine plus group cognitive-behavioral therapy; repetitive transcranial magnetic stimulation; and chamomile extract can improve symptoms in patients with generalized anxiety disorder.
Related Resources
- Abell SR, El-Mallakh RS. Serotonin-mediated anxiety: how to recognize and treat it. Current Psychiatry. 2021;20(11):37-40. doi:10.12788/cp.0168
Drug Brand Names
Duloxetine • Cymbalta
Escitalopram • Lexapro
Vortioxetine • Trintellix
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association; 2022.
2. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766. doi:10.1056/NEJMoa0804633
3. Strawn JR, Sakolsky DJ, Rynn MA. Psychopharmacologic treatment of children and adolescents with anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-539. doi:10.1016/j.chc.2012.05.003
4. Beidel DC, Turner SM, Sallee FR, et al. SET-C versus fluoxetine in the treatment of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1622-1632. doi:10.1097/chi.0b013e318154bb57
5. Wetherell JL, Petkus AJ, White KS, et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry. 2013;170(7):782-789. doi:10.1176/app.ajp.2013.12081104
6. Stein DJ. Evidence-based pharmacotherapy of generalised anxiety disorder: focus on agomelatine. Adv Ther. 2021;38(Suppl 2):52-60. doi:10.1007/s12325-021-01860-1
7. Andrews G, Bell C, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry. 2018;52(12):1109-1172. doi:10.1177/0004867418799453
8. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-439. doi:10.1177/0269881114525674
9. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract. 2012;16(2):77-84. doi:10.3109/13651501.2012.667114
10. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1(Suppl 1):S1. doi:10.1186/1471-244X-14-S1-S1
11. Generalised anxiety disorder and panic disorder in adults: management. National Institute for Health and Care Excellence. January 26, 2011. Updated June 15, 2020. Accessed April 27, 2022. https://www.nice.org.uk/guidance/cg113
12. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
13. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
14. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
15. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
16. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
17. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
18. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
19. Stein DJ, Khoo J, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
20. Amsterdam JD, Li Y, Soeller I, et al. A randomized, double-blind, placebo-controlled trial of oral Matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. J Clin Psychopharmacol. 2009;29(4):378-382. doi:10.1097/JCP.0b013e3181ac935c
21. Amsterdam JD, Shults J, Soeller I, et al. Chamomile (Matricaria recutita) may provide antidepressant activity in anxious, depressed humans: an exploratory study. Altern Ther Health Med. 2012;18(5):44-49.
22. Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214. doi:10.1080/15622975.2016.1190867
23. Elnazer HY, Baldwin DS. Investigation of cortisol levels in patients with anxiety disorders: a structured review. Curr Top Behav Neurosci. 2014;18:191-216. doi:10.1007/7854_2014_299
24. de Bodinat C, Guardiola-Lemaitre B, Mocaër E, et al. Agomelatine, the first melatonergic antidepressant: discovery, characterization and development. Nat Rev Drug Discov. 2010;9(8):628-642. doi:10.1038/nrd3140
25. Guardiola-Lemaitre B, de Bodinat C, Delagrange P, et al. Agomelatine: mechanism of action and pharmacological profile in relation to antidepressant properties. Br J Pharmacol. 2014;171(15):3604-3619. doi:10.1111/bph.12720
26. Stein DJ, Ahokas A, Jarema M, et al. Efficacy and safety of agomelatine (10 or 25 mg/day) in non-depressed out-patients with generalized anxiety disorder: a 12-week, double-blind, placebo-controlled study. Eur Neuropsychopharmacol. 2017;27(5):526-537. doi:10.1016/j.euroneuro.2017.02.007
Generalized anxiety disorder (GAD) typically begins in early adulthood and persists throughout life. Many individuals with GAD report they have felt anxious their entire lives. The essential symptom of GAD is excessive anxiety and worry about numerous events or activities. The intensity, duration, and/or frequency of the anxiety and worry are out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control their worry and prevent worrisome thoughts from interfering with attention to everyday tasks.1
Treatment of GAD typically consists of psychotherapy and pharmacotherapy. Several studies have suggested that concurrent psychotherapy amplifies the benefits of pharmacotherapy.2-5 Additionally, combined treatment may differentially target specific symptoms (eg, cognitive vs somatic). The addition of psychotherapy may also increase treatment adherence and decrease potential adverse effects of pharmacotherapy.
Multiple classes of medications are available for treating GAD. Current guidelines and evidence suggest that selective serotonin reuptake inhibitors (SSRIs) should be considered a first-line intervention, followed by serotonin-norepinephrine reuptake inhibitors.6-11 While the evidence supporting pharmacotherapy for GAD continues to expand, many patients with GAD do not respond to first-line treatment. There is limited data regarding second-line or augmentation strategies for treating these patients. Because current treatment options for GAD are commonly associated with suboptimal treatment outcomes, researchers are investigating the use of nonpharmacologic biological interventions, such as repetitive transcranial magnetic stimulation (rTMS), which was first cleared by the FDA to treat major depressive disorder (MDD) in 2008.
In Part 1 of this 2-part article, we review 8 randomized controlled trials (RCTs) of biological interventions for GAD that have been published within the last 5 years (Table12-19).
1. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
GAD is highly prevalent in adolescents, and SSRIs are often used as first-line agents. However, treatment response is often variable, and clinicians often use trial-and-error to identify an appropriate medication and dose that will result in meaningful improvement. Understanding an individual’s pharmacokinetic response may help predict response and guide therapy. Adult studies have shown cytochrome P450 (CYP) 2C19 metabolizes several SSRIs, including escitalopram, with faster CYP2C19 metabolism leading to decreased plasma concentrations. Strawn et al12 studied the effects of escitalopram in adolescents with GAD as well as the effects of CYP2C19 metabolism.
Study design
- A double-blind, placebo-controlled trial evaluated 51 adolescents (age 12 to 17) who met DSM-IV-TR criteria for GAD. They had a baseline Pediatric Anxiety Rating Scale (PARS) score ≥15 and a Clinical Global Impressions–Severity (CGI-S) Scale score ≥4.
- Participants were randomized to escitalopram (n = 26; scheduled titration to 15 mg/d, then flexible to 20 mg/d), or placebo (n = 25) and monitored for 8 weeks.
- Patients with panic disorder, agoraphobia, or social anxiety disorder were also enrolled, but GAD was the primary diagnosis.
- The primary outcome was change in PARS score and change from baseline in CGI-S and Clinical Global Impressions–Improvement (CGI-I) scale scores, with assessments completed at Week 1, Week 2, Week 4, Week 6, and Week 8, or at early termination.
- Genomic DNA was obtained via buccal swab to assess 9 alleles of CYP2C19. Plasma concentrations of escitalopram and its major metabolite, desmethylescitalopram, were collected to assess plasma escitalopram and desmethylescitalopram area under the curve for 24 hours (AUC0-24) and maximum plasma concentration (CMAX).
Outcomes
- Escitalopram was superior to placebo, evident by statistically significantly greater changes in PARS and CGI scores.
- Greater improvement over time on PARS was correlated with intermediate CYP2C19 metabolizers, and greater response as measured by CGI-I was associated with having at least 1 long allele of SLC6A4 and being an intermediate CYP2C19 metabolizer.
