Anxiety Disorders

Among healthy middle-aged men, those who were more anxious were more likely to develop high levels of multiple biomarkers of cardiometabolic risk over a 40-year follow-up in a new study.

“By middle adulthood, higher anxiety levels are associated with stable differences” in biomarkers of risk for coronary artery disease (CAD), stroke, and type 2 diabetes, which “are maintained into older ages,” the researchers wrote.

Anxious individuals “may experience deteriorations in cardiometabolic health earlier in life and remain on a stable trajectory of heightened risk into older ages,” they concluded.

The study, led by Lewina Lee, PhD, was published online Jan. 24, 2022, in the Journal of the American Heart Association.

“Men who had higher levels of anxiety at the beginning of the study had consistently higher biological risk for cardiometabolic disease than less anxious men from midlife into old age,” Dr. Lee, assistant professor of psychiatry, Boston University, summarized in an email.

Clinicians may not screen for heart disease and diabetes, and/or only discuss lifestyle modifications when patients are older or have the first signs of disease, she added.

However, the study findings “suggest that worries and anxiety are associated with preclinical pathophysiological processes that tend to culminate in cardiometabolic disease” and show “the importance of screening for mental health difficulties, such as worries and anxiety, in men as early as in their 30s and 40s,” she stressed.

Since most of the men were White (97%) and veterans (94%), “it would be important for future studies to evaluate if these associations exist among women, people from diverse racial and ethnic groups, and in more socioeconomically varying samples, and to consider how anxiety may relate to the development of cardiometabolic risk in much younger individuals than those in our study,” Dr. Lee said in a press release from the American Heart Association.

“This study adds to the growing body of research that link psychological health to cardiovascular risk,” Glenn N. Levine, MD, who was not involved with this research, told this news organization in an email.

“We know that factors such as depression and stress can increase cardiac risk; this study further supports that anxiety can as well,” added Dr. Levine, chief of cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston.

“Everyone experiences some anxiety in their life,” he added. However, “if a provider senses that a patient’s anxiety is far beyond the ‘normal’ that we all have from time to time, and it is seemingly adversely impacting both their psychological and physical health, it would be reasonable to suggest to the patient that it might be useful to speak with a mental health professional, and if the patient is receptive, to then make a formal consultation or referral,” said Dr. Levine, who was writing group chair of a recent AHA Scientific Statement on mind-heart-body connection.
 

Neuroticism and worry

Several studies have linked anxiety to a greater risk of cardiometabolic disease onset, Dr. Lee and colleagues wrote, but it is unclear if anxious individuals have a steadily worsening risk as they age, or if they have a higher risk in middle age, which stays the same in older age.

To investigate this, they analyzed data from 1561 men who were seen at the VA Boston outpatient clinic and did not have CAD, type 2 diabetes, stroke, or cancer when they enrolled in the Normative Aging Study.

The men had a mean age of 53 years (range, 33-84) in 1975 and were followed until 2015 or until dropout from the study or death.

At baseline, the study participants filled in the Eysenck Personality Inventory, which assesses neuroticism, and also responded to a scale indicating how much they worry about 20 issues (excluding health).

“Neuroticism,” the researchers explained, “is a tendency to perceive experiences as threatening, feel that challenges are uncontrollable, and experience frequent and disproportionately intense negative emotions,” such as fear, anxiety, sadness, and anger, “across many situations.”

“Worry refers to attempts to solve a problem where future outcome is uncertain and potentially positive or negative,” Dr. Lee noted. Although worry can be healthy and lead to constructive solutions, “it may be unhealthy, especially when it becomes uncontrollable and interferes with day-to-day functioning.”

Of note, in 1980, the American Psychiatric Association removed the term neurosis from its diagnostic manual. What was previously called neurosis is included as part of generalized anxiety disorder; GAD also encompasses excessive worry.
 

Cardiometabolic risk from midlife to old age

The men in the current study had on-site physical examinations every 3-5 years.

The researchers calculated the men’s cardiometabolic risk score (from 0 to 7) by assigning 1 point each for the following: systolic blood pressure greater than 130 mm Hg, diastolic blood pressure greater than 85 mm Hg, total cholesterol of at least 240 mg/dL, triglycerides of at least 150 mg/dL, body mass index of at least 30 kg/m2, glucose of at least 100 mg/dL, and erythrocyte sedimentation rate of at least 14 mm/hour.

Alternatively, patients were assigned a point each for taking medication that could affect these markers (except for body mass index).

Overall, on average, at baseline, the men had a cardiometabolic risk score of 2.9. From age 33-65, this score increased to 3.8, and then it did not increase as much later on.

That is, the cardiometabolic risk score increased by 0.8 per decade until age 65, followed by a slower increase of 0.5 per decade.

At all ages, men with higher levels of neuroticism or worry had a higher cardiometabolic risk score

Each additional standard deviation of neuroticism was associated with a 13% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up, after adjusting for age, demographics, and family history of CAD, but the relationship was attenuated after also adjusting for health behaviors (for example, smoking, alcohol consumption, physical activity, and past-year physician visit at baseline).

Similarly, each additional standard deviation of worry was associated with a 10% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up after the same adjustments, and was also no longer significantly different after the same further adjustments.

The research was supported by grants from the National Institutes of Health and a Senior Research Career Scientist Award from the Office of Research and Development, Department of Veterans Affairs. The Normative Aging Study is a research component of the Massachusetts Veterans Epidemiology Research and Information Center and is supported by the VA Cooperative Studies Program/Epidemiological Research Centers. The study authors and Dr. Levine disclosed no relevant financial relationships.

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

Among healthy middle-aged men, those who were more anxious were more likely to develop high levels of multiple biomarkers of cardiometabolic risk over a 40-year follow-up in a new study.

“By middle adulthood, higher anxiety levels are associated with stable differences” in biomarkers of risk for coronary artery disease (CAD), stroke, and type 2 diabetes, which “are maintained into older ages,” the researchers wrote.

Anxious individuals “may experience deteriorations in cardiometabolic health earlier in life and remain on a stable trajectory of heightened risk into older ages,” they concluded.

The study, led by Lewina Lee, PhD, was published online Jan. 24, 2022, in the Journal of the American Heart Association.

“Men who had higher levels of anxiety at the beginning of the study had consistently higher biological risk for cardiometabolic disease than less anxious men from midlife into old age,” Dr. Lee, assistant professor of psychiatry, Boston University, summarized in an email.

Clinicians may not screen for heart disease and diabetes, and/or only discuss lifestyle modifications when patients are older or have the first signs of disease, she added.

However, the study findings “suggest that worries and anxiety are associated with preclinical pathophysiological processes that tend to culminate in cardiometabolic disease” and show “the importance of screening for mental health difficulties, such as worries and anxiety, in men as early as in their 30s and 40s,” she stressed.

Since most of the men were White (97%) and veterans (94%), “it would be important for future studies to evaluate if these associations exist among women, people from diverse racial and ethnic groups, and in more socioeconomically varying samples, and to consider how anxiety may relate to the development of cardiometabolic risk in much younger individuals than those in our study,” Dr. Lee said in a press release from the American Heart Association.

“This study adds to the growing body of research that link psychological health to cardiovascular risk,” Glenn N. Levine, MD, who was not involved with this research, told this news organization in an email.

“We know that factors such as depression and stress can increase cardiac risk; this study further supports that anxiety can as well,” added Dr. Levine, chief of cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston.

“Everyone experiences some anxiety in their life,” he added. However, “if a provider senses that a patient’s anxiety is far beyond the ‘normal’ that we all have from time to time, and it is seemingly adversely impacting both their psychological and physical health, it would be reasonable to suggest to the patient that it might be useful to speak with a mental health professional, and if the patient is receptive, to then make a formal consultation or referral,” said Dr. Levine, who was writing group chair of a recent AHA Scientific Statement on mind-heart-body connection.
 

Neuroticism and worry

Several studies have linked anxiety to a greater risk of cardiometabolic disease onset, Dr. Lee and colleagues wrote, but it is unclear if anxious individuals have a steadily worsening risk as they age, or if they have a higher risk in middle age, which stays the same in older age.

To investigate this, they analyzed data from 1561 men who were seen at the VA Boston outpatient clinic and did not have CAD, type 2 diabetes, stroke, or cancer when they enrolled in the Normative Aging Study.

The men had a mean age of 53 years (range, 33-84) in 1975 and were followed until 2015 or until dropout from the study or death.

At baseline, the study participants filled in the Eysenck Personality Inventory, which assesses neuroticism, and also responded to a scale indicating how much they worry about 20 issues (excluding health).

“Neuroticism,” the researchers explained, “is a tendency to perceive experiences as threatening, feel that challenges are uncontrollable, and experience frequent and disproportionately intense negative emotions,” such as fear, anxiety, sadness, and anger, “across many situations.”

“Worry refers to attempts to solve a problem where future outcome is uncertain and potentially positive or negative,” Dr. Lee noted. Although worry can be healthy and lead to constructive solutions, “it may be unhealthy, especially when it becomes uncontrollable and interferes with day-to-day functioning.”

Of note, in 1980, the American Psychiatric Association removed the term neurosis from its diagnostic manual. What was previously called neurosis is included as part of generalized anxiety disorder; GAD also encompasses excessive worry.
 

Cardiometabolic risk from midlife to old age

The men in the current study had on-site physical examinations every 3-5 years.

The researchers calculated the men’s cardiometabolic risk score (from 0 to 7) by assigning 1 point each for the following: systolic blood pressure greater than 130 mm Hg, diastolic blood pressure greater than 85 mm Hg, total cholesterol of at least 240 mg/dL, triglycerides of at least 150 mg/dL, body mass index of at least 30 kg/m2, glucose of at least 100 mg/dL, and erythrocyte sedimentation rate of at least 14 mm/hour.

Alternatively, patients were assigned a point each for taking medication that could affect these markers (except for body mass index).

Overall, on average, at baseline, the men had a cardiometabolic risk score of 2.9. From age 33-65, this score increased to 3.8, and then it did not increase as much later on.

That is, the cardiometabolic risk score increased by 0.8 per decade until age 65, followed by a slower increase of 0.5 per decade.

At all ages, men with higher levels of neuroticism or worry had a higher cardiometabolic risk score

Each additional standard deviation of neuroticism was associated with a 13% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up, after adjusting for age, demographics, and family history of CAD, but the relationship was attenuated after also adjusting for health behaviors (for example, smoking, alcohol consumption, physical activity, and past-year physician visit at baseline).

Similarly, each additional standard deviation of worry was associated with a 10% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up after the same adjustments, and was also no longer significantly different after the same further adjustments.

The research was supported by grants from the National Institutes of Health and a Senior Research Career Scientist Award from the Office of Research and Development, Department of Veterans Affairs. The Normative Aging Study is a research component of the Massachusetts Veterans Epidemiology Research and Information Center and is supported by the VA Cooperative Studies Program/Epidemiological Research Centers. The study authors and Dr. Levine disclosed no relevant financial relationships.

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

Among healthy middle-aged men, those who were more anxious were more likely to develop high levels of multiple biomarkers of cardiometabolic risk over a 40-year follow-up in a new study.

“By middle adulthood, higher anxiety levels are associated with stable differences” in biomarkers of risk for coronary artery disease (CAD), stroke, and type 2 diabetes, which “are maintained into older ages,” the researchers wrote.

Anxious individuals “may experience deteriorations in cardiometabolic health earlier in life and remain on a stable trajectory of heightened risk into older ages,” they concluded.

The study, led by Lewina Lee, PhD, was published online Jan. 24, 2022, in the Journal of the American Heart Association.

“Men who had higher levels of anxiety at the beginning of the study had consistently higher biological risk for cardiometabolic disease than less anxious men from midlife into old age,” Dr. Lee, assistant professor of psychiatry, Boston University, summarized in an email.

Clinicians may not screen for heart disease and diabetes, and/or only discuss lifestyle modifications when patients are older or have the first signs of disease, she added.

However, the study findings “suggest that worries and anxiety are associated with preclinical pathophysiological processes that tend to culminate in cardiometabolic disease” and show “the importance of screening for mental health difficulties, such as worries and anxiety, in men as early as in their 30s and 40s,” she stressed.

Since most of the men were White (97%) and veterans (94%), “it would be important for future studies to evaluate if these associations exist among women, people from diverse racial and ethnic groups, and in more socioeconomically varying samples, and to consider how anxiety may relate to the development of cardiometabolic risk in much younger individuals than those in our study,” Dr. Lee said in a press release from the American Heart Association.

“This study adds to the growing body of research that link psychological health to cardiovascular risk,” Glenn N. Levine, MD, who was not involved with this research, told this news organization in an email.

“We know that factors such as depression and stress can increase cardiac risk; this study further supports that anxiety can as well,” added Dr. Levine, chief of cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston.

“Everyone experiences some anxiety in their life,” he added. However, “if a provider senses that a patient’s anxiety is far beyond the ‘normal’ that we all have from time to time, and it is seemingly adversely impacting both their psychological and physical health, it would be reasonable to suggest to the patient that it might be useful to speak with a mental health professional, and if the patient is receptive, to then make a formal consultation or referral,” said Dr. Levine, who was writing group chair of a recent AHA Scientific Statement on mind-heart-body connection.
 

Neuroticism and worry

Several studies have linked anxiety to a greater risk of cardiometabolic disease onset, Dr. Lee and colleagues wrote, but it is unclear if anxious individuals have a steadily worsening risk as they age, or if they have a higher risk in middle age, which stays the same in older age.

To investigate this, they analyzed data from 1561 men who were seen at the VA Boston outpatient clinic and did not have CAD, type 2 diabetes, stroke, or cancer when they enrolled in the Normative Aging Study.

The men had a mean age of 53 years (range, 33-84) in 1975 and were followed until 2015 or until dropout from the study or death.

At baseline, the study participants filled in the Eysenck Personality Inventory, which assesses neuroticism, and also responded to a scale indicating how much they worry about 20 issues (excluding health).

“Neuroticism,” the researchers explained, “is a tendency to perceive experiences as threatening, feel that challenges are uncontrollable, and experience frequent and disproportionately intense negative emotions,” such as fear, anxiety, sadness, and anger, “across many situations.”

“Worry refers to attempts to solve a problem where future outcome is uncertain and potentially positive or negative,” Dr. Lee noted. Although worry can be healthy and lead to constructive solutions, “it may be unhealthy, especially when it becomes uncontrollable and interferes with day-to-day functioning.”

Of note, in 1980, the American Psychiatric Association removed the term neurosis from its diagnostic manual. What was previously called neurosis is included as part of generalized anxiety disorder; GAD also encompasses excessive worry.
 

Cardiometabolic risk from midlife to old age

The men in the current study had on-site physical examinations every 3-5 years.

The researchers calculated the men’s cardiometabolic risk score (from 0 to 7) by assigning 1 point each for the following: systolic blood pressure greater than 130 mm Hg, diastolic blood pressure greater than 85 mm Hg, total cholesterol of at least 240 mg/dL, triglycerides of at least 150 mg/dL, body mass index of at least 30 kg/m2, glucose of at least 100 mg/dL, and erythrocyte sedimentation rate of at least 14 mm/hour.

Alternatively, patients were assigned a point each for taking medication that could affect these markers (except for body mass index).

Overall, on average, at baseline, the men had a cardiometabolic risk score of 2.9. From age 33-65, this score increased to 3.8, and then it did not increase as much later on.

That is, the cardiometabolic risk score increased by 0.8 per decade until age 65, followed by a slower increase of 0.5 per decade.

At all ages, men with higher levels of neuroticism or worry had a higher cardiometabolic risk score

Each additional standard deviation of neuroticism was associated with a 13% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up, after adjusting for age, demographics, and family history of CAD, but the relationship was attenuated after also adjusting for health behaviors (for example, smoking, alcohol consumption, physical activity, and past-year physician visit at baseline).

Similarly, each additional standard deviation of worry was associated with a 10% increased risk of having six or more of the seven cardiometabolic risk markers during follow-up after the same adjustments, and was also no longer significantly different after the same further adjustments.

The research was supported by grants from the National Institutes of Health and a Senior Research Career Scientist Award from the Office of Research and Development, Department of Veterans Affairs. The Normative Aging Study is a research component of the Massachusetts Veterans Epidemiology Research and Information Center and is supported by the VA Cooperative Studies Program/Epidemiological Research Centers. The study authors and Dr. Levine disclosed no relevant financial relationships.

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

A spoonful of sugar helps the medicine go down – but what if the sugar is the medicine?

Nearly three in four children with irritable bowel syndrome (IBS) or unexplained abdominal pain reported at least a 30% improvement in discomfort after taking a regimen of sugar water they knew had no medicinal properties.

The findings, published online in JAMA Pediatrics on Jan. 31, 2022, also revealed that participants used significantly less rescue medications when taking the so-called “open-label placebo.” The magnitude of the effect was enough to meet one of the criteria from the Food and Drug Administration to approve drugs to treat IBS, which affects between 10% and 15% of U.S. children.

Although open-label placebo is not ready for clinical use, IBS expert Miranda van Tilburg, PhD, said she is “glad we have evidence” of a strong response in this patient population and that the results “may make clinicians rethink how they introduce treatments.

“By emphasizing their belief that a treatment may work, clinicians can harness the placebo effect,” Dr. van Tilburg, professor of medicine and vice chair of research at Marshall University, Huntington, W.Va., told this news organization.

Study leader Samuel Nurko, MD, MPH, the director of the functional abdominal pain program at Harvard Medical School, Boston, said placebo-controlled trials in patients with IBS and functional abdominal pain consistently show a “very high placebo response.” The question his group set out to answer, he said, was: “Can we get the pain symptoms of these children better by giving them placebo with no deception?”

Between 2015 and 2018, Dr. Nurko and colleagues randomly assigned 30 children and adolescents, aged 8-18 years, with IBS or functional abdominal pain to receive either an open-label inert liquid placebo – consisting of 85% sucrose, citric acid, purified water, and the preservative methyl paraben – twice daily for 3 weeks followed by 3 weeks with no placebo, or to follow the reverse sequence. Roughly half (53%) of the children had functional abdominal pain, and 47% had IBS as defined by Rome III criteria.

Researchers at the three participating clinical sites followed a standardized protocol for explaining the nature of placebo (“like sugar pills without medication”), telling participants that adults with conditions like theirs often benefit from placebo when they receive it as part of blinded, randomized clinical trials. Participants in the study were allowed to use hyoscyamine, an anticholinergic medication, as rescue treatment during the trial.

Dr. Nurko’s team reported that patients had a mean pain score of 39.9 on a 100-point visual analogue scale during the open-label placebo phase of the trial and a mean score of 45 during the control period. That difference was statistically significant (P = .03).

Participants took an average of two hyoscyamine pills during the placebo phase, compared with 3.8 pills during the 3-week period when they did not receive placebo (P < .001).

Nearly three-fourths (73.3%) of children in the study reported that open-label placebo improved their pain by over 30%, thus meeting one of the FDA’s criteria for clinical evaluation of drugs for IBS. Half said the placebo liquid cut their pain by more than 50%.

Dr. Nurko said the findings highlight the need to address “mind-body connections” in the management of gut-brain disorders. Like Dr. van Tilburg, he cautioned that open-label placebo “is not ready for widespread use. Placebo is complicated, and we need to understand the mechanism” underlying its efficacy.

“The idea is eventually we will be able to sort out the exact mechanism and harness it for clinical practice,” he added.

However, Dr. van Tilburg expressed that using placebo therapy to treat children and adolescents with these conditions could send the message that “the pain is not real or all in their heads. Children with chronic pain encounter a lot of stigma, and this kind of treatment may increase the feeling of not being believed. We should be careful to avoid this.”

The study was funded by the National Institutes of Health, the Swiss National Science Foundation, the Schwartz family fund, the Foundation for the Science of the Therapeutic Relationship, and the Morgan Family Foundation.

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

A spoonful of sugar helps the medicine go down – but what if the sugar is the medicine?

Nearly three in four children with irritable bowel syndrome (IBS) or unexplained abdominal pain reported at least a 30% improvement in discomfort after taking a regimen of sugar water they knew had no medicinal properties.

The findings, published online in JAMA Pediatrics on Jan. 31, 2022, also revealed that participants used significantly less rescue medications when taking the so-called “open-label placebo.” The magnitude of the effect was enough to meet one of the criteria from the Food and Drug Administration to approve drugs to treat IBS, which affects between 10% and 15% of U.S. children.

Although open-label placebo is not ready for clinical use, IBS expert Miranda van Tilburg, PhD, said she is “glad we have evidence” of a strong response in this patient population and that the results “may make clinicians rethink how they introduce treatments.

“By emphasizing their belief that a treatment may work, clinicians can harness the placebo effect,” Dr. van Tilburg, professor of medicine and vice chair of research at Marshall University, Huntington, W.Va., told this news organization.

Study leader Samuel Nurko, MD, MPH, the director of the functional abdominal pain program at Harvard Medical School, Boston, said placebo-controlled trials in patients with IBS and functional abdominal pain consistently show a “very high placebo response.” The question his group set out to answer, he said, was: “Can we get the pain symptoms of these children better by giving them placebo with no deception?”

Between 2015 and 2018, Dr. Nurko and colleagues randomly assigned 30 children and adolescents, aged 8-18 years, with IBS or functional abdominal pain to receive either an open-label inert liquid placebo – consisting of 85% sucrose, citric acid, purified water, and the preservative methyl paraben – twice daily for 3 weeks followed by 3 weeks with no placebo, or to follow the reverse sequence. Roughly half (53%) of the children had functional abdominal pain, and 47% had IBS as defined by Rome III criteria.

Researchers at the three participating clinical sites followed a standardized protocol for explaining the nature of placebo (“like sugar pills without medication”), telling participants that adults with conditions like theirs often benefit from placebo when they receive it as part of blinded, randomized clinical trials. Participants in the study were allowed to use hyoscyamine, an anticholinergic medication, as rescue treatment during the trial.

Dr. Nurko’s team reported that patients had a mean pain score of 39.9 on a 100-point visual analogue scale during the open-label placebo phase of the trial and a mean score of 45 during the control period. That difference was statistically significant (P = .03).

Participants took an average of two hyoscyamine pills during the placebo phase, compared with 3.8 pills during the 3-week period when they did not receive placebo (P < .001).

Nearly three-fourths (73.3%) of children in the study reported that open-label placebo improved their pain by over 30%, thus meeting one of the FDA’s criteria for clinical evaluation of drugs for IBS. Half said the placebo liquid cut their pain by more than 50%.

Dr. Nurko said the findings highlight the need to address “mind-body connections” in the management of gut-brain disorders. Like Dr. van Tilburg, he cautioned that open-label placebo “is not ready for widespread use. Placebo is complicated, and we need to understand the mechanism” underlying its efficacy.

“The idea is eventually we will be able to sort out the exact mechanism and harness it for clinical practice,” he added.

However, Dr. van Tilburg expressed that using placebo therapy to treat children and adolescents with these conditions could send the message that “the pain is not real or all in their heads. Children with chronic pain encounter a lot of stigma, and this kind of treatment may increase the feeling of not being believed. We should be careful to avoid this.”

The study was funded by the National Institutes of Health, the Swiss National Science Foundation, the Schwartz family fund, the Foundation for the Science of the Therapeutic Relationship, and the Morgan Family Foundation.

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

A spoonful of sugar helps the medicine go down – but what if the sugar is the medicine?

Nearly three in four children with irritable bowel syndrome (IBS) or unexplained abdominal pain reported at least a 30% improvement in discomfort after taking a regimen of sugar water they knew had no medicinal properties.

The findings, published online in JAMA Pediatrics on Jan. 31, 2022, also revealed that participants used significantly less rescue medications when taking the so-called “open-label placebo.” The magnitude of the effect was enough to meet one of the criteria from the Food and Drug Administration to approve drugs to treat IBS, which affects between 10% and 15% of U.S. children.

Although open-label placebo is not ready for clinical use, IBS expert Miranda van Tilburg, PhD, said she is “glad we have evidence” of a strong response in this patient population and that the results “may make clinicians rethink how they introduce treatments.

“By emphasizing their belief that a treatment may work, clinicians can harness the placebo effect,” Dr. van Tilburg, professor of medicine and vice chair of research at Marshall University, Huntington, W.Va., told this news organization.

Study leader Samuel Nurko, MD, MPH, the director of the functional abdominal pain program at Harvard Medical School, Boston, said placebo-controlled trials in patients with IBS and functional abdominal pain consistently show a “very high placebo response.” The question his group set out to answer, he said, was: “Can we get the pain symptoms of these children better by giving them placebo with no deception?”

Between 2015 and 2018, Dr. Nurko and colleagues randomly assigned 30 children and adolescents, aged 8-18 years, with IBS or functional abdominal pain to receive either an open-label inert liquid placebo – consisting of 85% sucrose, citric acid, purified water, and the preservative methyl paraben – twice daily for 3 weeks followed by 3 weeks with no placebo, or to follow the reverse sequence. Roughly half (53%) of the children had functional abdominal pain, and 47% had IBS as defined by Rome III criteria.

Researchers at the three participating clinical sites followed a standardized protocol for explaining the nature of placebo (“like sugar pills without medication”), telling participants that adults with conditions like theirs often benefit from placebo when they receive it as part of blinded, randomized clinical trials. Participants in the study were allowed to use hyoscyamine, an anticholinergic medication, as rescue treatment during the trial.

Dr. Nurko’s team reported that patients had a mean pain score of 39.9 on a 100-point visual analogue scale during the open-label placebo phase of the trial and a mean score of 45 during the control period. That difference was statistically significant (P = .03).

Participants took an average of two hyoscyamine pills during the placebo phase, compared with 3.8 pills during the 3-week period when they did not receive placebo (P < .001).

Nearly three-fourths (73.3%) of children in the study reported that open-label placebo improved their pain by over 30%, thus meeting one of the FDA’s criteria for clinical evaluation of drugs for IBS. Half said the placebo liquid cut their pain by more than 50%.

Dr. Nurko said the findings highlight the need to address “mind-body connections” in the management of gut-brain disorders. Like Dr. van Tilburg, he cautioned that open-label placebo “is not ready for widespread use. Placebo is complicated, and we need to understand the mechanism” underlying its efficacy.

“The idea is eventually we will be able to sort out the exact mechanism and harness it for clinical practice,” he added.

However, Dr. van Tilburg expressed that using placebo therapy to treat children and adolescents with these conditions could send the message that “the pain is not real or all in their heads. Children with chronic pain encounter a lot of stigma, and this kind of treatment may increase the feeling of not being believed. We should be careful to avoid this.”

The study was funded by the National Institutes of Health, the Swiss National Science Foundation, the Schwartz family fund, the Foundation for the Science of the Therapeutic Relationship, and the Morgan Family Foundation.

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

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Violence against women remains a global dilemma in need of attention. Physical violence in particular, is the most prevalent type of violence across all genders, races, and nationalities.

The Centers for Disease Control and Prevention says more than 43 million women and 38 million men report experiencing psychological aggression by an intimate partner in their lifetime. Meanwhile, 11 million women and 5 million men report enduring sexual or physical violence and intimate partner violence (IPV), and/or stalking by an intimate partner during their lifetimes, according to the CDC.1

COVID pandemic’s influence

Isolation tied to the COVID-19 pandemic has been linked to increased IPV. A study conducted by researchers at the University of California, Davis, suggested that extra stress experienced during the COVID-19 pandemic caused by income loss, and the inability to pay for housing and food exacerbated the prevalence of IPV early during the pandemic.⁶

That study, where researchers collected in surveys of nearly 400 adults in the beginning in April 2020 for 10 weeks, showed that more services and communication are needed so that frontline health care and food bank workers, for example, in addition to social workers, doctors, and therapists, can spot the signs and ask clients questions about potential IPV. They could then link survivors to pertinent assistance and resources.

Furthermore, multiple factors probably have played a pivotal role in increasing the prevalence of IPV during the COVID-19 pandemic. For instance, disruption to usual health and social services as well as diminished access to support systems, such as shelters, and charity helplines negatively affected the reporting of domestic violence.

Long before the pandemic, over the past decade, international and national bodies have played a crucial role in terms of improving the awareness and response to domestic violence.^7,8 In addition, several policies have been introduced in countries around the globe emphasizing the need to inquire routinely about domestic violence. Nevertheless, mental health services often fail to adequately address domestic violence in clinical encounters. A systematic review of domestic violence assessment screening performed in a variety of health care settings found that evidence was insufficient to conclude that routine inquiry improved morbidity and mortality among victims of IPV.⁹ So the question becomes: How can we get our patients to tell us about these experiences so we can intervene?
 