- While plasma escitalopram exposure (AUC0-24) significantly decreased and desmethylcitalopram-to-escitalopram ratios increased with faster CYP2C19 metabolism at 15 mg/d, escitalopram exposure at the 15 mg/d dose and escitalopram-to-desmethylcitalopram ratios did not differ at Week 8 between responders and nonresponders. Patients with activation symptoms had higher CMAX and AUC0-24.
- Changes in vital signs, corrected QT interval, and adverse events were similar in both groups.
Conclusions/limitations
- For adolescents with GAD, escitalopram showed a benefit compared to placebo.
- Allelic differences in CYP2C19 metabolism may lead to variations in pharmacokinetics, and understanding a patient’s CYP2C19 phenotype may help guide dosing escitalopram and predicting adverse effects.
- This study enrolled a small, predominantly female, White, treatment-naïve sample, which may limit conclusions on allelic differences. Additionally, the sample included adolescents with severe anxiety and comorbid anxiety conditions, which may limit generalizability.
Continue to: #2
2. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
Vortioxetine, an FDA-approved antidepressant, has been shown to improve anxiety symptoms in patients with GAD. Additionally, vortioxetine has shown positive effects in patients with MDD, with greater improvement seen in the working and professional population. Due to the overlap between MDD and GAD, Christensen et al13 assessed the effectiveness of vortioxetine on anxiety symptoms in individuals who were working.
Study design
- Researchers conducted a post-hoc analysis of a previously completed randomized, placebo-controlled trial of 301 patients as well as a previously completed randomized, placebo-controlled relapse prevention study of 687 patients. Patients in both groups met DSM-IV-TR criteria for GAD.
- Inclusion criteria included a Hamilton Anxiety Rating Scale (HAM-A) score ≥20 with HAM-A scores ≥2 on items 1 (anxious mood), and 2 (tension), and a Montgomery-Åsberg Depression Rating Scale (MADRS) score ≤16 at screening and baseline.
- Researchers compared participants who were working or pursuing an education vs the full study sample.
Outcomes
- Vortioxetine was significantly associated with benefits in anxiety symptoms, functioning, and quality of life in both working participants and the total population, with the greatest effects seen in professional (ie, managers, administrators) and associate professional (ie, technical, nursing, clerical workers, or secretarial) positions. Working participants who received placebo were more likely to relapse compared to those receiving vortioxetine.
- There did not appear to be a statistically significant benefit or increase in relapse among the skilled labor group (ie, building, electrical/factory worker, or services/sales) while receiving vortioxetine.
Conclusions/limitations
- Vortioxetine may have a more pronounced effect in patients who are working or pursuing an education vs the full GAD population, which suggests that targeting this medication at particular patient demographics may be beneficial.
- Working patients with GAD may also differ from nonworking patients by factors other than work, such as education, support system, motivation, and other personal factors.
- This study was a post-hoc analysis, which limits definitive conclusions but may help guide future studies.
Continue to: #3
3. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
Treatment of GAD should include nonmedication options such as psychotherapy to help enhance efficacy. Few studies have evaluated whether combined cognitive-behavioral therapy (CBT) plus medication has more benefit than medication monotherapy, specifically in patients with GAD. In this randomized trial, Xie et al14 examined how a study population undergoing CBT and receiving duloxetine differed from those receiving duloxetine monotherapy for GAD.
Study design
- In this randomized, open-label trial, adults who met DSM-IV criteria for GAD and had a HAM-A score >14 were randomized to group CBT plus duloxetine (n = 89) or duloxetine only (n = 81), with follow-up at Week 4, Week 8, and Month 3.
- The primary outcomes included response and remission rates based on HAM-A score. Secondary outcomes included HAM-A total score reductions, psychic anxiety (HAMA-PA) and somatic anxiety (HAMA-SA) subscale score reductions, Hamilton Depression Rating Scale score reductions, and reductions in overall illness severity as measured by CGI-S, the Global Assessment of Functioning Scale, and the 12-item Short-Form Health Survey.
Outcomes
- At Week 4, combined therapy was superior to duloxetine alone as evident by the primary and most secondary outcomes, with continued benefits but smaller effect size at Week 8.
- At Month 3, combined therapy was significantly better only in HAM-A total score and HAMA-PA score reductions.
Conclusions/limitations
- Patients who received group CBT plus duloxetine treatment experienced faster improvement of GAD symptoms compared to patients who received duloxetine monotherapy, though the difference reduced over time.
- The most benefit appeared to be for psychic anxiety symptoms, which suggests that group CBT can help change cognition style.
- This study had a short follow-up period, high dropout rates, and recruited patients from only 1 institution.
4. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
Insomnia and anxiety often present together. rTMS has demonstrated efficacy in various psychiatric illnesses, but there is limited research regarding its effectiveness in GAD. Additionally, little is known regarding the benefits of rTMS for patients with comorbid insomnia and GAD. Huang et al15 examined the therapeutic effects of rTMS in patients with comorbid insomnia and GAD.
Continue to: Study design
Study design
- Adults who met DSM-IV criteria for GAD and insomnia were randomized to receive 10 days of low-intensity rTMS on the right parietal lobe (n = 18) or a sham procedure (n = 18). Inclusion criteria also included a score ≥14 on HAM-A, ≥7 on the Pittsburgh Sleep Quality Index (PSQI), and <20 on the 24-item Hamilton Depression Rating Scale (HAM-D).
- rTMS settings included a frequency of 1 Hz, 90% intensity of the resting motor threshold, 3 trains of 500 pulses, and an intertrain interval of 10 minutes.
- Study measurements included HAM-A, PSQI, and HAM-D at baseline, posttreatment at Day 10, Week 2 follow-up, and Month 1 follow-up.
Outcomes
- Significantly more patients in the rTMS group had a meaningful response as measured by change in HAM-A score at posttreatment and both follow-up sessions.
- The rTMS group had significant remission compared to the sham group at posttreatment and Week 2 follow-up, but showed no significant difference at Month 1.
- There were significant improvements in insomnia symptoms in the rTMS group at the posttreatment and follow-up time points.
Conclusions/limitations
- Low-frequency rTMS over the right parietal cortex is an effective treatment option for patients with comorbid GAD and insomnia.
- This study had a small sample size consisting of participants from only 1 institution.
5. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
GAD often presents with comorbid depression. While antidepressants are the standard approach to treatment of both conditions, patients may seek alternative therapies. In previous studies,20Matricaria chamomilla L. (chamomile) has been shown to reduce GAD symptoms, and post-hoc analyses21 have shown its benefits in treating depression. Amsterdam et al16 assessed the effects of chamomile on patients with GAD with and without comorbid depression.
Study design
- As part of an RCT, 179 adults who met DSM-IV-TR criteria for GAD underwent an 8-week open-label phase of chamomile extract therapy (1,500 mg/d). Participants who responded were enrolled in a randomized, double-blind, placebo-control trial. Amsterdam et al16 specifically analyzed the 8-week open label portion of the study.
- Participants were divided into 2 groups: GAD without comorbid depression (n = 100), and GAD with comorbid depression (n = 79).
- Outcome measures included the 7-item generalized anxiety disorder scale (GAD-7), HAM-A, Beck Anxiety Inventory, 17-item HAM-D, 6-item HAM-D, and the Beck Depression Inventory (BDI).
Continue to: Outcomes
Outcomes
- Patients with comorbid depression experienced a greater, statistically significant reduction in HAM-D core symptom scores (depressed mood, guilt, suicide ideation, work and interest, retardation, and somatic symptoms general).
- The comorbid depression group experienced a trend (but not significant) reduction in total HAM-D and BDI scores.
Conclusions/limitations
- Chamomile extract may help reduce depressive symptoms in patients with GAD who also have depression.
- This study was not powered to detect significant differences in depression outcome ratings between groups, was exploratory, and was not a controlled trial.
6. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
Nonpharmacologic modalities, including rTMS, may be effective alternatives for treating GAD. Dilkov et al17 examined whether excitatory rTMS is an effective treatment option for GAD.
Study design
- In this double-blind, sham-controlled trial, adults who met DSM-IV criteria for GAD were randomized to excitatory rTMS of the right dorsolateral prefrontal cortex therapy (n = 15) or a sham procedure (n = 25).
- rTMS settings included a frequency of 20 Hz, 110% intensity of resting motor threshold, 20 trains, 9 seconds/train, and 51-second intertrain intervals.
- Outcomes were measured by HAM-A, CGI, and 21-item HAM-D.
Outcomes
- At the conclusion of 25 treatments, the rTMS group experienced a statistically significant reduction in GAD symptoms as measured by HAM-A.
- Improvements were also noted in the CGI and HAM-D scores in the rTMS group compared to the sham group.
- The benefits continued at the Week 4 follow-up visit.
Conclusions/limitations
- Participants in the rTMS group experienced a significant decrease in anxiety symptoms, which suggests that rTMS may be an effective treatment for GAD.
- The benefits appear sustainable even after the conclusion of the rTMS sessions.
- This study had a small sample size and excluded patients with comorbid psychiatric conditions.
Continue to: #7
7. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
Dysregulated stress response has been proposed as a mechanism for anxiety.22,23 Patients with GAD have been reported to have alterations in cortisol levels, specifically lower morning cortisol levels and a less steep diurnal cortisol slope; however, it is not clear how treatment affects these levels. Keefe et al18 examined whether chamomile therapy in patients with GAD affects cortisol levels.
Study design
- In an 8-week, open-label study, 45 adults who met DSM-IV criteria for GAD received chamomile extract capsules 1,500 mg/d.
- Participants used at-home kits to collect their saliva so cortisol levels could be assessed at 8
am , 12pm , 4pm , and 8pm . - The GAD-7 was used to assess anxiety symptoms.
Outcomes
- Participants who experienced greater improvements in GAD symptoms had relative increases in morning cortisol levels compared to their baseline levels.
- Participants who experienced greater improvements in GAD symptoms had a greater decrease in cortisol levels throughout the day (ie, greater diurnal slope).
Conclusions/limitations
- Greater improvement in GAD symptoms after treatment with chamomile extract appeared to be correlated with increased morning cortisol levels and a steeper diurnal cortisol slope after awakening, which suggests that treatment of GAD may help improve dysregulated stress biology.
- This study had a small sample size and was not placebo-controlled.
Continue to: #8
8. Stein DJ, Khoo JP, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
Compared to the medications that are FDA-approved for GAD, agomelatine has a different mechanism of action, and has shown to be efficacious and tolerable in previous studies.24-26 In this study, Stein et al19 compared agomelatine vs escitalopram for patients with severe GAD.
Study design
- In a 12-week, double-blind study, adults who met DSM-IV-TR criteria for GAD were randomized to agomelatine 25 to 50 mg/d (n = 261) or escitalopram 10 to 20 mg/d (n = 262).
- Participants had to meet specific criteria for severe anxiety, including a HAM-A total score ≥25.
- The primary outcome measure was the change in HAM-A score from baseline to Week 12. Secondary outcome measures included the rate of response as determined by change in scores on the HAM-PA, HAM-SA, CGI, Toronto Hospital Alertness Test, Snaith-Hamilton Pleasure Scale, and Leeds Sleep Evaluation Questionnaire.
Outcomes
- Participants in both the agomelatine and escitalopram groups reported similar, clinically significant mean reductions in HAM-A scores at Week 12.
- There were no significant differences in secondary measures between the 2 groups, and both groups experienced improvement in psychic and somatic symptoms, alertness, and sleep.
- Overall, the agomelatine group experienced fewer adverse events compared to the escitalopram group.
Conclusions/limitations
- Agomelatine may be an efficacious and well-tolerated treatment option for severe GAD.
- This study excluded individuals with comorbid conditions.
Bottom Line
Recent research suggests that escitalopram; vortioxetine; agomelatine; duloxetine plus group cognitive-behavioral therapy; repetitive transcranial magnetic stimulation; and chamomile extract can improve symptoms in patients with generalized anxiety disorder.
Related Resources
- Abell SR, El-Mallakh RS. Serotonin-mediated anxiety: how to recognize and treat it. Current Psychiatry. 2021;20(11):37-40. doi:10.12788/cp.0168
Drug Brand Names
Duloxetine • Cymbalta
Escitalopram • Lexapro
Vortioxetine • Trintellix
Generalized anxiety disorder (GAD) typically begins in early adulthood and persists throughout life. Many individuals with GAD report they have felt anxious their entire lives. The essential symptom of GAD is excessive anxiety and worry about numerous events or activities. The intensity, duration, and/or frequency of the anxiety and worry are out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control their worry and prevent worrisome thoughts from interfering with attention to everyday tasks.1
Treatment of GAD typically consists of psychotherapy and pharmacotherapy. Several studies have suggested that concurrent psychotherapy amplifies the benefits of pharmacotherapy.2-5 Additionally, combined treatment may differentially target specific symptoms (eg, cognitive vs somatic). The addition of psychotherapy may also increase treatment adherence and decrease potential adverse effects of pharmacotherapy.
Multiple classes of medications are available for treating GAD. Current guidelines and evidence suggest that selective serotonin reuptake inhibitors (SSRIs) should be considered a first-line intervention, followed by serotonin-norepinephrine reuptake inhibitors.6-11 While the evidence supporting pharmacotherapy for GAD continues to expand, many patients with GAD do not respond to first-line treatment. There is limited data regarding second-line or augmentation strategies for treating these patients. Because current treatment options for GAD are commonly associated with suboptimal treatment outcomes, researchers are investigating the use of nonpharmacologic biological interventions, such as repetitive transcranial magnetic stimulation (rTMS), which was first cleared by the FDA to treat major depressive disorder (MDD) in 2008.
In Part 1 of this 2-part article, we review 8 randomized controlled trials (RCTs) of biological interventions for GAD that have been published within the last 5 years (Table12-19).
1. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
GAD is highly prevalent in adolescents, and SSRIs are often used as first-line agents. However, treatment response is often variable, and clinicians often use trial-and-error to identify an appropriate medication and dose that will result in meaningful improvement. Understanding an individual’s pharmacokinetic response may help predict response and guide therapy. Adult studies have shown cytochrome P450 (CYP) 2C19 metabolizes several SSRIs, including escitalopram, with faster CYP2C19 metabolism leading to decreased plasma concentrations. Strawn et al12 studied the effects of escitalopram in adolescents with GAD as well as the effects of CYP2C19 metabolism.