Gender differences in perpetuating IPV

Several studies have found that abuse can result in various mental illnesses, such as depression, PTSD, anxiety, and suicidal ideation. Again, men have a disproportionately higher rate of perpetrating IPV, compared with women. This theory has been a source of debate in the academic community for years, but recent research has confirmed that women do perpetuate violence against their partners to some extent.^10,11

Some members of the LGBTQ+ community also report experiencing violence from partners, so as clinicians, we also need to raise our awareness about the existence of violence among same-sex couples. In fact, a team of Italian researchers report more than 50% of gay men and almost 75% of lesbian women reported that they had been psychologically abused by a partner.¹² More research into this area is needed.
 

Our role as health care professionals

The U.S. Preventive Services Task Force advises that all clinic visits include regular IPV screening.¹³ But these screenings are all too rare. In fact, a meta-analysis of 19 trials of more than 1,600 participants showed only 9%-40% of doctors routinely test for IPV.¹⁴ That research clearly shows how important it is for all clinicians to execute IPV screening. However, numerous challenges toward screening exist, including personal discomfort, limited time during appointments, insufficient resources, and inadequate training.

One ongoing debate revolves around which clinician should screen for IPV. Should the psychiatrist carry out this role – or perhaps the primary care physician, nurse, or social worker? These issues become even more fraught when clinicians worry about offending the patient – especially if the clinician is a male.¹⁵

The bottom line is that physicians should inquire about intimate partner violence, because research indicates that women are more likely to reveal abuse when prompted. In addition, during physician appointments, they can use the physician-patient therapeutic connection to conduct a domestic violence evaluation, give resources to victims, and provide ongoing care. Patients who exhibit treatment resistance, persistent pain, depression, sleeplessness, and headaches should prompt psychiatrists to conduct additional investigations into the likelihood of intimate partner violence and domestic abuse.

W also should be attentive when counseling patients about domestic violence when suggesting life-changing events such as pregnancy, employment loss, separation, or divorce. Similar to the recommendations of the USPSTF that all women and men should be screened for IPV, it is suggested that physicians be conscious of facilitating a conversation and not being overtly judgmental while observing body cues. Using the statements such as “we have been hearing a lot of violence in our community lately” could be a segue to introduce the subject.

Asking the question of whether you are being hit rather than being abused has allowed more women to open up more about domestic violence. While physicians are aware that most victims might recant and often go back to their abusers, victims need to be counseled that the abuse might intensify and lead to death.

For women who perpetuate IPV and survivors of IPV, safety is the priority. Physicians should provide safety options and be the facilitators. Studies have shown that fewer victims get the referral to the supporting agencies when IPV is indicated, which puts their safety at risk. In women who commit IPV, clinicians should assess the role of the individual in an IPV disclosure. There are various treatment modalities, whether the violence is performed through self-defense, bidirectionally, or because of aggression.

With the advancement of technology, web-based training on how to ask for IPV, documentation, acknowledgment, and structured referral increase physicians’ confidence when faced with an IPV disclosure than none.¹⁶ Treatment modalities should include medication reconciliation and cognitive-behavioral therapy – focusing on emotion regulation.

Using instruments such as the danger assessment tool can help physicians intervene early, reducing the risk of domestic violence and IPV recurrence instead of using clinical assessment alone.¹⁷ Physicians should convey empathy, validate victims, and help, especially when abuse is reported.

Also, it is important to evaluate survivors’ safety. Counseling can help people rebuild their self-esteem. Structured referrals for psychiatric help and support services are needed to help survivors on the long road to recovery.

Training all physicians, regardless of specialty, is essential to improve prompt IPV identification and bring awareness to resources available to survivors when IPV is disclosed. Although we described an association between IPV victims becoming possible perpetrators of IPV, more long-term studies are required to show the various processes that influence IPV perpetration rates, especially by survivors.

We would also like international and national regulatory bodies to increase the awareness of IPV and adequately address IPV with special emphasis on how mental health services should assess, identify, and respond to services for people who are survivors and perpetrators of IPV.

Dr. Kumari, Dr. Otite, Dr. Afzal, Dr. Alcera, and Dr. Doumas are affiliated with Hackensack Meridian Health at Ocean Medical Center, Brick, N.J. They have no conflicts of interest.

References

1. Centers for Disease Control and Prevention. Preventing intimate partner violence. 2020 Oct 9.

2. Yu R et al. PLOS Med. 16(12):e1002995. doi: 10.1371/journal.pmed.1002995.

3. Oram S et al. Epidemiol Psychiatr Sci. 2014 Dec;23(4):361-76.

4. Munro OE and Sellbom M. Pers Ment Health. 2020 Mar 11. doi: 10.1002/pmh.1480.

5. Sahraian A et al. Asian J Psychiatry. 2020 Jun. doi: 10.1016/j.ajp.2020.102062.

6. Nikos-Rose K. “COVID-19 Isolation Linked to Increased Domestic Violence, Researchers Suggest.” 2021 Feb 24. University of California, Davis.

7. World Health Organization. “Responding to intimate partner violence and sexual violence against women.” WHO clinical policy guidelines. 2013.

8. National Institute for Health and Care Excellence. “Domestic violence and abuse: Multi-agency working.” PH50. 2014 Feb 26.

9. Feder GS et al. Arch Intern Med. 2006;166(1):22-37.

10. Gondolf EW. Violence Against Women. 2014 Dec;20(12)1539-46.

11. Hamberger LK and Larsen SE. J Fam Violence. 2015;30(6):699-717.

12. Rollè L et al. Front Psychol. 21 Aug 2018. doi: 10.3389/fpsyg.2018.01506.

13. Paterno MT and Draughon JE. J Midwif Women Health. 2016;61(31):370-5.

14. Kalra N et al. Cochrane Database Syst Rev. 2021 May 31;5(5)CD012423.

15. Larsen SE and Hamberger LK. J Fam Viol. 2015;30:1007-30.

16. Kalra N et al. Cochrane Database Syst Rev. 2017 Feb;2017(2):CD012423.

17. Campbell JC et al. J Interpers Violence. 2009;24(4):653-74.

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

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

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

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

Depending on the data you’re looking at, 40%-60% of physicians are burned out.

Research studies and the eye test reveal the painfully obvious: Colleagues are tired, winded, spent, and at times way past burned out. People aren’t asking me if they’re burned out. They know they’re burned out; heck, they can even recite the Maslach burnout inventory, forward and backward, in a mask, or while completing a COVID quarantine. A fair share of people know the key steps to prevent burnout and promote recovery.

What I’m starting to see more of is, “Why should I even bother to recover from this? Why pick myself up again just to get another occupational stress injury (burnout, demoralization, moral injury, etc.)?” In other words, it’s not just simply about negating burnout; it’s about supporting and facilitating the motivation to work.

We’ve been through so much with COVID that it might be challenging to remember when you saw a truly engaged work environment. No doubt, we have outstanding professionals across medicine who answer the bell every day. However, if you’ve been looking closely, many teams/units have lost a bit of the zip and pep. The synergy and trust aren’t as smooth, and at noon, everyone counts the hours to the end of the shift.

You may be thinking, Well, of course, they are; we’re still amid a pandemic, and people have been through hell. Your observation would be correct, except I’ve personally seen some teams weather the pandemic storm and still remain engaged (some even more involved).

The No. 1 consult result for the GW Resiliency and Well-Being Center, where I work, has been on lectures for burnout. The R&WC has given so many of these lectures that my dreams take the form of a PowerPoint presentation. Overall the talks have gone very well. We’ve added skills sections on practices of whole-person care. We’ve blitzed the daylights out of restorative sleep, yet I know we are still searching for the correct narrative.

Motivated staff, faculty, and students will genuinely take in the information and follow the recommendations; however, they still struggle to find that drive and zest for work. Yes, moving from burnout to neutral is reasonable but likely won’t move the needle of your professional or personal life. We need to have the emotional energy and the clear desire to utilize that energy for a meaningful purpose.

Talking about burnout in specific ways is straightforward and, in my opinion, much easier than talking about engagement. Part of the challenge when trying to discuss engagement is that people can feel invalidated or that you’re telling them to be stoic. Or worse yet, that the problem of burnout primarily lies with them. It’s essential to recognize the role of an organizational factor in burnout (approximately 80%, depending on the study); still, even if you address burnout, people may not be miserable, but it doesn’t mean they will stay at their current job (please cue intro music for the Great Resignation).

Engagement models have existed for some time and certainly have gained much more attention in health care settings over the past 2 decades. Engagement can be described as having three components: dedication, vigor, and absorption. When a person is filling all three of these components over time, presto – you get the much-sought-after state of the supremely engaged professional.

These models definitely give us excellent starting points to approach engagement from a pre-COVID era. In COVID and beyond, I’m not sure how these models will stand up in a hybrid work environment, where autonomy and flexibility could be more valued than ever. Personally, COVID revealed some things I was missing in my work pre-COVID:

• Time to think and process. This was one of the great things about being a consultation-liaison psychiatrist; it was literally feast or famine.
• Doing what I’m talented at and really enjoy.
• Time is short, and I want to be more present in the life of my family.
• Growth and curiosity are vitally important to me. These have to be part of my daily ritual and practice.

The list above isn’t exhaustive, but I’ve found them to be my own personal recipe for being engaged. Over the next series of articles, I’m going to focus on engagement and factors related to key resilience. These articles will be informed by a front-line view from my colleagues, and hopefully start to separate the myth from reality on the subject of health professional engagement and resilience.

Everyone be safe and well!

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

Over-the-counter cannabidiol (CBD) products appear to improve pain, sleep, and anxiety disorders, preliminary research suggests.

Interim findings from Advancing CBD Education and Science, a 100% virtual, open label, randomized, controlled trial, show study participants experienced various degrees of “clinically meaningful” improvements in sleep quality, anxiety, and pain.

“ACES is the largest clinical trial ever conducted on commercially available CBD products and provides first-of-its-kind real world evidence into what conditions users may experience benefit from CBD usage, whether these benefits are clinically meaningful, what attributes of CBD products may impact health outcomes, and what side effects may occur,” study coinvestigator Jessica Saleska, PhD, MPH, director of research at Radicle Science, the company that conducted the study, told this news organization.
 

Scant evidence

Despite the growing market size of commercially available CBD products “there is still scant data on the effectiveness of over-the-counter cannabinoid products due to the cost, speed, and scale limitations of the current approach to scientific research,” Jeff Chen, MD, MBA, cofounder and CEO of Radicle Science, told this news organization.

One of the study’s goals, said Ethan Russo, MD, a neurologist, founder/CEO of CReDO Science, and scientific adviser for Radicle, is to help consumers make informed decisions before purchasing and using commercially available oral CBD products. 

Designed to eliminate all physical infrastructure, which minimizes costs and facilitates faster execution, ACES was conducted much like a phase 4 clinical trial, collating real-world data gathered over 4 weeks.

“The process that Radicle scientists [have] advanced is sort of a crowdsourcing approach to doing clinical science,” Dr. Russo said. “Hopefully, there is going to be a considerable amount of data generated that [will] affect people’s buying options.”

The study also aimed to evaluate product attributes, including composition, mode of use, dosage, dosage timing and frequency, and their correlation to degrees of outcomes.

Dr. Russo explained why product composition is an important factor, especially when dealing with CBD. “What happens with any given [CBD] preparation is going to be totally a function of other components, if any. 

“For example, there’s this mistaken notion that cannabidiol is sedating; it is not. Pure cannabidiol is stimulating in low and moderate amounts. Where the confusion has arisen is that the early chemovars containing cannabidiol were also predominant in myrcene, the sedating terpene, [thereby] creating this misimpression that it is good for sleep,” he added.

However, CBD might also affect sleep by reducing anxiety that interferes with it. “What’s clear is that cannabidiol is an antianxiety agent, if you have a sufficient dose,” Dr. Russo said.

The 4-week study included 2,704 participants aged 21 years and older, self-reporting anxiety, chronic pain, or sleep disturbances as a primary reason for taking CBD. Study participants were randomly assigned to receive 1 of 13 commercially available oral CBD extracts.

Participants were allocated to 1 of 14 cohorts, comprising 13 treatment groups with 208 participants each who received a single CBD product, or a wait-list control group of 296 participants who received product at the study’s end.

The primary outcome focused on “clinically meaningful” changes, which were defined as “distinct and palpable improvements in quality of life through improvements in respective health outcomes.”

Secondary outcomes included changes in sleep, anxiety, and pain based on several validated indices, including the PROMIS (Patient-Reported Outcome Measurement Information System) Sleep Short Form; the PROMIS Anxiety Scale; the Patient Global Impression of Change; the Pain, Enjoyment, General Activity scale; and the General Anxiety Disorder–7 scale.

The interim study results are promising, with participants reporting, on average, a 71% improvement in well-being. Additionally, 63% reported clinically meaningful improvements in anxiety, and 61% in sleep quality. The CBD products provided smaller benefits in pain management, with less than half (47%) experiencing meaningful improvements.

In addition to improvement in sleep, pain, and anxiety, these data highlight how rapidly benefits occurred; most were realized during the first week of the study, with up to 61% of treatment group participants reporting a therapeutic effect within 1-4 hours of taking their assigned product.
 

Overcoming the placebo effect

Commenting on the research, Justin Strickland, PhD, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, who was not involved in the research, said without knowing a lot about the pharmacology of the products being tested, early dramatic improvements in these measures, such as sleep impairment, are common.

“There are some data to suggest that there is an expectancy effect when we talk about the therapeutic benefit of cannabinoid products, (i.e., when someone has the expectation that they are going to experience a stronger effect) but this is true of any drug in an open label trial,” Dr. Strickland added.

Dr. Russo took the point a step further. “It’s getting near impossible to look at cannabinoid compounds, even with randomized, controlled trials because of the burgeoning placebo responses. When you couple it with the fact that consumers have the mistaken notion that cannabis-based drugs are miraculous, the expectations are so high that everyone thinks that they’re on the real stuff, even if it’s a placebo group.”

Still, both Dr. Strickland and Dr. Russo highlighted the fact that ACES mirrors real-world experience, which will they hope will inform the use of CBD and CBD-based preparations moving forward. By removing certain barriers like institutional bureaucracy or federal funding restrictions inherent to more traditional randomized controlled trial design, ACES might provide data that bridge the gap between efficacy and effectiveness.

ACES was funded by Radicle Science. Dr. Chen is cofounder and CEO of Radicle Science. Dr. Russo and Dr. Strickland disclosed no relevant financial relationships.

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

Over-the-counter cannabidiol (CBD) products appear to improve pain, sleep, and anxiety disorders, preliminary research suggests.

Interim findings from Advancing CBD Education and Science, a 100% virtual, open label, randomized, controlled trial, show study participants experienced various degrees of “clinically meaningful” improvements in sleep quality, anxiety, and pain.

“ACES is the largest clinical trial ever conducted on commercially available CBD products and provides first-of-its-kind real world evidence into what conditions users may experience benefit from CBD usage, whether these benefits are clinically meaningful, what attributes of CBD products may impact health outcomes, and what side effects may occur,” study coinvestigator Jessica Saleska, PhD, MPH, director of research at Radicle Science, the company that conducted the study, told this news organization.
 

Scant evidence

Despite the growing market size of commercially available CBD products “there is still scant data on the effectiveness of over-the-counter cannabinoid products due to the cost, speed, and scale limitations of the current approach to scientific research,” Jeff Chen, MD, MBA, cofounder and CEO of Radicle Science, told this news organization.

One of the study’s goals, said Ethan Russo, MD, a neurologist, founder/CEO of CReDO Science, and scientific adviser for Radicle, is to help consumers make informed decisions before purchasing and using commercially available oral CBD products. 

Designed to eliminate all physical infrastructure, which minimizes costs and facilitates faster execution, ACES was conducted much like a phase 4 clinical trial, collating real-world data gathered over 4 weeks.

“The process that Radicle scientists [have] advanced is sort of a crowdsourcing approach to doing clinical science,” Dr. Russo said. “Hopefully, there is going to be a considerable amount of data generated that [will] affect people’s buying options.”

The study also aimed to evaluate product attributes, including composition, mode of use, dosage, dosage timing and frequency, and their correlation to degrees of outcomes.

Dr. Russo explained why product composition is an important factor, especially when dealing with CBD. “What happens with any given [CBD] preparation is going to be totally a function of other components, if any. 

“For example, there’s this mistaken notion that cannabidiol is sedating; it is not. Pure cannabidiol is stimulating in low and moderate amounts. Where the confusion has arisen is that the early chemovars containing cannabidiol were also predominant in myrcene, the sedating terpene, [thereby] creating this misimpression that it is good for sleep,” he added.

However, CBD might also affect sleep by reducing anxiety that interferes with it. “What’s clear is that cannabidiol is an antianxiety agent, if you have a sufficient dose,” Dr. Russo said.

The 4-week study included 2,704 participants aged 21 years and older, self-reporting anxiety, chronic pain, or sleep disturbances as a primary reason for taking CBD. Study participants were randomly assigned to receive 1 of 13 commercially available oral CBD extracts.

Participants were allocated to 1 of 14 cohorts, comprising 13 treatment groups with 208 participants each who received a single CBD product, or a wait-list control group of 296 participants who received product at the study’s end.

The primary outcome focused on “clinically meaningful” changes, which were defined as “distinct and palpable improvements in quality of life through improvements in respective health outcomes.”

Secondary outcomes included changes in sleep, anxiety, and pain based on several validated indices, including the PROMIS (Patient-Reported Outcome Measurement Information System) Sleep Short Form; the PROMIS Anxiety Scale; the Patient Global Impression of Change; the Pain, Enjoyment, General Activity scale; and the General Anxiety Disorder–7 scale.

The interim study results are promising, with participants reporting, on average, a 71% improvement in well-being. Additionally, 63% reported clinically meaningful improvements in anxiety, and 61% in sleep quality. The CBD products provided smaller benefits in pain management, with less than half (47%) experiencing meaningful improvements.

In addition to improvement in sleep, pain, and anxiety, these data highlight how rapidly benefits occurred; most were realized during the first week of the study, with up to 61% of treatment group participants reporting a therapeutic effect within 1-4 hours of taking their assigned product.
 

Overcoming the placebo effect

Commenting on the research, Justin Strickland, PhD, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, who was not involved in the research, said without knowing a lot about the pharmacology of the products being tested, early dramatic improvements in these measures, such as sleep impairment, are common.

“There are some data to suggest that there is an expectancy effect when we talk about the therapeutic benefit of cannabinoid products, (i.e., when someone has the expectation that they are going to experience a stronger effect) but this is true of any drug in an open label trial,” Dr. Strickland added.

Dr. Russo took the point a step further. “It’s getting near impossible to look at cannabinoid compounds, even with randomized, controlled trials because of the burgeoning placebo responses. When you couple it with the fact that consumers have the mistaken notion that cannabis-based drugs are miraculous, the expectations are so high that everyone thinks that they’re on the real stuff, even if it’s a placebo group.”

Still, both Dr. Strickland and Dr. Russo highlighted the fact that ACES mirrors real-world experience, which will they hope will inform the use of CBD and CBD-based preparations moving forward. By removing certain barriers like institutional bureaucracy or federal funding restrictions inherent to more traditional randomized controlled trial design, ACES might provide data that bridge the gap between efficacy and effectiveness.

ACES was funded by Radicle Science. Dr. Chen is cofounder and CEO of Radicle Science. Dr. Russo and Dr. Strickland disclosed no relevant financial relationships.

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

Over-the-counter cannabidiol (CBD) products appear to improve pain, sleep, and anxiety disorders, preliminary research suggests.

Interim findings from Advancing CBD Education and Science, a 100% virtual, open label, randomized, controlled trial, show study participants experienced various degrees of “clinically meaningful” improvements in sleep quality, anxiety, and pain.

“ACES is the largest clinical trial ever conducted on commercially available CBD products and provides first-of-its-kind real world evidence into what conditions users may experience benefit from CBD usage, whether these benefits are clinically meaningful, what attributes of CBD products may impact health outcomes, and what side effects may occur,” study coinvestigator Jessica Saleska, PhD, MPH, director of research at Radicle Science, the company that conducted the study, told this news organization.
 

Scant evidence

Despite the growing market size of commercially available CBD products “there is still scant data on the effectiveness of over-the-counter cannabinoid products due to the cost, speed, and scale limitations of the current approach to scientific research,” Jeff Chen, MD, MBA, cofounder and CEO of Radicle Science, told this news organization.

One of the study’s goals, said Ethan Russo, MD, a neurologist, founder/CEO of CReDO Science, and scientific adviser for Radicle, is to help consumers make informed decisions before purchasing and using commercially available oral CBD products. 

Designed to eliminate all physical infrastructure, which minimizes costs and facilitates faster execution, ACES was conducted much like a phase 4 clinical trial, collating real-world data gathered over 4 weeks.

“The process that Radicle scientists [have] advanced is sort of a crowdsourcing approach to doing clinical science,” Dr. Russo said. “Hopefully, there is going to be a considerable amount of data generated that [will] affect people’s buying options.”

The study also aimed to evaluate product attributes, including composition, mode of use, dosage, dosage timing and frequency, and their correlation to degrees of outcomes.

Dr. Russo explained why product composition is an important factor, especially when dealing with CBD. “What happens with any given [CBD] preparation is going to be totally a function of other components, if any. 

“For example, there’s this mistaken notion that cannabidiol is sedating; it is not. Pure cannabidiol is stimulating in low and moderate amounts. Where the confusion has arisen is that the early chemovars containing cannabidiol were also predominant in myrcene, the sedating terpene, [thereby] creating this misimpression that it is good for sleep,” he added.

However, CBD might also affect sleep by reducing anxiety that interferes with it. “What’s clear is that cannabidiol is an antianxiety agent, if you have a sufficient dose,” Dr. Russo said.

The 4-week study included 2,704 participants aged 21 years and older, self-reporting anxiety, chronic pain, or sleep disturbances as a primary reason for taking CBD. Study participants were randomly assigned to receive 1 of 13 commercially available oral CBD extracts.

Participants were allocated to 1 of 14 cohorts, comprising 13 treatment groups with 208 participants each who received a single CBD product, or a wait-list control group of 296 participants who received product at the study’s end.

The primary outcome focused on “clinically meaningful” changes, which were defined as “distinct and palpable improvements in quality of life through improvements in respective health outcomes.”

Secondary outcomes included changes in sleep, anxiety, and pain based on several validated indices, including the PROMIS (Patient-Reported Outcome Measurement Information System) Sleep Short Form; the PROMIS Anxiety Scale; the Patient Global Impression of Change; the Pain, Enjoyment, General Activity scale; and the General Anxiety Disorder–7 scale.

The interim study results are promising, with participants reporting, on average, a 71% improvement in well-being. Additionally, 63% reported clinically meaningful improvements in anxiety, and 61% in sleep quality. The CBD products provided smaller benefits in pain management, with less than half (47%) experiencing meaningful improvements.

In addition to improvement in sleep, pain, and anxiety, these data highlight how rapidly benefits occurred; most were realized during the first week of the study, with up to 61% of treatment group participants reporting a therapeutic effect within 1-4 hours of taking their assigned product.
 

Overcoming the placebo effect

Commenting on the research, Justin Strickland, PhD, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, who was not involved in the research, said without knowing a lot about the pharmacology of the products being tested, early dramatic improvements in these measures, such as sleep impairment, are common.

“There are some data to suggest that there is an expectancy effect when we talk about the therapeutic benefit of cannabinoid products, (i.e., when someone has the expectation that they are going to experience a stronger effect) but this is true of any drug in an open label trial,” Dr. Strickland added.

Dr. Russo took the point a step further. “It’s getting near impossible to look at cannabinoid compounds, even with randomized, controlled trials because of the burgeoning placebo responses. When you couple it with the fact that consumers have the mistaken notion that cannabis-based drugs are miraculous, the expectations are so high that everyone thinks that they’re on the real stuff, even if it’s a placebo group.”

Still, both Dr. Strickland and Dr. Russo highlighted the fact that ACES mirrors real-world experience, which will they hope will inform the use of CBD and CBD-based preparations moving forward. By removing certain barriers like institutional bureaucracy or federal funding restrictions inherent to more traditional randomized controlled trial design, ACES might provide data that bridge the gap between efficacy and effectiveness.

ACES was funded by Radicle Science. Dr. Chen is cofounder and CEO of Radicle Science. Dr. Russo and Dr. Strickland disclosed no relevant financial relationships.

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

The experience of practicing reproductive psychiatry in the context of the pandemic has highlighted unique situations I’ve written about in previous columns that have affected pregnant and postpartum women during the pandemic, such as the management of anxiety and insomnia.

The pandemic has also seen a shift to telemedicine and an opportunity to use virtual platforms to engage with colleagues in our subspecialty across the country. These forums of engagement, which we realize virtually with so many of our colleagues, has prompted me to refine and galvanize what I consider to be some principles that guide frequently encountered clinical scenarios in reproductive psychiatry.

To open 2022, I wanted to revisit the practices I nearly “always” (or conversely, “never”) follow as a reproductive psychiatrist across the numerous clinical situations and variations on the associated clinical themes encountered as we see patients during pregnancy and the postpartum period.
 

Things we ‘always’ do

1. I continue to make maternal euthymia the North Star of treatment before, during, and after pregnancy.

Before pregnancy, maternal euthymia may be realized through optimization of pharmacologic and nonpharmacologic treatments and waiting to conceive until patients are emotionally well. Sustaining euthymia during pregnancy is a critical issue because of the extent to which euthymia during pregnancy predicts postpartum course. According to many studies, postpartum euthymia is the strongest predictor of long-term neurobehavioral outcome and risk for later child psychopathology. At the end of the day, there are few things I would not do with respect to treatment of maternal psychiatric disorder if the upside afforded maternal euthymia.

2. I almost always treat with consistency of medication across the peripartum period.

Although there have been discussions about the wisdom of changing medications, such as antidepressants, benzodiazepines, and mood stabilizers, that have afforded euthymia during pregnancy as patients approach their delivery date, the evidence base supporting switching medications at that time is exceedingly sparse. The time to adjust or to modify is typically not just prior to delivery unless it is to prevent postpartum psychiatric disorder (see below).

3. I simplify regimens before pregnancy if it’s unclear which medications have afforded patients euthymia.

We have a growing appreciation that polypharmacy is the rule in treatment of affective disorder for both unipolar and bipolar illness. Consultation before pregnancy is the ideal time to take a particularly careful history and think about simplifying regimens where adding medicines hasn’t clearly provided enhanced clinical benefit to the patient.

4. When making a treatment plan for psychiatric disorder during pregnancy, I consider the impact of untreated psychiatric disorder (even if not absolutely quantifiable) on fetal, neonatal, and maternal well-being.

Perhaps now more than even 5-10 years ago, we have better data describing the adverse effects of untreated psychiatric illness on fetal, neonatal, and maternal well-being.

We always try to deliberately consider the effect of a specific treatment on fetal well-being. Less attention (and science) has focused on the effect on pregnancy of deferring treatment; historically, this has not been adequately quantified in the risk-benefit decision. Yet, there is growing evidence of the increased adverse effects of activating the stress axis on everything from intrauterine fetal programming in the brain to effects on obstetrical outcomes such as preterm labor and delivery.

5. I appreciate the value of postpartum prophylaxis for pregnant women with bipolar disorder to mitigate risk of relapse.

We have spoken over the last 20 months of the pandemic, particularly in reproductive psychiatry circles, about the importance of keeping reproductive-age women with bipolar disorder emotionally well as they plan to conceive, during pregnancy, and in the postpartum period. The management of bipolar disorder during this time can be a humbling experience. Clinical roughening can be quick and severe, and so we do everything that we can for these women.

The area in which we have the strongest evidence base for mitigating risk with bipolar women is the value of postpartum prophylaxis during the peripartum period, regardless of what patients have done with their mood-stabilizing medications during pregnancy. Given the risk for postpartum disease, even though there are varying amounts of evidence on prophylactic benefit of specific mood stabilizers (i.e., lithium vs. atypical antipsychotics), the value of prophylaxis against worsening of bipolar disorder postpartum is widely accepted.

The importance of this has been particularly underscored during the pandemic where postpartum support, although available, has been more tenuous given the fluctuations in COVID-19 status around the country. The availability of friends and loved ones as support during the postpartum period has become less reliable in certain circumstances during the pandemic. In some cases, COVID-19 surges have wreaked havoc on travel plans and support persons have contracted the virus, rendering on-site support nonviable given safety concerns. Last-minute shifts of support plans have been responsible for disruption of care plans for new moms and by extension, have affected the ability to protect the sleep of bipolar women, which is critical. Keeping bipolar women well during the postpartum period with plans and backup plans for management remains critical.
 