Study design
- A double-blind, placebo-controlled trial evaluated 51 adolescents (age 12 to 17) who met DSM-IV-TR criteria for GAD. They had a baseline Pediatric Anxiety Rating Scale (PARS) score ≥15 and a Clinical Global Impressions–Severity (CGI-S) Scale score ≥4.
- Participants were randomized to escitalopram (n = 26; scheduled titration to 15 mg/d, then flexible to 20 mg/d), or placebo (n = 25) and monitored for 8 weeks.
- Patients with panic disorder, agoraphobia, or social anxiety disorder were also enrolled, but GAD was the primary diagnosis.
- The primary outcome was change in PARS score and change from baseline in CGI-S and Clinical Global Impressions–Improvement (CGI-I) scale scores, with assessments completed at Week 1, Week 2, Week 4, Week 6, and Week 8, or at early termination.
- Genomic DNA was obtained via buccal swab to assess 9 alleles of CYP2C19. Plasma concentrations of escitalopram and its major metabolite, desmethylescitalopram, were collected to assess plasma escitalopram and desmethylescitalopram area under the curve for 24 hours (AUC0-24) and maximum plasma concentration (CMAX).
Outcomes
- Escitalopram was superior to placebo, evident by statistically significantly greater changes in PARS and CGI scores.
- Greater improvement over time on PARS was correlated with intermediate CYP2C19 metabolizers, and greater response as measured by CGI-I was associated with having at least 1 long allele of SLC6A4 and being an intermediate CYP2C19 metabolizer.
- While plasma escitalopram exposure (AUC0-24) significantly decreased and desmethylcitalopram-to-escitalopram ratios increased with faster CYP2C19 metabolism at 15 mg/d, escitalopram exposure at the 15 mg/d dose and escitalopram-to-desmethylcitalopram ratios did not differ at Week 8 between responders and nonresponders. Patients with activation symptoms had higher CMAX and AUC0-24.
- Changes in vital signs, corrected QT interval, and adverse events were similar in both groups.
Conclusions/limitations
- For adolescents with GAD, escitalopram showed a benefit compared to placebo.
- Allelic differences in CYP2C19 metabolism may lead to variations in pharmacokinetics, and understanding a patient’s CYP2C19 phenotype may help guide dosing escitalopram and predicting adverse effects.
- This study enrolled a small, predominantly female, White, treatment-naïve sample, which may limit conclusions on allelic differences. Additionally, the sample included adolescents with severe anxiety and comorbid anxiety conditions, which may limit generalizability.
Continue to: #2
2. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
Vortioxetine, an FDA-approved antidepressant, has been shown to improve anxiety symptoms in patients with GAD. Additionally, vortioxetine has shown positive effects in patients with MDD, with greater improvement seen in the working and professional population. Due to the overlap between MDD and GAD, Christensen et al13 assessed the effectiveness of vortioxetine on anxiety symptoms in individuals who were working.
Study design
- Researchers conducted a post-hoc analysis of a previously completed randomized, placebo-controlled trial of 301 patients as well as a previously completed randomized, placebo-controlled relapse prevention study of 687 patients. Patients in both groups met DSM-IV-TR criteria for GAD.
- Inclusion criteria included a Hamilton Anxiety Rating Scale (HAM-A) score ≥20 with HAM-A scores ≥2 on items 1 (anxious mood), and 2 (tension), and a Montgomery-Åsberg Depression Rating Scale (MADRS) score ≤16 at screening and baseline.
- Researchers compared participants who were working or pursuing an education vs the full study sample.
Outcomes
- Vortioxetine was significantly associated with benefits in anxiety symptoms, functioning, and quality of life in both working participants and the total population, with the greatest effects seen in professional (ie, managers, administrators) and associate professional (ie, technical, nursing, clerical workers, or secretarial) positions. Working participants who received placebo were more likely to relapse compared to those receiving vortioxetine.
- There did not appear to be a statistically significant benefit or increase in relapse among the skilled labor group (ie, building, electrical/factory worker, or services/sales) while receiving vortioxetine.
Conclusions/limitations
- Vortioxetine may have a more pronounced effect in patients who are working or pursuing an education vs the full GAD population, which suggests that targeting this medication at particular patient demographics may be beneficial.
- Working patients with GAD may also differ from nonworking patients by factors other than work, such as education, support system, motivation, and other personal factors.
- This study was a post-hoc analysis, which limits definitive conclusions but may help guide future studies.
Continue to: #3
3. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
Treatment of GAD should include nonmedication options such as psychotherapy to help enhance efficacy. Few studies have evaluated whether combined cognitive-behavioral therapy (CBT) plus medication has more benefit than medication monotherapy, specifically in patients with GAD. In this randomized trial, Xie et al14 examined how a study population undergoing CBT and receiving duloxetine differed from those receiving duloxetine monotherapy for GAD.
Study design
- In this randomized, open-label trial, adults who met DSM-IV criteria for GAD and had a HAM-A score >14 were randomized to group CBT plus duloxetine (n = 89) or duloxetine only (n = 81), with follow-up at Week 4, Week 8, and Month 3.
- The primary outcomes included response and remission rates based on HAM-A score. Secondary outcomes included HAM-A total score reductions, psychic anxiety (HAMA-PA) and somatic anxiety (HAMA-SA) subscale score reductions, Hamilton Depression Rating Scale score reductions, and reductions in overall illness severity as measured by CGI-S, the Global Assessment of Functioning Scale, and the 12-item Short-Form Health Survey.
Outcomes
- At Week 4, combined therapy was superior to duloxetine alone as evident by the primary and most secondary outcomes, with continued benefits but smaller effect size at Week 8.
- At Month 3, combined therapy was significantly better only in HAM-A total score and HAMA-PA score reductions.
Conclusions/limitations
- Patients who received group CBT plus duloxetine treatment experienced faster improvement of GAD symptoms compared to patients who received duloxetine monotherapy, though the difference reduced over time.
- The most benefit appeared to be for psychic anxiety symptoms, which suggests that group CBT can help change cognition style.
- This study had a short follow-up period, high dropout rates, and recruited patients from only 1 institution.
4. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
Insomnia and anxiety often present together. rTMS has demonstrated efficacy in various psychiatric illnesses, but there is limited research regarding its effectiveness in GAD. Additionally, little is known regarding the benefits of rTMS for patients with comorbid insomnia and GAD. Huang et al15 examined the therapeutic effects of rTMS in patients with comorbid insomnia and GAD.
Continue to: Study design
Study design
- Adults who met DSM-IV criteria for GAD and insomnia were randomized to receive 10 days of low-intensity rTMS on the right parietal lobe (n = 18) or a sham procedure (n = 18). Inclusion criteria also included a score ≥14 on HAM-A, ≥7 on the Pittsburgh Sleep Quality Index (PSQI), and <20 on the 24-item Hamilton Depression Rating Scale (HAM-D).
- rTMS settings included a frequency of 1 Hz, 90% intensity of the resting motor threshold, 3 trains of 500 pulses, and an intertrain interval of 10 minutes.
- Study measurements included HAM-A, PSQI, and HAM-D at baseline, posttreatment at Day 10, Week 2 follow-up, and Month 1 follow-up.