Things we ‘never’ do

1. I never taper antidepressants (just prior to delivery), I never check plasma levels of selective serotonin reuptake inhibitors (across pregnancy, or just prior to labor and delivery), and I never use sodium valproate (during pregnancy).

Although there has been some discussion about the potential to mitigate risk for maternal or neonatal toxicity with lowering of agents such as lithium or lamotrigine during pregnancy, I do not routinely check plasma levels or arbitrarily change the dose of antidepressants, lithium, or lamotrigine during pregnancy in the absence of clinical symptoms.

We know full well that plasma levels of medications decline during pregnancy because of hemodilution with lithium and antidepressants and, in the case of lamotrigine, the effects of rising estrogen concentration during pregnancy on the metabolism of lamotrigine. While several studies have shown the decrease of SSRI concentration during pregnancy absent a change in dose of medication, these data have not correlated changes in plasma concentration of SSRI with a frank change in clinical status across pregnancy. Unlike what we see in conditions like epilepsy, where doses are increased to maintain therapeutic plasma levels to mitigate risk for seizure, those therapeutic plasma levels do not clearly exist for the psychiatric medications most widely used to treat psychiatric disorders.

We also almost never use sodium valproate in reproductive-age women despite its efficacy in both the acute and maintenance treatment of bipolar disorder given the risk of both major malformations associated with first-trimester fetal exposure to valproate and the data suggesting longer-term adverse neurobehavioral effects associated with its use during pregnancy.

2. We never suggest patients defer pregnancy based on their underlying psychiatric disorder.

Our role is to provide the best information regarding reproductive safety of psychiatric medications and risks of untreated psychiatric disorder to patients as they and relevant parties weigh the risks of pursuing one treatment or another. Those are private choices, and women and their partners make private decisions applying their own calculus with respect to moving forward with plans to conceive.

3. We never switch antidepressants once a woman has become pregnant.

Although we continue to see patients switched to older SSRIs such as sertraline with documentation of pregnancy, a patient’s road to getting well is sometimes very lengthy. In the absence of indicting reproductive safety data for any particular antidepressant, for patients who have gotten well on an antidepressant, even one for which we have less information, we stay the course and do not switch arbitrarily to an older SSRI for which we may have more reproductive safety data.

If we have the luxury prior to pregnancy to switch a patient to an untried and better studied antidepressant with more data supporting safety, we do so. But this is rarely the case. More often, we see women presenting with a newly documented pregnancy (frequently unplanned, with half of pregnancies across the country still being unplanned across sociodemographic lines) on an antidepressant with varying amounts of reproductive safety information available for the medicine being taken, and frequently after failed previous trials of other antidepressants. In this scenario, we rarely see the time of a newly documented pregnancy as an opportunity to pursue a new trial of an antidepressant without known efficacy for that patient; we stay the course and hope for sustained euthymia on the drug which has afforded euthymia to date.
 

Final thoughts

Dos and don’ts are relative in reproductive psychiatry. We tend to apply available data and clinical experience as we guide patients on a case-by-case basis, considering the most currently available rigorous reproductive safety data, as well as the individual patient’s clinical status and her personal wishes.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

The experience of practicing reproductive psychiatry in the context of the pandemic has highlighted unique situations I’ve written about in previous columns that have affected pregnant and postpartum women during the pandemic, such as the management of anxiety and insomnia.

The pandemic has also seen a shift to telemedicine and an opportunity to use virtual platforms to engage with colleagues in our subspecialty across the country. These forums of engagement, which we realize virtually with so many of our colleagues, has prompted me to refine and galvanize what I consider to be some principles that guide frequently encountered clinical scenarios in reproductive psychiatry.

To open 2022, I wanted to revisit the practices I nearly “always” (or conversely, “never”) follow as a reproductive psychiatrist across the numerous clinical situations and variations on the associated clinical themes encountered as we see patients during pregnancy and the postpartum period.
 

Things we ‘always’ do

1. I continue to make maternal euthymia the North Star of treatment before, during, and after pregnancy.

Before pregnancy, maternal euthymia may be realized through optimization of pharmacologic and nonpharmacologic treatments and waiting to conceive until patients are emotionally well. Sustaining euthymia during pregnancy is a critical issue because of the extent to which euthymia during pregnancy predicts postpartum course. According to many studies, postpartum euthymia is the strongest predictor of long-term neurobehavioral outcome and risk for later child psychopathology. At the end of the day, there are few things I would not do with respect to treatment of maternal psychiatric disorder if the upside afforded maternal euthymia.

2. I almost always treat with consistency of medication across the peripartum period.

Although there have been discussions about the wisdom of changing medications, such as antidepressants, benzodiazepines, and mood stabilizers, that have afforded euthymia during pregnancy as patients approach their delivery date, the evidence base supporting switching medications at that time is exceedingly sparse. The time to adjust or to modify is typically not just prior to delivery unless it is to prevent postpartum psychiatric disorder (see below).

3. I simplify regimens before pregnancy if it’s unclear which medications have afforded patients euthymia.

We have a growing appreciation that polypharmacy is the rule in treatment of affective disorder for both unipolar and bipolar illness. Consultation before pregnancy is the ideal time to take a particularly careful history and think about simplifying regimens where adding medicines hasn’t clearly provided enhanced clinical benefit to the patient.

4. When making a treatment plan for psychiatric disorder during pregnancy, I consider the impact of untreated psychiatric disorder (even if not absolutely quantifiable) on fetal, neonatal, and maternal well-being.

Perhaps now more than even 5-10 years ago, we have better data describing the adverse effects of untreated psychiatric illness on fetal, neonatal, and maternal well-being.

We always try to deliberately consider the effect of a specific treatment on fetal well-being. Less attention (and science) has focused on the effect on pregnancy of deferring treatment; historically, this has not been adequately quantified in the risk-benefit decision. Yet, there is growing evidence of the increased adverse effects of activating the stress axis on everything from intrauterine fetal programming in the brain to effects on obstetrical outcomes such as preterm labor and delivery.

5. I appreciate the value of postpartum prophylaxis for pregnant women with bipolar disorder to mitigate risk of relapse.

We have spoken over the last 20 months of the pandemic, particularly in reproductive psychiatry circles, about the importance of keeping reproductive-age women with bipolar disorder emotionally well as they plan to conceive, during pregnancy, and in the postpartum period. The management of bipolar disorder during this time can be a humbling experience. Clinical roughening can be quick and severe, and so we do everything that we can for these women.

The area in which we have the strongest evidence base for mitigating risk with bipolar women is the value of postpartum prophylaxis during the peripartum period, regardless of what patients have done with their mood-stabilizing medications during pregnancy. Given the risk for postpartum disease, even though there are varying amounts of evidence on prophylactic benefit of specific mood stabilizers (i.e., lithium vs. atypical antipsychotics), the value of prophylaxis against worsening of bipolar disorder postpartum is widely accepted.

The importance of this has been particularly underscored during the pandemic where postpartum support, although available, has been more tenuous given the fluctuations in COVID-19 status around the country. The availability of friends and loved ones as support during the postpartum period has become less reliable in certain circumstances during the pandemic. In some cases, COVID-19 surges have wreaked havoc on travel plans and support persons have contracted the virus, rendering on-site support nonviable given safety concerns. Last-minute shifts of support plans have been responsible for disruption of care plans for new moms and by extension, have affected the ability to protect the sleep of bipolar women, which is critical. Keeping bipolar women well during the postpartum period with plans and backup plans for management remains critical.
 

Things we ‘never’ do

1. I never taper antidepressants (just prior to delivery), I never check plasma levels of selective serotonin reuptake inhibitors (across pregnancy, or just prior to labor and delivery), and I never use sodium valproate (during pregnancy).

Although there has been some discussion about the potential to mitigate risk for maternal or neonatal toxicity with lowering of agents such as lithium or lamotrigine during pregnancy, I do not routinely check plasma levels or arbitrarily change the dose of antidepressants, lithium, or lamotrigine during pregnancy in the absence of clinical symptoms.

We know full well that plasma levels of medications decline during pregnancy because of hemodilution with lithium and antidepressants and, in the case of lamotrigine, the effects of rising estrogen concentration during pregnancy on the metabolism of lamotrigine. While several studies have shown the decrease of SSRI concentration during pregnancy absent a change in dose of medication, these data have not correlated changes in plasma concentration of SSRI with a frank change in clinical status across pregnancy. Unlike what we see in conditions like epilepsy, where doses are increased to maintain therapeutic plasma levels to mitigate risk for seizure, those therapeutic plasma levels do not clearly exist for the psychiatric medications most widely used to treat psychiatric disorders.

We also almost never use sodium valproate in reproductive-age women despite its efficacy in both the acute and maintenance treatment of bipolar disorder given the risk of both major malformations associated with first-trimester fetal exposure to valproate and the data suggesting longer-term adverse neurobehavioral effects associated with its use during pregnancy.

2. We never suggest patients defer pregnancy based on their underlying psychiatric disorder.

Our role is to provide the best information regarding reproductive safety of psychiatric medications and risks of untreated psychiatric disorder to patients as they and relevant parties weigh the risks of pursuing one treatment or another. Those are private choices, and women and their partners make private decisions applying their own calculus with respect to moving forward with plans to conceive.

3. We never switch antidepressants once a woman has become pregnant.

Although we continue to see patients switched to older SSRIs such as sertraline with documentation of pregnancy, a patient’s road to getting well is sometimes very lengthy. In the absence of indicting reproductive safety data for any particular antidepressant, for patients who have gotten well on an antidepressant, even one for which we have less information, we stay the course and do not switch arbitrarily to an older SSRI for which we may have more reproductive safety data.

If we have the luxury prior to pregnancy to switch a patient to an untried and better studied antidepressant with more data supporting safety, we do so. But this is rarely the case. More often, we see women presenting with a newly documented pregnancy (frequently unplanned, with half of pregnancies across the country still being unplanned across sociodemographic lines) on an antidepressant with varying amounts of reproductive safety information available for the medicine being taken, and frequently after failed previous trials of other antidepressants. In this scenario, we rarely see the time of a newly documented pregnancy as an opportunity to pursue a new trial of an antidepressant without known efficacy for that patient; we stay the course and hope for sustained euthymia on the drug which has afforded euthymia to date.
 

Final thoughts

Dos and don’ts are relative in reproductive psychiatry. We tend to apply available data and clinical experience as we guide patients on a case-by-case basis, considering the most currently available rigorous reproductive safety data, as well as the individual patient’s clinical status and her personal wishes.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

The experience of practicing reproductive psychiatry in the context of the pandemic has highlighted unique situations I’ve written about in previous columns that have affected pregnant and postpartum women during the pandemic, such as the management of anxiety and insomnia.

The pandemic has also seen a shift to telemedicine and an opportunity to use virtual platforms to engage with colleagues in our subspecialty across the country. These forums of engagement, which we realize virtually with so many of our colleagues, has prompted me to refine and galvanize what I consider to be some principles that guide frequently encountered clinical scenarios in reproductive psychiatry.

To open 2022, I wanted to revisit the practices I nearly “always” (or conversely, “never”) follow as a reproductive psychiatrist across the numerous clinical situations and variations on the associated clinical themes encountered as we see patients during pregnancy and the postpartum period.
 

Things we ‘always’ do

1. I continue to make maternal euthymia the North Star of treatment before, during, and after pregnancy.

Before pregnancy, maternal euthymia may be realized through optimization of pharmacologic and nonpharmacologic treatments and waiting to conceive until patients are emotionally well. Sustaining euthymia during pregnancy is a critical issue because of the extent to which euthymia during pregnancy predicts postpartum course. According to many studies, postpartum euthymia is the strongest predictor of long-term neurobehavioral outcome and risk for later child psychopathology. At the end of the day, there are few things I would not do with respect to treatment of maternal psychiatric disorder if the upside afforded maternal euthymia.

2. I almost always treat with consistency of medication across the peripartum period.

Although there have been discussions about the wisdom of changing medications, such as antidepressants, benzodiazepines, and mood stabilizers, that have afforded euthymia during pregnancy as patients approach their delivery date, the evidence base supporting switching medications at that time is exceedingly sparse. The time to adjust or to modify is typically not just prior to delivery unless it is to prevent postpartum psychiatric disorder (see below).

3. I simplify regimens before pregnancy if it’s unclear which medications have afforded patients euthymia.

We have a growing appreciation that polypharmacy is the rule in treatment of affective disorder for both unipolar and bipolar illness. Consultation before pregnancy is the ideal time to take a particularly careful history and think about simplifying regimens where adding medicines hasn’t clearly provided enhanced clinical benefit to the patient.

4. When making a treatment plan for psychiatric disorder during pregnancy, I consider the impact of untreated psychiatric disorder (even if not absolutely quantifiable) on fetal, neonatal, and maternal well-being.

Perhaps now more than even 5-10 years ago, we have better data describing the adverse effects of untreated psychiatric illness on fetal, neonatal, and maternal well-being.

We always try to deliberately consider the effect of a specific treatment on fetal well-being. Less attention (and science) has focused on the effect on pregnancy of deferring treatment; historically, this has not been adequately quantified in the risk-benefit decision. Yet, there is growing evidence of the increased adverse effects of activating the stress axis on everything from intrauterine fetal programming in the brain to effects on obstetrical outcomes such as preterm labor and delivery.

5. I appreciate the value of postpartum prophylaxis for pregnant women with bipolar disorder to mitigate risk of relapse.

We have spoken over the last 20 months of the pandemic, particularly in reproductive psychiatry circles, about the importance of keeping reproductive-age women with bipolar disorder emotionally well as they plan to conceive, during pregnancy, and in the postpartum period. The management of bipolar disorder during this time can be a humbling experience. Clinical roughening can be quick and severe, and so we do everything that we can for these women.

The area in which we have the strongest evidence base for mitigating risk with bipolar women is the value of postpartum prophylaxis during the peripartum period, regardless of what patients have done with their mood-stabilizing medications during pregnancy. Given the risk for postpartum disease, even though there are varying amounts of evidence on prophylactic benefit of specific mood stabilizers (i.e., lithium vs. atypical antipsychotics), the value of prophylaxis against worsening of bipolar disorder postpartum is widely accepted.

The importance of this has been particularly underscored during the pandemic where postpartum support, although available, has been more tenuous given the fluctuations in COVID-19 status around the country. The availability of friends and loved ones as support during the postpartum period has become less reliable in certain circumstances during the pandemic. In some cases, COVID-19 surges have wreaked havoc on travel plans and support persons have contracted the virus, rendering on-site support nonviable given safety concerns. Last-minute shifts of support plans have been responsible for disruption of care plans for new moms and by extension, have affected the ability to protect the sleep of bipolar women, which is critical. Keeping bipolar women well during the postpartum period with plans and backup plans for management remains critical.
 

Things we ‘never’ do

1. I never taper antidepressants (just prior to delivery), I never check plasma levels of selective serotonin reuptake inhibitors (across pregnancy, or just prior to labor and delivery), and I never use sodium valproate (during pregnancy).

Although there has been some discussion about the potential to mitigate risk for maternal or neonatal toxicity with lowering of agents such as lithium or lamotrigine during pregnancy, I do not routinely check plasma levels or arbitrarily change the dose of antidepressants, lithium, or lamotrigine during pregnancy in the absence of clinical symptoms.

We know full well that plasma levels of medications decline during pregnancy because of hemodilution with lithium and antidepressants and, in the case of lamotrigine, the effects of rising estrogen concentration during pregnancy on the metabolism of lamotrigine. While several studies have shown the decrease of SSRI concentration during pregnancy absent a change in dose of medication, these data have not correlated changes in plasma concentration of SSRI with a frank change in clinical status across pregnancy. Unlike what we see in conditions like epilepsy, where doses are increased to maintain therapeutic plasma levels to mitigate risk for seizure, those therapeutic plasma levels do not clearly exist for the psychiatric medications most widely used to treat psychiatric disorders.

We also almost never use sodium valproate in reproductive-age women despite its efficacy in both the acute and maintenance treatment of bipolar disorder given the risk of both major malformations associated with first-trimester fetal exposure to valproate and the data suggesting longer-term adverse neurobehavioral effects associated with its use during pregnancy.

2. We never suggest patients defer pregnancy based on their underlying psychiatric disorder.

Our role is to provide the best information regarding reproductive safety of psychiatric medications and risks of untreated psychiatric disorder to patients as they and relevant parties weigh the risks of pursuing one treatment or another. Those are private choices, and women and their partners make private decisions applying their own calculus with respect to moving forward with plans to conceive.

3. We never switch antidepressants once a woman has become pregnant.

Although we continue to see patients switched to older SSRIs such as sertraline with documentation of pregnancy, a patient’s road to getting well is sometimes very lengthy. In the absence of indicting reproductive safety data for any particular antidepressant, for patients who have gotten well on an antidepressant, even one for which we have less information, we stay the course and do not switch arbitrarily to an older SSRI for which we may have more reproductive safety data.

If we have the luxury prior to pregnancy to switch a patient to an untried and better studied antidepressant with more data supporting safety, we do so. But this is rarely the case. More often, we see women presenting with a newly documented pregnancy (frequently unplanned, with half of pregnancies across the country still being unplanned across sociodemographic lines) on an antidepressant with varying amounts of reproductive safety information available for the medicine being taken, and frequently after failed previous trials of other antidepressants. In this scenario, we rarely see the time of a newly documented pregnancy as an opportunity to pursue a new trial of an antidepressant without known efficacy for that patient; we stay the course and hope for sustained euthymia on the drug which has afforded euthymia to date.
 

Final thoughts

Dos and don’ts are relative in reproductive psychiatry. We tend to apply available data and clinical experience as we guide patients on a case-by-case basis, considering the most currently available rigorous reproductive safety data, as well as the individual patient’s clinical status and her personal wishes.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital (MGH) in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

Almost 4 years had passed since Pearl Harbor forced the United States into the Second World War when three military and government services members went to the American Psychiatric Association with a plea: They needed soldiers who could pass the military’s mental and emotional health screening.

The military had rejected or discharged more than 2.5 million servicemen and volunteers on mental health grounds, and frustrated psychiatrists in the service didn’t know where else to turn but to their century-old professional psychiatric organization.

But the APA had grown so large and unwieldy by then that its size, bureaucracy, and singular focus on research left few resources for helping solve an urgent national mental health problem, no matter how worthy it was.

“At the time, the APA was kind of the face of organized psychiatry, but it was organized in a way that did not lend itself to addressing the needs of the military,” said Jack W. Bonner III, MD, professor emeritus of psychiatry at the University of South Carolina, Greenville. “It was considered sort of a stodgy organization that really wasn’t nimble enough to reorganize to look at those needs at that point in time.”

And that, the military psychiatrists decided, would not do. Desperate to solve the problem, they took matters into their own hands.

Nearly 2 years later, 15 psychiatrists, mostly military or ex-military, gathered in the hotel room of the U.S. Army Medical Corps chief of neuropsychiatry the night before the annual APA conference. It was 1946, and America had won the war – but with a huge toll on mental health, both in and out of the military. Aside from veterans’ “shell shock” and the specter of inadequate troops for potential future conflicts, huge social shifts had occurred during the war, and public mental health hospitals and community resources had deteriorated just as demand for psychiatrists and mental health personnel well outstripped supply.

If the APA wasn’t going to tackle these problems head on, the 15 psychiatrists decided, they would force it to, and they enshrined that goal in the name they gave themselves: the Group for the Advancement of Psychiatry. Two days later, three of them challenged incumbent APA officers in elections and won. The infiltration of these “Young Turks,” as they thought of themselves, had begun. From that point forward, GAP members have frequently held APA leadership positions, and APA leaders have often gone on to join GAP. Gradually, the smaller upstart organization nudged the behemoth toward more involvement with social issues, but GAP remains more nimble given its size.

“The APA is a pretty leviathan organization and can’t deal with issues in the same way a smaller organization can, and GAP can fulfill that role of being much more responsive to contemporary issues,” said Dr. Bonner, who is a member of GAP’s planning, marketing, and communications committee.
 

The think tank of psychiatry

If it seems strange today that such progressivism arose from military medical officers, equally striking is how that nascent group has improbably grown from its modest, pragmatic beginnings into a psychiatry “think tank” today. Now in its 75th year, GAP can boast of its influence at the locus of nearly every intersection of society and psychiatry, from mental health care in prisons to use of controversial treatments such as shock therapy, from racial tensions to gender inequality, from medical school curricula to mental institution standards, from LBGTQ rights to climate change.

“We’re not here to do the latest double-blind, placebo-controlled research on things,” said Lawrence S. Gross, MD, president of GAP, professor of clinical psychiatry and the behavioral sciences at the University of Southern California, Los Angeles, and a member of the committee on psychopharmacology. “It’s more for leaders to think about issues in different areas that affect the field of psychiatry and how they interface with society.”

Or, more simply, “GAP is a group that predominantly exists for one major purpose, and that is to add to the body of knowledge in the field,” said Sy Saeed, MD, MS, chair of the department of psychiatry at East Carolina University, Greenville, N.C., and chair of the group’s administration and leadership committee.

And the organization doesn’t shy from controversial topics, either, such as examining direct-to-consumer marketing and when patients should stop antidepressant therapy.

“We’re very good at getting marketed to on when to start medications, but how good are we at actually timing when to cut back on them? How long is long enough to treat?” Dr. Gross asked. The organization continues to have “an undercurrent of recognizing and fostering change and making people aware of things that may be controversial at times but also further the field by looking at these different areas of psychiatry.”

Despite the group’s relatively small size of about 200 members, its impact touches nearly everyone in the profession, whether they realize it or not. And though the group certainly has its weaknesses – such as steep membership fees that may deter some from joining and its need to improve membership diversity – GAP actively seeks ways to address these internal challenges just as it does external ones.

“It’s probably one of the best-kept secrets in psychiatry,” Dr. Gross said. But it’s a secret the members want out. That’s one reason members consider the organization’s crown jewel to be its fellowship program. In fact, Steven S. Sharfstein, MD, MPA, a former GAP president, clinical professor of psychiatry at the University of Maryland, Baltimore, and chair of the planning, marketing, and communications committee, did not formally join GAP until the 1980s. But he first became involved with the group as a resident in the fellowship program in 1969.

In its current incarnation, 12 fellows spend 2 years as working members of GAP, assigned to one of its committees to put in work just like every other member is expected to do, but they reap the wisdom and mentorship of its members at the same time.

One thing that makes GAP so special to its members is the ability “to mentor young psychiatrists, going from generation to generation trying to identify leaders and facilitate their growth,” Dr. Gross said. And that process, through not only the fellowship program but also through the members’ diversity of ages and career stages, sustains the organization’s vigor.

“Its strength is that you create this continuum where senior people get to mentor people who are early in their career, and this way, the knowledge continues,” Dr. Saaed said.
 

Creation, not death, by committee

In the early years, GAP’s longevity was in question. Once it had successfully steered the APA toward taking more action to address social problems, did it still have a role to play? A majority of members decided that it did. “New problems arose as old ones were solved,” wrote the late Albert Deutsch in an early history of GAP, and “some steps which were confidently expected to repair an ill or defect did not turn out to be completely effective.” In its first decade, GAP members led the APA to establish new medical director and director of information positions, to improve professional standards and facilitate improvement of mental health facilities, and to expand training.

But where GAP really excelled was in developing projects, something the APA wasn’t well-suited to do, explained Carol C. Nadelson, MD, professor of psychiatry at Harvard Medical School, Boston, a member of the gender and mental health committee, and a past president of GAP. And the breadth of those projects has “expanded as the field has changed and evolved,” said Dr. Nadelson, the first woman president of the APA.

Those projects, the beating heart of GAP’s work, come from its specialized working committees, groups of 6-12 members who spend a couple years focused on a single question or problem in psychiatry that the committee has decided needs attention. The number of committees has grown from 9 at its founding to 32 today, shrinking and expanding as society’s needs demand. Each committee looks for an area it thinks is important and needs attention or updating and then decides how to proceed in addressing it. This structure as a confederation of committees differs greatly from other medical organizations.

“Committees really function in an autonomous, almost independent manner,” Dr. Bonner said. “They control their work, what they do, and how they do it, and the executive structure of the organization has very little impact on those individual committees.”

It’s only when a committee produces whatever project it’s working on that it’s disseminated to the rest of the organization for review.

“The fact that it’s such a federated organization is both a strength and a weakness,” said Roberto Lewis-Fernández, MD, professor of clinical psychiatry at Columbia University, New York, and chair of the cultural psychiatry committee. The tension between becoming too siloed within a committee and needing some sense of greater unity and the cross-pollination that provides is always present, but it’s perhaps also part of the organization’s vibrancy as it constantly seeks the right balance.

It also sometimes allows for fruitful collaborations, such as a recent publication produced by both the religion committee and the LGBTQ+ committee on helping LGBTQ+ teenagers and communities of faith, pointed out Jack Drescher, MD, a GAP past president who serves as clinical professor of psychiatry at Columbia University, and a member of the LGBTQ and media committees.

GAP is also unique in expecting every member to actively put in work toward its mission.

“If you join the APA, you can do absolutely nothing, or you can go to a conference once a year and learn from other people, but you don’t have to be active,” said Gail Robinson, MD, professor of psychiatry and ob.gyn. at the University of Toronto and chair of GAP’s gender and mental health committee. But if you’re a GAP member who isn’t contributing, expect to hear from someone asking how they can help you figure out how you can contribute.

Expecting that much work from members means meeting more often than most medical societies. Except during the pandemic, GAP members have always met twice a year for a long weekend in White Plains, N.Y., to focus almost exclusively on the committees’ current projects. Each meeting allows members “to immerse themselves in thinking about topics that the various committees find of interest and think might be of interest to the rest of the world,” said David Adler, MD, a professor of psychiatry and medicine at Tufts Medical Center in Boston, and chair of the GAP publication board. Whereas APA meetings are massive, frenetic events focused primarily on new research and continuing education for tens of thousands of attendees, GAP meetings are more intimidate and meditative, “a time in which the leaders can exchange ideas in a more private setting,” Dr. Adler said.

What makes GAP’s meetings so special is that they provide a temporary refuge with the explicit goal of encouraging unhurried discussion and deliberation about big ideas that matter, Dr. Robinson said.

“One of the enjoyable parts of GAP is that you have time to think,” Dr. Robinson said. “In your regular life, you’re seeing patients, you’re doing research or organizing things, but in GAP, you can sit with a group of like-minded, interested people and toss some ideas around about what’s important right now. What should we be looking at? What is the field not paying enough attention to? And then the ideas bubble up. In a lot of other organizations, you’re doing specific work, some of it political, some in terms of the organization, but to just sort of sit and think about what’s important in your field and what people should know more about is a different kind of feeling.”
 

A force for change

The work GAP produces has had a substantial impact on the field of psychiatry and society in general over the past 7 and a half decades. Consider this list of just a handful of GAP contributions in its first decade.

• Guidance regarding electroconvulsive therapy in 1947, followed by an update, in response to reaction to the first document, in 1950.
• A guide to school integration after Brown v. Board of Education that considered the psychiatric challenges of integration.
• A report for employers on workers with epilepsy for occupational health and safety.
• Publications that raised mental hospital standards in the 1950s.
• A range of action documents used by medical schools, psychology and social work departments and agencies, governmental bodies, courts, industry, public schools, and community health and welfare agencies.

Over the years, GAP’s influence has sometimes been overt – such as publishing the only diagnostic and statistical manual for child psychiatry for years before that material was incorporated into the official DSM. Sometimes it’s just ahead of the curve, such as the women’s mental health committee publishing a paper that reviewed the evidence on “abortion trauma syndrome” and concluding that it doesn’t exist shortly before the American Psychological Association and the U.K.’s Royal College of Psychiatrists published reviews with similar conclusions. In a few instances, GAP has caused shifts in how the APA operates, such as encouraging the larger organization to publish books on mental health, said Dr. Sharfstein, a past president of the APA.

Much of the organization’s impact occurs through its effects on education, which affects clinical psychiatry at large.“Some reports are very much designed to have an impact on psychiatry education, residency training and curriculum development, which would have a big impact on practice,” Dr. Sharfstein said. An example is the committee on disasters, which examines the best ways for mental health professionals to respond to and mitigate the mental health fallout from the consequences of natural and manmade disasters.

Most often, though, GAP’s influence is akin to strategically planting very carefully cultivated seeds throughout the academic and clinical media ecosystems and letting them bloom how they will. For example, Dr. Lewis-Fernández described a project the cultural committee published in 2013: a checklist for how a psychiatry research article should address topics related to race, ethnicity, and culture. After reviewing articles in the field and their methodologies, the group developed a checklist of best practices and tested them with articles in the field to see how the checklist held up before publishing it.