Outcomes
- Significantly more patients in the rTMS group had a meaningful response as measured by change in HAM-A score at posttreatment and both follow-up sessions.
- The rTMS group had significant remission compared to the sham group at posttreatment and Week 2 follow-up, but showed no significant difference at Month 1.
- There were significant improvements in insomnia symptoms in the rTMS group at the posttreatment and follow-up time points.
Conclusions/limitations
- Low-frequency rTMS over the right parietal cortex is an effective treatment option for patients with comorbid GAD and insomnia.
- This study had a small sample size consisting of participants from only 1 institution.
5. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
GAD often presents with comorbid depression. While antidepressants are the standard approach to treatment of both conditions, patients may seek alternative therapies. In previous studies,20Matricaria chamomilla L. (chamomile) has been shown to reduce GAD symptoms, and post-hoc analyses21 have shown its benefits in treating depression. Amsterdam et al16 assessed the effects of chamomile on patients with GAD with and without comorbid depression.
Study design
- As part of an RCT, 179 adults who met DSM-IV-TR criteria for GAD underwent an 8-week open-label phase of chamomile extract therapy (1,500 mg/d). Participants who responded were enrolled in a randomized, double-blind, placebo-control trial. Amsterdam et al16 specifically analyzed the 8-week open label portion of the study.
- Participants were divided into 2 groups: GAD without comorbid depression (n = 100), and GAD with comorbid depression (n = 79).
- Outcome measures included the 7-item generalized anxiety disorder scale (GAD-7), HAM-A, Beck Anxiety Inventory, 17-item HAM-D, 6-item HAM-D, and the Beck Depression Inventory (BDI).
Continue to: Outcomes
Outcomes
- Patients with comorbid depression experienced a greater, statistically significant reduction in HAM-D core symptom scores (depressed mood, guilt, suicide ideation, work and interest, retardation, and somatic symptoms general).
- The comorbid depression group experienced a trend (but not significant) reduction in total HAM-D and BDI scores.
Conclusions/limitations
- Chamomile extract may help reduce depressive symptoms in patients with GAD who also have depression.
- This study was not powered to detect significant differences in depression outcome ratings between groups, was exploratory, and was not a controlled trial.
6. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
Nonpharmacologic modalities, including rTMS, may be effective alternatives for treating GAD. Dilkov et al17 examined whether excitatory rTMS is an effective treatment option for GAD.
Study design
- In this double-blind, sham-controlled trial, adults who met DSM-IV criteria for GAD were randomized to excitatory rTMS of the right dorsolateral prefrontal cortex therapy (n = 15) or a sham procedure (n = 25).
- rTMS settings included a frequency of 20 Hz, 110% intensity of resting motor threshold, 20 trains, 9 seconds/train, and 51-second intertrain intervals.
- Outcomes were measured by HAM-A, CGI, and 21-item HAM-D.
Outcomes
- At the conclusion of 25 treatments, the rTMS group experienced a statistically significant reduction in GAD symptoms as measured by HAM-A.
- Improvements were also noted in the CGI and HAM-D scores in the rTMS group compared to the sham group.
- The benefits continued at the Week 4 follow-up visit.
Conclusions/limitations
- Participants in the rTMS group experienced a significant decrease in anxiety symptoms, which suggests that rTMS may be an effective treatment for GAD.
- The benefits appear sustainable even after the conclusion of the rTMS sessions.
- This study had a small sample size and excluded patients with comorbid psychiatric conditions.
Continue to: #7
7. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
Dysregulated stress response has been proposed as a mechanism for anxiety.22,23 Patients with GAD have been reported to have alterations in cortisol levels, specifically lower morning cortisol levels and a less steep diurnal cortisol slope; however, it is not clear how treatment affects these levels. Keefe et al18 examined whether chamomile therapy in patients with GAD affects cortisol levels.
Study design
- In an 8-week, open-label study, 45 adults who met DSM-IV criteria for GAD received chamomile extract capsules 1,500 mg/d.
- Participants used at-home kits to collect their saliva so cortisol levels could be assessed at 8
am , 12pm , 4pm , and 8pm . - The GAD-7 was used to assess anxiety symptoms.
Outcomes
- Participants who experienced greater improvements in GAD symptoms had relative increases in morning cortisol levels compared to their baseline levels.
- Participants who experienced greater improvements in GAD symptoms had a greater decrease in cortisol levels throughout the day (ie, greater diurnal slope).
Conclusions/limitations
- Greater improvement in GAD symptoms after treatment with chamomile extract appeared to be correlated with increased morning cortisol levels and a steeper diurnal cortisol slope after awakening, which suggests that treatment of GAD may help improve dysregulated stress biology.
- This study had a small sample size and was not placebo-controlled.
Continue to: #8
8. Stein DJ, Khoo JP, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
Compared to the medications that are FDA-approved for GAD, agomelatine has a different mechanism of action, and has shown to be efficacious and tolerable in previous studies.24-26 In this study, Stein et al19 compared agomelatine vs escitalopram for patients with severe GAD.
Study design
- In a 12-week, double-blind study, adults who met DSM-IV-TR criteria for GAD were randomized to agomelatine 25 to 50 mg/d (n = 261) or escitalopram 10 to 20 mg/d (n = 262).
- Participants had to meet specific criteria for severe anxiety, including a HAM-A total score ≥25.
- The primary outcome measure was the change in HAM-A score from baseline to Week 12. Secondary outcome measures included the rate of response as determined by change in scores on the HAM-PA, HAM-SA, CGI, Toronto Hospital Alertness Test, Snaith-Hamilton Pleasure Scale, and Leeds Sleep Evaluation Questionnaire.
Outcomes
- Participants in both the agomelatine and escitalopram groups reported similar, clinically significant mean reductions in HAM-A scores at Week 12.
- There were no significant differences in secondary measures between the 2 groups, and both groups experienced improvement in psychic and somatic symptoms, alertness, and sleep.
- Overall, the agomelatine group experienced fewer adverse events compared to the escitalopram group.
Conclusions/limitations
- Agomelatine may be an efficacious and well-tolerated treatment option for severe GAD.
- This study excluded individuals with comorbid conditions.
Bottom Line
Recent research suggests that escitalopram; vortioxetine; agomelatine; duloxetine plus group cognitive-behavioral therapy; repetitive transcranial magnetic stimulation; and chamomile extract can improve symptoms in patients with generalized anxiety disorder.
Related Resources
- Abell SR, El-Mallakh RS. Serotonin-mediated anxiety: how to recognize and treat it. Current Psychiatry. 2021;20(11):37-40. doi:10.12788/cp.0168
Drug Brand Names
Duloxetine • Cymbalta
Escitalopram • Lexapro
Vortioxetine • Trintellix
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association; 2022.
2. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766. doi:10.1056/NEJMoa0804633
3. Strawn JR, Sakolsky DJ, Rynn MA. Psychopharmacologic treatment of children and adolescents with anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-539. doi:10.1016/j.chc.2012.05.003
4. Beidel DC, Turner SM, Sallee FR, et al. SET-C versus fluoxetine in the treatment of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1622-1632. doi:10.1097/chi.0b013e318154bb57
5. Wetherell JL, Petkus AJ, White KS, et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry. 2013;170(7):782-789. doi:10.1176/app.ajp.2013.12081104
6. Stein DJ. Evidence-based pharmacotherapy of generalised anxiety disorder: focus on agomelatine. Adv Ther. 2021;38(Suppl 2):52-60. doi:10.1007/s12325-021-01860-1
7. Andrews G, Bell C, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry. 2018;52(12):1109-1172. doi:10.1177/0004867418799453
8. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-439. doi:10.1177/0269881114525674
9. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract. 2012;16(2):77-84. doi:10.3109/13651501.2012.667114
10. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1(Suppl 1):S1. doi:10.1186/1471-244X-14-S1-S1
11. Generalised anxiety disorder and panic disorder in adults: management. National Institute for Health and Care Excellence. January 26, 2011. Updated June 15, 2020. Accessed April 27, 2022. https://www.nice.org.uk/guidance/cg113
12. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
13. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
14. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
15. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
16. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
17. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
18. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
19. Stein DJ, Khoo J, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
20. Amsterdam JD, Li Y, Soeller I, et al. A randomized, double-blind, placebo-controlled trial of oral Matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. J Clin Psychopharmacol. 2009;29(4):378-382. doi:10.1097/JCP.0b013e3181ac935c
21. Amsterdam JD, Shults J, Soeller I, et al. Chamomile (Matricaria recutita) may provide antidepressant activity in anxious, depressed humans: an exploratory study. Altern Ther Health Med. 2012;18(5):44-49.
22. Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214. doi:10.1080/15622975.2016.1190867
23. Elnazer HY, Baldwin DS. Investigation of cortisol levels in patients with anxiety disorders: a structured review. Curr Top Behav Neurosci. 2014;18:191-216. doi:10.1007/7854_2014_299
24. de Bodinat C, Guardiola-Lemaitre B, Mocaër E, et al. Agomelatine, the first melatonergic antidepressant: discovery, characterization and development. Nat Rev Drug Discov. 2010;9(8):628-642. doi:10.1038/nrd3140
25. Guardiola-Lemaitre B, de Bodinat C, Delagrange P, et al. Agomelatine: mechanism of action and pharmacological profile in relation to antidepressant properties. Br J Pharmacol. 2014;171(15):3604-3619. doi:10.1111/bph.12720
26. Stein DJ, Ahokas A, Jarema M, et al. Efficacy and safety of agomelatine (10 or 25 mg/day) in non-depressed out-patients with generalized anxiety disorder: a 12-week, double-blind, placebo-controlled study. Eur Neuropsychopharmacol. 2017;27(5):526-537. doi:10.1016/j.euroneuro.2017.02.007
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. American Psychiatric Association; 2022.
2. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766. doi:10.1056/NEJMoa0804633
3. Strawn JR, Sakolsky DJ, Rynn MA. Psychopharmacologic treatment of children and adolescents with anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-539. doi:10.1016/j.chc.2012.05.003
4. Beidel DC, Turner SM, Sallee FR, et al. SET-C versus fluoxetine in the treatment of childhood social phobia. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1622-1632. doi:10.1097/chi.0b013e318154bb57
5. Wetherell JL, Petkus AJ, White KS, et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry. 2013;170(7):782-789. doi:10.1176/app.ajp.2013.12081104
6. Stein DJ. Evidence-based pharmacotherapy of generalised anxiety disorder: focus on agomelatine. Adv Ther. 2021;38(Suppl 2):52-60. doi:10.1007/s12325-021-01860-1
7. Andrews G, Bell C, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry. 2018;52(12):1109-1172. doi:10.1177/0004867418799453
8. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-439. doi:10.1177/0269881114525674
9. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract. 2012;16(2):77-84. doi:10.3109/13651501.2012.667114
10. Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14 Suppl 1(Suppl 1):S1. doi:10.1186/1471-244X-14-S1-S1
11. Generalised anxiety disorder and panic disorder in adults: management. National Institute for Health and Care Excellence. January 26, 2011. Updated June 15, 2020. Accessed April 27, 2022. https://www.nice.org.uk/guidance/cg113
12. Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. J Clin Psychiatry. 2020;81(5):20m13396. doi:10.4088/JCP.20m13396
13. Christensen MC, Loft H, Florea I, et al. Efficacy of vortioxetine in working patients with generalized anxiety disorder. CNS Spectr. 2019;24(2):249-257. doi:10.1017/S1092852917000761
14. Xie ZJ, Han N, Law S, et al. The efficacy of group cognitive-behavioural therapy plus duloxetine for generalised anxiety disorder versus duloxetine alone. Acta Neuropsychiatr. 2019;31(6):316-324. doi:10.1017/neu.2019.32
15. Huang Z, Li Y, Bianchi MT, et al. Repetitive transcranial magnetic stimulation of the right parietal cortex for comorbid generalized anxiety disorder and insomnia: a randomized, double-blind, sham-controlled pilot study. Brain Stimul. 2018;11(5):1103-1109. doi:10.1016/j.brs.2018.05.016
16. Amsterdam JD, Li QS, Xie SX, et al. Putative antidepressant effect of chamomile (Matricaria chamomilla L.) oral extract in subjects with comorbid generalized anxiety disorder and depression. J Altern Complement Med. 2020;26(9):813-819. doi:10.1089/acm.2019.0252
17. Dilkov D, Hawken ER, Kaludiev E, et al. Repetitive transcranial magnetic stimulation of the right dorsal lateral prefrontal cortex in the treatment of generalized anxiety disorder: a randomized, double-blind sham controlled clinical trial. Prog Neuropsychopharmacol Biol Psychiatry. 2017;78:61-65. doi:10.1016/j.pnpbp.2017.05.018
18. Keefe JR, Guo W, Li QS, et al. An exploratory study of salivary cortisol changes during chamomile extract therapy of moderate to severe generalized anxiety disorder. J Psychiatr Res. 2018;96:189-195. doi:10.1016/j.jpsychires.2017.10.011
19. Stein DJ, Khoo J, Ahokas A, et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. Eur Neuropsychopharmacol. 2018;28(8):970-979. doi:10.1016/j.euroneuro.2018.05.006
20. Amsterdam JD, Li Y, Soeller I, et al. A randomized, double-blind, placebo-controlled trial of oral Matricaria recutita (chamomile) extract therapy for generalized anxiety disorder. J Clin Psychopharmacol. 2009;29(4):378-382. doi:10.1097/JCP.0b013e3181ac935c
21. Amsterdam JD, Shults J, Soeller I, et al. Chamomile (Matricaria recutita) may provide antidepressant activity in anxious, depressed humans: an exploratory study. Altern Ther Health Med. 2012;18(5):44-49.