“Initially, some people read it, some people didn’t, but over time, it’s gotten picked up, and it’s now about to be used in a journal on psychiatric services as a guide to authors and reviews on the appropriate use of these concepts,” Dr. Lewis-Fernández said.

GAP’s influence also blooms through the cross-pollination that occurs at meetings, where leaders in psychiatry from all across the country come together, discuss ideas, and then take new ideas back to their universities, where they teach them to their residents. Perhaps the best example of this influence in recent years has been a increasing shift in teaching about LGBTQ+ issues.

“There’s an underrepresentation of teaching about LGBTQ+ issues in many psychiatric training programs in many medical schools,” Dr. Drescher said. The organization has worked to raise awareness about these gaps in the education of medical students and mental health professionals and then address it, such as designing an online module curriculum in the early 2000s for how to teach residents about LGBTQ+ mental health issues and then updating it as needed.

Perhaps GAP’s greatest lifetime achievement is forcing the field of psychiatry to confront the fact that it – and its patients – do not stand apart from the society in which they exist.

“People aren’t just psychiatric disorders. They live in society, and society has an impact on them, and that affects how people cope,” Dr. Robinson said. That was once a radical concept, but now “psychiatry as a whole has moved to be more broadly expansive” just as GAP itself has broadened its scope, as evidenced by the wide range of committees, more than triple what the organization had at its founding. “GAP was really at the vanguard of that expansion into the recognizing the need to consider the interaction between the individual and the environment they live in socially.”

That’s never been more true than during the COVID-19 pandemic, contributing to perhaps the greatest mental health crisis in the nation’s history since World War II. But the pandemic hasn’t slowed down GAP’s work. In fact, in some ways, the pandemic has facilitated the group’s ability to meet more often virtually and focus on acute issues the pandemic itself has caused. The psychopathology committee published one paper on the impact of telehealth on treating the chronic mentally ill during COVID, and another delved into rethinking where things stand with institutional racism within psychiatry. The women’s mental health committee published articles on the impact of COVID on pregnant and postpartum women, and the impact of COVID on minority women.
 

Confronting challenges within, too

For all its positive influence, GAP has its weaknesses as well. Two of the biggest barriers to membership, for example, are the steep dues and travel to the twice annual meetings, Dr. Lewis-Fernández said.

The membership dues are not needlessly high: The organization relies on philanthropy and dues for all of its activities, most recently, secured endowments from institutional and individual donors to fund all of the GAP fellows, Dr. Gross said.

“With a low number of members, the cost is larger per member,” Dr. Bonner explained. In fact, GAP has only recently overcome a period of financial uncertainty, now finally on solid ground in terms of fundings.

While the dues can be onerous, Dr. Lewis-Fernández said the organization has been actively thinking about ways to reduce it, particularly for those who may need help if traveling from farther away or younger-career individuals, such as those without tenure or with young families.

It can also be difficult for the organization to attract diverse members from different racial and ethnic groups when leaders in psychiatry from those backgrounds are courted by many other groups, or just to attract younger members in general, but GAP continues to seek ways to overcome those challenges.

“The majority of people in GAP have some kind of academic interest, and the nature of being an early career psychiatrist in academia is that you have to publish to get promoted,” Dr. Bonner said. GAP’s historical practice of producing publications by committee without individual attribution was a disincentive to those early-career folks. “More recently, we’ve changed that so that now individuals can put their names on their product, which has eliminated that particular barriers for young people.”

As the organization continues to seek ways to address those issues, it also faces the same challenges as every other scientific group: Staying relevant in the new, and constantly changing, media landscape.

“It’s an interesting evolution because it started off with books and monographs for many, many years,” Dr. Robinson said, “and then it kind of moved away from that to more articles.” More recently, some committees have returned to writing books while others explore other forms of media to keep up with the times. Long gone are the days when a committee might spend 2-10 years producing one monograph.

“In today’s world, you can’t be relevant operating that way,” said Dr. Bonner, noting that some committees have produced videos or podcasts.

But the sheer amount of information out there is intimidating as well. “Nowadays, a lot of people get their information off the Internet, and how do you actually sift through that?” Dr. Saeed said. “How you find signal in this noise is a whole different thing now, so how GAP produces its information is at that trajectory right now. Should we be producing more electronic books? What should be our peer-review process? How do we make sure the information is current? If we are about sharing information and generating new knowledge, what’s the best way of disseminating that?”

A testament to the organization’s willingness to confront that challenge, however, is its exploration of every possible platform – even those well outside the traditional ones. The climate committee, for example, recently set about addressing climate anxiety in children, but they didn’t produce a report or develop a teaching module or even develop a series of podcasts. Instead, the committee collaborated with Jeremy D. Wortzel, MPhil, an MD and MPH candidate at the University of Pennsylvania, Philadelphia, and Lena K. Champlin, a doctoral candidate in environmental science at Drexel University, Philadelpha, to write a children’s book. “Coco’s Fire: Changing Climate Anxiety into Climate Action” was published in October 2021.
 

GAP continues to leave its mark

For all the work that members put into the organization, members say they reap substantial benefits as well. Dr. Saaed recalls feeling flattered when invited to join the organization because of how influential it is and the opportunity to work with so many leaders in psychiatry. “When you come to GAP committee meetings, you would run into people whose book or research you might have read and who are very prominent in the field,” he said.

Dr. Drescher credited GAP with helping him develop his voice and polish his editing skills, which later aided him when he became editor of the Journal of Gay and Lesbian Mental Health. When the LGBTQ+ committee shifted from reports to writing op-eds, members learned how to write opinion pieces and then teach members of other committees those skills, resulting in GAP-produced op-eds in consumer and trade publications. And then there are the intangible rewards that leave a profound impact on members.

Some members see GAP as central to their professional lives and perhaps legacies.

“Outside of the medical center, this has probably been the most important professional organization of my career, and I think there are a lot of people who feel that way,” Dr. Adler said. “It’s a very unique experience, and the goal is to examine today’s critical issues and say something about them in a way in which maybe the world will take notice.”

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

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

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

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

First-year psychiatry resident Jake Goodman, MD, knew he was taking a chance when he opened up on his popular social media platforms about his personal mental health battle. He mulled over the decision for several weeks before deciding to take the plunge.

As he voiced recently on his TikTok page, his biggest social media fanbase, with 1.3 million followers, it felt freeing to get his personal struggle off his chest.

“I’m a doctor in training, and most doctors would advise me not to post this,” the 29-year-old from Miami said in the video last month, which garnered 1.2 million views on TikTok alone. “They would say it’s risky for my career. But I didn’t join the medical field to continue the toxic status quo. I’m part of a new generation of health care professionals that are not afraid to be vulnerable and talk about mental health.”

“Dr. Jake,” as he calls himself on social media, admitted he was a physician who treats mental illness and also takes medication for it. “It felt good to say that. And by the way, I’m proud of it,” he said in the TikTok post.

A champion of mental health throughout the pandemic, Dr. Goodman called attention to the illness in the medical field. In a message on Instagram, he stated, “Opening up about your mental health as a medical professional, especially as a doctor who treats mental illness, can be taboo ... So here’s me leading by example.”

He also cited statistics on the challenge: “1 in 2 people will be diagnosed with a mental health illness at some point in their life. Yet many of us will never take medication that can help correct the chemical imbalance in our brains due to medication stigma: the fear that taking medications for our mental health somehow makes us weak.”

Mental health remains an issue among residents. Nearly 70% of residents polled by Medscape in its 2021 Residents Lifestyle & Happiness Report said they strongly or somewhat agree there’s a stigma against seeking mental health help. And nearly half, or 47% of those polled, said they sometimes (36%) or always/most of the time (11%) were depressed. The latter category rose in the past year.

Dr. Goodman told this news organization that he became passionate about mental health when he lost a college friend to suicide. “It really exposed the stigma” of mental health, he said. “I always knew it was there, but it took me seeing someone lose his life and [asking] why didn’t he feel comfortable talking to us, and why didn’t I feel comfortable talking to him?”
 

Stress of medical training

The decision to pursue psychiatry as his specialty came after a rotation in a clinic for people struggling with substance use disorders. “I was enthralled to see people change their life ... just by mental health care.” It’s why he went into medicine, he tells this news organization. “I always wanted to be in a field to help people [before they hit] rock bottom, when no one else could be there for them.”

Dr. Goodman’s personal battle with mental health didn’t arise until he started residency. “I was not really myself.” He said he felt numb and burned out. “I was not getting as much enjoyment out of things.” A friend pointed out that he might be depressed, so he went to see a therapist and then a psychiatrist and started on medication. “It had a profound impact on how I felt.”

Still, it took a while before Dr. Goodman was comfortable sharing his story with the 1.6 million followers he had already built across his social media platforms.

“I started on social media in 2020 with the goal of advocating for mental health and inspiring future doctors.” He said the message seemed to resonate with people struggling during the early part of the pandemic. On his social media accounts, he also talks about medical school, residency, and being a health care provider. His fiancé is also a resident doctor, in internal medicine.

Dr. Goodman is also trying to create a more realistic image of doctors than the superheroes he believed they were growing up. He wants those who grow up wanting to be doctors and who look up to him to see him as a human being with vulnerabilities, such as mental health.

“You can be a doctor and have mental health issues. Seeking treatment for mental health makes you a better doctor, and for other health care workers suffering in the midst of the pandemic, I want to let them know they are not alone.”

He pointed to the statistic that doctors have one of the highest suicide rates of any professions. “It’s better to talk about that in the early stages of training.”

Students, residents, or attending physicians who have mental health challenges shouldn’t allow their symptoms to go untreated, Dr. Goodman added. “Holding in all the stress and anxiety and feelings in a very traumatic field may be dangerous. Opening up and seeking treatment, that’s the brave thing to do.”

One of his goals is to campaign for the removal of a question on state medical licensing forms requiring doctors to report any mental health diagnosis. It’s why doctors may be afraid to admit that they are struggling. “I’m still here. It didn’t ruin my career.”

Doctors who seek treatment for mental health are theoretically protected under the Americans With Disabilities Act from being refused a license on the basis of that diagnosis. Dr. Goodman hopes to advocate at the state level to reduce discrimination and increase accessibility for doctors to seek mental health care.

Still, Dr. Goodman concedes he was initially fearful of the repercussions. “I opened up about it because this post could save lives. I was doing what I believed in.”

So if he runs into barriers to receive his medical license because of his admission, “that’s a serious problem,” he said. “There is already a shortage of doctors. We’ll see what happens in a few years. I am not the only one who will answer ‘yes’ to having sought treatment for a mental illness. The questions do not really need to be there.”

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

Behavior problems, anxiety, and depression in youths were associated with these individuals participating in remote schooling during broader social lockdowns in a new study.

The systematic review, which was published in JAMA Pediatrics on Jan. 18, 2022, was based on data from 36 studies from 11 countries on mental health, physical health, and well-being in children and adolescents aged 0-18 years. The total population included 79,781 children and 18,028 parents or caregivers. The studies reflected the first wave of pandemic school closures and lockdowns from February to July 2020, with the duration of school closure ranging from 1 week to 3 months.

“There are strong theoretical reasons to suggest that school closures may have contributed to a considerable proportion of the harms identified here, particularly mental health harms, through reduction in social contacts with peers and teachers,” Russell Viner, PhD, of UCL Great Ormond St Institute of Child Health, London, and colleagues wrote in their paper.

The researchers included 9 longitudinal pre-post studies, 5 cohort studies, 21 cross-sectional studies, and 1 modeling study in their analysis. Overall, approximately one-third of the studies (36%) were considered high quality, and approximately two-thirds (64%) of the studies were published in journals. Twenty-five of the reports analyzed focused on mental health and well-being.

Schools provide not only education, but also services including meals, health care, and health supplies. Schools also serve as a safety net and source of social support for children, the researchers noted.

The losses children may have experienced during school closures occurred during a time when more than 167,000 children younger than 18 years lost a parent or caregiver to COVID-19, according to a recent report titled “Hidden Pain” by researchers at the University of Pennsylvania, Nemours Children’s Health, and the COVID Collaborative. Although not addressed in the current study, school closures would prevent bereaved children from receiving social-emotional support from friends and teachers. This crisis of loss also prompted the American Academy of Pediatrics to issue a National State of Emergency in Children’s Mental Health in October 2021.
 

New study results

These studies identified associations between school closures during broader lockdowns and increased emotional and behavioral problems, as well as increased restlessness and inattention. Across these studies, 18%-60% of children and adolescents scored higher than the risk thresholds for diagnoses of distress, especially depressive symptoms and anxiety.

Although two studies showed no significant association with suicide in response to school closures during lockdowns, three studies suggested increased use of screen time, two studies reported increased social media use, and six studies reported lower levels of physical activity.

Three studies of child abuse showed decreases in notifications during lockdowns, likely driven by lack of referrals from schools, the authors noted. A total of 10 studies on sleep and 5 studies on diet showed inconsistent evidence of harm during the specific period of school closures and social lockdowns.

“The contrast of rises in distress with decreases in presentations suggests that there was an escalation of unmet mental health need during lockdowns in already vulnerable children and adolescents,” the researchers wrote. “More troubling still is evidence of a reduction in the ability of the health and social care systems to protect children in many countries, as shown by the large falls in child protection referrals seen in high-quality cohort studies.”
 

‘Study presents concrete assessments rather than speculation’

“Concerns have been widely expressed in the lay media and beyond that school closures could negatively impact the mental and physical health of children and adolescents,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview. “The authors presented a narrative synthesis summarizing available evidence for the first wave of COVID-19 on school closures during the broader social lockdown occurring during this period.”

The “importance” of this research is that “it is not a single convenience sample study, but a systematic review from 11 countries including the United States, United Kingdom, China, and Turkey, among others, and that the quality of the information was graded,” Dr. Jay said. “Although not a meta-analysis, the study presents concrete assessments rather than speculation and overviews its limitations so that the clinician can weigh this information. Importantly, the authors excluded closure of schools with transmission of infection.

“Clearly, school lockdowns as a measure of controlling infectious disease needs balance with potential of negative health behaviors in children and adolescents. Ongoing prospective longitudinal studies are needed as sequential waves of the pandemic continue,” she emphasized.