22. Bandelow B, Baldwin D, Abelli M, et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry. 2017;18(3):162-214. doi:10.1080/15622975.2016.1190867
23. Elnazer HY, Baldwin DS. Investigation of cortisol levels in patients with anxiety disorders: a structured review. Curr Top Behav Neurosci. 2014;18:191-216. doi:10.1007/7854_2014_299
24. de Bodinat C, Guardiola-Lemaitre B, Mocaër E, et al. Agomelatine, the first melatonergic antidepressant: discovery, characterization and development. Nat Rev Drug Discov. 2010;9(8):628-642. doi:10.1038/nrd3140
25. Guardiola-Lemaitre B, de Bodinat C, Delagrange P, et al. Agomelatine: mechanism of action and pharmacological profile in relation to antidepressant properties. Br J Pharmacol. 2014;171(15):3604-3619. doi:10.1111/bph.12720
26. Stein DJ, Ahokas A, Jarema M, et al. Efficacy and safety of agomelatine (10 or 25 mg/day) in non-depressed out-patients with generalized anxiety disorder: a 12-week, double-blind, placebo-controlled study. Eur Neuropsychopharmacol. 2017;27(5):526-537. doi:10.1016/j.euroneuro.2017.02.007
Termination of pregnancy for medical reasons: A mental health perspective
Termination of pregnancy for medical reasons (TFMR) occurs when a pregnancy is ended due to medical complications that threaten the health of a pregnant individual and/or fetus, or when a fetus has a poor prognosis or life-limiting diagnosis. It is distinct from the American College of Obstetricians and Gynecologists identification of all abortions as medically indicated. Common indications for TFMR include life-threatening pregnancy complications (eg, placental abruption, hyperemesis gravidarum, exacerbation of psychiatric illness), chromosomal abnormalities (eg, Trisomy 13, 18, and 21; Klinefelter syndrome), and fetal anomalies (eg, neural tube defects, cardiac defects, renal agenesis). In this article, we discuss the negative psychological outcomes of TFMR, and how to screen and intervene to best help women who experience TFMR.
Psychiatric sequelae of TFMR
Unlike abortions in general, negative psychological outcomes are common among women who experience TFMR.1 Nearly one-half of women develop symptoms of posttraumatic stress disorder (PTSD), and approximately one-fourth show signs of depression at 4 months after termination.2 Such symptoms usually improve with time but may return around trauma anniversaries (date of diagnosis or termination). Women with a history of trauma, a prior psychiatric diagnosis, and/or no living children are at greater risk. Self-blame, doubt, and high levels of distress are also risk factors.2-4 Protective factors include positive coping strategies (such as acceptance or reframing), higher perceived social support, and high self-efficacy.3,4
Screening: What to ask, and how
Use open-ended questions to ask about a patient’s obstetric history:
- Have you ever been pregnant?
- If you’re comfortable sharing, what were the outcomes of these pregnancies?
If a woman discloses that she has experienced a TFMR, screen for and normalize psychiatric outcomes by asking:
- Symptoms of grief, depression, and anxiety are common after TFMR. Have you experienced such symptoms?
- What impact has terminating your pregnancy for medical reasons had on your mental health?
Screening tools such as the General Self-Efficacy Scale can help assess predictive factors, while other scales can assess specific diagnoses (eg, Patient Health Questionaire-9 for depression, Impact of Event Scale-Revised and PTSD Checklist for DSM-5 for trauma-related symptoms, Traumatic Grief Inventory Self Report Version for pathological grief). The Edinburgh Postnatal Depression Scale can assess for depression, but if you use this instrument, exclude statements that reference a current pregnancy or recent delivery.
How to best help
Interventions should be specific and targeted. Thus, consider the individual nature of the experience and variation in attachment that can occur over time.5 OB-GYN and perinatal psychiatry clinicians can recommend local resources and support groups that specifically focus on TFMR, rather than on general pregnancy loss. Refer patients to therapists who specialize in pregnancy loss, reproductive trauma, and/or TFMR. Cognitive-behavioral therapy and acceptance and commitment therapy may be appropriate and effective.3 Online support groups (such as Termination of Pregnancy for Medical Reasons; www.facebook.com/groups/TFMRgroup/) can supplement or fill gaps in local resources. Suggest books that discuss TFMR, such
1. González-Ramos Z, Zuriguel-Pérez E, Albacar-Riobóo N, et al. The emotional responses of women when terminating a pregnancy for medical reasons: a scoping review. Midwifery. 2021;103:103095. doi:10.1016/j.midw.2021.103095
2. Korenromp MJ, Page-Christiaens GCML, van den Bout J, et al. Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Am J Obstet Gynecol. 2009;201(2):160.e1-7.
3. Lafarge C, Mitchell K, Fox P. Perinatal grief following a termination of pregnancy for foetal abnormality: the impact of coping strategies. Prenat Diagn. 2013;33(12):1173-1182.
4. Korenromp MJ, Christiaens GC, van den Bout J, et al. Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study. Prenat Diagn. 2005;25(3):253-260.
5. Lou S, Hvidtjørn D, Jørgensen ML, Vogel I. “I had to think: this is not a child.” A qualitative exploration of how women/couples articulate their relation to the fetus/child following termination of a wanted pregnancy due to Down syndrome. Sex Reprod Healthc. 2021;28:100606. doi: 10.1016/j.srhc.2021.100606
6. Brooks C (ed.). Our Heartbreaking Choices: Forty-Six Women Share Their Stories of Interrupting a Much-Wanted Pregnancy. iUniverse; 2008.
Termination of pregnancy for medical reasons (TFMR) occurs when a pregnancy is ended due to medical complications that threaten the health of a pregnant individual and/or fetus, or when a fetus has a poor prognosis or life-limiting diagnosis. It is distinct from the American College of Obstetricians and Gynecologists identification of all abortions as medically indicated. Common indications for TFMR include life-threatening pregnancy complications (eg, placental abruption, hyperemesis gravidarum, exacerbation of psychiatric illness), chromosomal abnormalities (eg, Trisomy 13, 18, and 21; Klinefelter syndrome), and fetal anomalies (eg, neural tube defects, cardiac defects, renal agenesis). In this article, we discuss the negative psychological outcomes of TFMR, and how to screen and intervene to best help women who experience TFMR.
Psychiatric sequelae of TFMR
Unlike abortions in general, negative psychological outcomes are common among women who experience TFMR.1 Nearly one-half of women develop symptoms of posttraumatic stress disorder (PTSD), and approximately one-fourth show signs of depression at 4 months after termination.2 Such symptoms usually improve with time but may return around trauma anniversaries (date of diagnosis or termination). Women with a history of trauma, a prior psychiatric diagnosis, and/or no living children are at greater risk. Self-blame, doubt, and high levels of distress are also risk factors.2-4 Protective factors include positive coping strategies (such as acceptance or reframing), higher perceived social support, and high self-efficacy.3,4
Screening: What to ask, and how
Use open-ended questions to ask about a patient’s obstetric history:
- Have you ever been pregnant?
- If you’re comfortable sharing, what were the outcomes of these pregnancies?
If a woman discloses that she has experienced a TFMR, screen for and normalize psychiatric outcomes by asking:
- Symptoms of grief, depression, and anxiety are common after TFMR. Have you experienced such symptoms?
- What impact has terminating your pregnancy for medical reasons had on your mental health?
Screening tools such as the General Self-Efficacy Scale can help assess predictive factors, while other scales can assess specific diagnoses (eg, Patient Health Questionaire-9 for depression, Impact of Event Scale-Revised and PTSD Checklist for DSM-5 for trauma-related symptoms, Traumatic Grief Inventory Self Report Version for pathological grief). The Edinburgh Postnatal Depression Scale can assess for depression, but if you use this instrument, exclude statements that reference a current pregnancy or recent delivery.
How to best help
Interventions should be specific and targeted. Thus, consider the individual nature of the experience and variation in attachment that can occur over time.5 OB-GYN and perinatal psychiatry clinicians can recommend local resources and support groups that specifically focus on TFMR, rather than on general pregnancy loss. Refer patients to therapists who specialize in pregnancy loss, reproductive trauma, and/or TFMR. Cognitive-behavioral therapy and acceptance and commitment therapy may be appropriate and effective.3 Online support groups (such as Termination of Pregnancy for Medical Reasons; www.facebook.com/groups/TFMRgroup/) can supplement or fill gaps in local resources. Suggest books that discuss TFMR, such
Termination of pregnancy for medical reasons (TFMR) occurs when a pregnancy is ended due to medical complications that threaten the health of a pregnant individual and/or fetus, or when a fetus has a poor prognosis or life-limiting diagnosis. It is distinct from the American College of Obstetricians and Gynecologists identification of all abortions as medically indicated. Common indications for TFMR include life-threatening pregnancy complications (eg, placental abruption, hyperemesis gravidarum, exacerbation of psychiatric illness), chromosomal abnormalities (eg, Trisomy 13, 18, and 21; Klinefelter syndrome), and fetal anomalies (eg, neural tube defects, cardiac defects, renal agenesis). In this article, we discuss the negative psychological outcomes of TFMR, and how to screen and intervene to best help women who experience TFMR.
Psychiatric sequelae of TFMR
Unlike abortions in general, negative psychological outcomes are common among women who experience TFMR.1 Nearly one-half of women develop symptoms of posttraumatic stress disorder (PTSD), and approximately one-fourth show signs of depression at 4 months after termination.2 Such symptoms usually improve with time but may return around trauma anniversaries (date of diagnosis or termination). Women with a history of trauma, a prior psychiatric diagnosis, and/or no living children are at greater risk. Self-blame, doubt, and high levels of distress are also risk factors.2-4 Protective factors include positive coping strategies (such as acceptance or reframing), higher perceived social support, and high self-efficacy.3,4
Screening: What to ask, and how
Use open-ended questions to ask about a patient’s obstetric history:
- Have you ever been pregnant?
- If you’re comfortable sharing, what were the outcomes of these pregnancies?
If a woman discloses that she has experienced a TFMR, screen for and normalize psychiatric outcomes by asking:
- Symptoms of grief, depression, and anxiety are common after TFMR. Have you experienced such symptoms?
- What impact has terminating your pregnancy for medical reasons had on your mental health?
Screening tools such as the General Self-Efficacy Scale can help assess predictive factors, while other scales can assess specific diagnoses (eg, Patient Health Questionaire-9 for depression, Impact of Event Scale-Revised and PTSD Checklist for DSM-5 for trauma-related symptoms, Traumatic Grief Inventory Self Report Version for pathological grief). The Edinburgh Postnatal Depression Scale can assess for depression, but if you use this instrument, exclude statements that reference a current pregnancy or recent delivery.
How to best help
Interventions should be specific and targeted. Thus, consider the individual nature of the experience and variation in attachment that can occur over time.5 OB-GYN and perinatal psychiatry clinicians can recommend local resources and support groups that specifically focus on TFMR, rather than on general pregnancy loss. Refer patients to therapists who specialize in pregnancy loss, reproductive trauma, and/or TFMR. Cognitive-behavioral therapy and acceptance and commitment therapy may be appropriate and effective.3 Online support groups (such as Termination of Pregnancy for Medical Reasons; www.facebook.com/groups/TFMRgroup/) can supplement or fill gaps in local resources. Suggest books that discuss TFMR, such
1. González-Ramos Z, Zuriguel-Pérez E, Albacar-Riobóo N, et al. The emotional responses of women when terminating a pregnancy for medical reasons: a scoping review. Midwifery. 2021;103:103095. doi:10.1016/j.midw.2021.103095
2. Korenromp MJ, Page-Christiaens GCML, van den Bout J, et al. Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Am J Obstet Gynecol. 2009;201(2):160.e1-7.
3. Lafarge C, Mitchell K, Fox P. Perinatal grief following a termination of pregnancy for foetal abnormality: the impact of coping strategies. Prenat Diagn. 2013;33(12):1173-1182.
4. Korenromp MJ, Christiaens GC, van den Bout J, et al. Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study. Prenat Diagn. 2005;25(3):253-260.
5. Lou S, Hvidtjørn D, Jørgensen ML, Vogel I. “I had to think: this is not a child.” A qualitative exploration of how women/couples articulate their relation to the fetus/child following termination of a wanted pregnancy due to Down syndrome. Sex Reprod Healthc. 2021;28:100606. doi: 10.1016/j.srhc.2021.100606
6. Brooks C (ed.). Our Heartbreaking Choices: Forty-Six Women Share Their Stories of Interrupting a Much-Wanted Pregnancy. iUniverse; 2008.
1. González-Ramos Z, Zuriguel-Pérez E, Albacar-Riobóo N, et al. The emotional responses of women when terminating a pregnancy for medical reasons: a scoping review. Midwifery. 2021;103:103095. doi:10.1016/j.midw.2021.103095
2. Korenromp MJ, Page-Christiaens GCML, van den Bout J, et al. Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months. Am J Obstet Gynecol. 2009;201(2):160.e1-7.
3. Lafarge C, Mitchell K, Fox P. Perinatal grief following a termination of pregnancy for foetal abnormality: the impact of coping strategies. Prenat Diagn. 2013;33(12):1173-1182.
4. Korenromp MJ, Christiaens GC, van den Bout J, et al. Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study. Prenat Diagn. 2005;25(3):253-260.
5. Lou S, Hvidtjørn D, Jørgensen ML, Vogel I. “I had to think: this is not a child.” A qualitative exploration of how women/couples articulate their relation to the fetus/child following termination of a wanted pregnancy due to Down syndrome. Sex Reprod Healthc. 2021;28:100606. doi: 10.1016/j.srhc.2021.100606
6. Brooks C (ed.). Our Heartbreaking Choices: Forty-Six Women Share Their Stories of Interrupting a Much-Wanted Pregnancy. iUniverse; 2008.
Children with migraine at high risk of comorbid anxiety, depression
Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.
“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.
The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.
The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
Incidence divergence
Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.
While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.
Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.
The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.
Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.
Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).
Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).
In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).
Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
‘Shocking’ lack of research
The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.
“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.
Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.
The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.
The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”
“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.
Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.
Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”
In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.
She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
High-level evidence
Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.
Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.
She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.
“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.
Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.
The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.
A version of this article first appeared on Medscape.com.
Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.
“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.
The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.
The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
Incidence divergence
Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.
While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.
Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.
The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.
Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.
Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).
Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).
In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).
Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
‘Shocking’ lack of research
The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.
“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.
Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.
The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.
The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”
“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.
Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.
Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”
In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.
She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
High-level evidence
Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.
Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.
She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.
“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.
Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.
The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.
A version of this article first appeared on Medscape.com.
Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.
“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.
The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.
The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
Incidence divergence
Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.
While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.
Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.
The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.
Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.
Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).
Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).
In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).
Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
‘Shocking’ lack of research
The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.
“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.
Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.
The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.
The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”
“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.
Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.
Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”
In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.
She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
High-level evidence
Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.
Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.
She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.
“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.
Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.
The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.
A version of this article first appeared on Medscape.com.