“Clinically, this study highlights the need for clinicians to consider [asking] about the impact of school closures and remote versus hybrid versus in-person education [as part of their] patients and families question inventory,” Dr. Jay said. “Also, the use of depression inventories can be offered to youth to assess their mental health state at a visit, either via telemedicine or in person, and ideally at sequential visits for a more in-depth assessment.”
 

Schools play key role in social and emotional development

“It was important to conduct this study now, because this current time is unprecedented,” Peter L. Loper Jr., MD, of the University of South Carolina, Columbia, said in an interview. “We know based on evolutionary biology, anthropology, and developmental psychology, among other disciplines, that meaningful interpersonal interactions embedded in the context of community are vital to supporting human well-being.

“In our current time, the primary framework of community for our children is the school setting; it is the predominant space where they engage in the interpersonal interactions necessary for developing resilience, their sense of purpose, belonging, and fidelity,” he emphasized.

“Rarely in the course of human existence have kids been removed from the broader context of community to this extent and for this duration,” Dr. Loper said. “This study capitalizes on this unprecedented moment to begin to further understand how compromises in our sociocultural infrastructure of community, like school closures and lockdowns, may manifest as mental health problems in children and adolescents. More importantly, it contributes to the exploration of potential unintended consequences of our current infection control measures so we can adapt to support the overall well-being of our children in this ‘new normal.’ ”

Dr. Loper added that he was not surprised by the new study’s findings.

“We were already seeing a decline in pediatric mental health and overall well-being in the years preceding COVID-19 because of the ‘isolation epidemic’ involving many of the factors that this study explored,” he said. “I think this review further illustrates the vital necessity of community to support the health and well-being of humans, and specifically children and adolescents.”

From a clinical standpoint, “we need to be intentional and consistent in balancing infection control measures with our kids’ fundamental psychosocial needs,” Dr. Loper said.

“We need to recognize that, when children and adolescents are isolated from community, their fundamental psychosocial needs go unmet,” he emphasized. “If children and adolescents cannot access the meaningful interpersonal interactions necessary for resilience, then they cannot overcome or navigate distress. They will exhibit the avoidance and withdrawal behaviors that accumulate to manifest as adverse mental health symptoms like anxiety and depression.

“Additional research is needed to further explore how compromises in the psychosocial infrastructure of community manifest as downstream symptom indicators such as anxiety and depression,” which are often manifestations of unmet needs, Dr. Loper said.
 

Limitations and strengths, according to authors

The findings were limited by several factors, including a lack of examination of school closures’ effects on mental health independent of broader social lockdowns, according to the researchers. Other limitations included the authors potentially having missed studies, inclusion of cross-sectional studies with relatively weak evidence, potential bias from studies using parent reports, and a focus on the first COVID-19 wave, during which many school closures were of limited duration. Also, the researchers said they did not include studies focused on particular groups, such as children with learning difficulties or autism.

The use of large databases from education as well as health care in studies analyzed were strengths of the new research, they said. The investigators received no outside funding for their study. The researchers, Dr. Jay, and Dr. Loper had no financial conflicts to disclose. Dr. Jay serves on the editorial advisory board of Pediatric News.

Behavior problems, anxiety, and depression in youths were associated with these individuals participating in remote schooling during broader social lockdowns in a new study.

The systematic review, which was published in JAMA Pediatrics on Jan. 18, 2022, was based on data from 36 studies from 11 countries on mental health, physical health, and well-being in children and adolescents aged 0-18 years. The total population included 79,781 children and 18,028 parents or caregivers. The studies reflected the first wave of pandemic school closures and lockdowns from February to July 2020, with the duration of school closure ranging from 1 week to 3 months.

“There are strong theoretical reasons to suggest that school closures may have contributed to a considerable proportion of the harms identified here, particularly mental health harms, through reduction in social contacts with peers and teachers,” Russell Viner, PhD, of UCL Great Ormond St Institute of Child Health, London, and colleagues wrote in their paper.

The researchers included 9 longitudinal pre-post studies, 5 cohort studies, 21 cross-sectional studies, and 1 modeling study in their analysis. Overall, approximately one-third of the studies (36%) were considered high quality, and approximately two-thirds (64%) of the studies were published in journals. Twenty-five of the reports analyzed focused on mental health and well-being.

Schools provide not only education, but also services including meals, health care, and health supplies. Schools also serve as a safety net and source of social support for children, the researchers noted.

The losses children may have experienced during school closures occurred during a time when more than 167,000 children younger than 18 years lost a parent or caregiver to COVID-19, according to a recent report titled “Hidden Pain” by researchers at the University of Pennsylvania, Nemours Children’s Health, and the COVID Collaborative. Although not addressed in the current study, school closures would prevent bereaved children from receiving social-emotional support from friends and teachers. This crisis of loss also prompted the American Academy of Pediatrics to issue a National State of Emergency in Children’s Mental Health in October 2021.
 

New study results

These studies identified associations between school closures during broader lockdowns and increased emotional and behavioral problems, as well as increased restlessness and inattention. Across these studies, 18%-60% of children and adolescents scored higher than the risk thresholds for diagnoses of distress, especially depressive symptoms and anxiety.

Although two studies showed no significant association with suicide in response to school closures during lockdowns, three studies suggested increased use of screen time, two studies reported increased social media use, and six studies reported lower levels of physical activity.

Three studies of child abuse showed decreases in notifications during lockdowns, likely driven by lack of referrals from schools, the authors noted. A total of 10 studies on sleep and 5 studies on diet showed inconsistent evidence of harm during the specific period of school closures and social lockdowns.

“The contrast of rises in distress with decreases in presentations suggests that there was an escalation of unmet mental health need during lockdowns in already vulnerable children and adolescents,” the researchers wrote. “More troubling still is evidence of a reduction in the ability of the health and social care systems to protect children in many countries, as shown by the large falls in child protection referrals seen in high-quality cohort studies.”
 

‘Study presents concrete assessments rather than speculation’

“Concerns have been widely expressed in the lay media and beyond that school closures could negatively impact the mental and physical health of children and adolescents,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview. “The authors presented a narrative synthesis summarizing available evidence for the first wave of COVID-19 on school closures during the broader social lockdown occurring during this period.”

The “importance” of this research is that “it is not a single convenience sample study, but a systematic review from 11 countries including the United States, United Kingdom, China, and Turkey, among others, and that the quality of the information was graded,” Dr. Jay said. “Although not a meta-analysis, the study presents concrete assessments rather than speculation and overviews its limitations so that the clinician can weigh this information. Importantly, the authors excluded closure of schools with transmission of infection.

“Clearly, school lockdowns as a measure of controlling infectious disease needs balance with potential of negative health behaviors in children and adolescents. Ongoing prospective longitudinal studies are needed as sequential waves of the pandemic continue,” she emphasized.

“Clinically, this study highlights the need for clinicians to consider [asking] about the impact of school closures and remote versus hybrid versus in-person education [as part of their] patients and families question inventory,” Dr. Jay said. “Also, the use of depression inventories can be offered to youth to assess their mental health state at a visit, either via telemedicine or in person, and ideally at sequential visits for a more in-depth assessment.”
 

Schools play key role in social and emotional development

“It was important to conduct this study now, because this current time is unprecedented,” Peter L. Loper Jr., MD, of the University of South Carolina, Columbia, said in an interview. “We know based on evolutionary biology, anthropology, and developmental psychology, among other disciplines, that meaningful interpersonal interactions embedded in the context of community are vital to supporting human well-being.

“In our current time, the primary framework of community for our children is the school setting; it is the predominant space where they engage in the interpersonal interactions necessary for developing resilience, their sense of purpose, belonging, and fidelity,” he emphasized.

“Rarely in the course of human existence have kids been removed from the broader context of community to this extent and for this duration,” Dr. Loper said. “This study capitalizes on this unprecedented moment to begin to further understand how compromises in our sociocultural infrastructure of community, like school closures and lockdowns, may manifest as mental health problems in children and adolescents. More importantly, it contributes to the exploration of potential unintended consequences of our current infection control measures so we can adapt to support the overall well-being of our children in this ‘new normal.’ ”

Dr. Loper added that he was not surprised by the new study’s findings.

“We were already seeing a decline in pediatric mental health and overall well-being in the years preceding COVID-19 because of the ‘isolation epidemic’ involving many of the factors that this study explored,” he said. “I think this review further illustrates the vital necessity of community to support the health and well-being of humans, and specifically children and adolescents.”

From a clinical standpoint, “we need to be intentional and consistent in balancing infection control measures with our kids’ fundamental psychosocial needs,” Dr. Loper said.

“We need to recognize that, when children and adolescents are isolated from community, their fundamental psychosocial needs go unmet,” he emphasized. “If children and adolescents cannot access the meaningful interpersonal interactions necessary for resilience, then they cannot overcome or navigate distress. They will exhibit the avoidance and withdrawal behaviors that accumulate to manifest as adverse mental health symptoms like anxiety and depression.

“Additional research is needed to further explore how compromises in the psychosocial infrastructure of community manifest as downstream symptom indicators such as anxiety and depression,” which are often manifestations of unmet needs, Dr. Loper said.
 

Limitations and strengths, according to authors

The findings were limited by several factors, including a lack of examination of school closures’ effects on mental health independent of broader social lockdowns, according to the researchers. Other limitations included the authors potentially having missed studies, inclusion of cross-sectional studies with relatively weak evidence, potential bias from studies using parent reports, and a focus on the first COVID-19 wave, during which many school closures were of limited duration. Also, the researchers said they did not include studies focused on particular groups, such as children with learning difficulties or autism.

The use of large databases from education as well as health care in studies analyzed were strengths of the new research, they said. The investigators received no outside funding for their study. The researchers, Dr. Jay, and Dr. Loper had no financial conflicts to disclose. Dr. Jay serves on the editorial advisory board of Pediatric News.

Behavior problems, anxiety, and depression in youths were associated with these individuals participating in remote schooling during broader social lockdowns in a new study.

The systematic review, which was published in JAMA Pediatrics on Jan. 18, 2022, was based on data from 36 studies from 11 countries on mental health, physical health, and well-being in children and adolescents aged 0-18 years. The total population included 79,781 children and 18,028 parents or caregivers. The studies reflected the first wave of pandemic school closures and lockdowns from February to July 2020, with the duration of school closure ranging from 1 week to 3 months.

“There are strong theoretical reasons to suggest that school closures may have contributed to a considerable proportion of the harms identified here, particularly mental health harms, through reduction in social contacts with peers and teachers,” Russell Viner, PhD, of UCL Great Ormond St Institute of Child Health, London, and colleagues wrote in their paper.

The researchers included 9 longitudinal pre-post studies, 5 cohort studies, 21 cross-sectional studies, and 1 modeling study in their analysis. Overall, approximately one-third of the studies (36%) were considered high quality, and approximately two-thirds (64%) of the studies were published in journals. Twenty-five of the reports analyzed focused on mental health and well-being.

Schools provide not only education, but also services including meals, health care, and health supplies. Schools also serve as a safety net and source of social support for children, the researchers noted.

The losses children may have experienced during school closures occurred during a time when more than 167,000 children younger than 18 years lost a parent or caregiver to COVID-19, according to a recent report titled “Hidden Pain” by researchers at the University of Pennsylvania, Nemours Children’s Health, and the COVID Collaborative. Although not addressed in the current study, school closures would prevent bereaved children from receiving social-emotional support from friends and teachers. This crisis of loss also prompted the American Academy of Pediatrics to issue a National State of Emergency in Children’s Mental Health in October 2021.
 

New study results

These studies identified associations between school closures during broader lockdowns and increased emotional and behavioral problems, as well as increased restlessness and inattention. Across these studies, 18%-60% of children and adolescents scored higher than the risk thresholds for diagnoses of distress, especially depressive symptoms and anxiety.

Although two studies showed no significant association with suicide in response to school closures during lockdowns, three studies suggested increased use of screen time, two studies reported increased social media use, and six studies reported lower levels of physical activity.

Three studies of child abuse showed decreases in notifications during lockdowns, likely driven by lack of referrals from schools, the authors noted. A total of 10 studies on sleep and 5 studies on diet showed inconsistent evidence of harm during the specific period of school closures and social lockdowns.

“The contrast of rises in distress with decreases in presentations suggests that there was an escalation of unmet mental health need during lockdowns in already vulnerable children and adolescents,” the researchers wrote. “More troubling still is evidence of a reduction in the ability of the health and social care systems to protect children in many countries, as shown by the large falls in child protection referrals seen in high-quality cohort studies.”
 

‘Study presents concrete assessments rather than speculation’

“Concerns have been widely expressed in the lay media and beyond that school closures could negatively impact the mental and physical health of children and adolescents,” M. Susan Jay, MD, of the Medical College of Wisconsin, Milwaukee, said in an interview. “The authors presented a narrative synthesis summarizing available evidence for the first wave of COVID-19 on school closures during the broader social lockdown occurring during this period.”

The “importance” of this research is that “it is not a single convenience sample study, but a systematic review from 11 countries including the United States, United Kingdom, China, and Turkey, among others, and that the quality of the information was graded,” Dr. Jay said. “Although not a meta-analysis, the study presents concrete assessments rather than speculation and overviews its limitations so that the clinician can weigh this information. Importantly, the authors excluded closure of schools with transmission of infection.

“Clearly, school lockdowns as a measure of controlling infectious disease needs balance with potential of negative health behaviors in children and adolescents. Ongoing prospective longitudinal studies are needed as sequential waves of the pandemic continue,” she emphasized.

“Clinically, this study highlights the need for clinicians to consider [asking] about the impact of school closures and remote versus hybrid versus in-person education [as part of their] patients and families question inventory,” Dr. Jay said. “Also, the use of depression inventories can be offered to youth to assess their mental health state at a visit, either via telemedicine or in person, and ideally at sequential visits for a more in-depth assessment.”
 

Schools play key role in social and emotional development

“It was important to conduct this study now, because this current time is unprecedented,” Peter L. Loper Jr., MD, of the University of South Carolina, Columbia, said in an interview. “We know based on evolutionary biology, anthropology, and developmental psychology, among other disciplines, that meaningful interpersonal interactions embedded in the context of community are vital to supporting human well-being.

“In our current time, the primary framework of community for our children is the school setting; it is the predominant space where they engage in the interpersonal interactions necessary for developing resilience, their sense of purpose, belonging, and fidelity,” he emphasized.

“Rarely in the course of human existence have kids been removed from the broader context of community to this extent and for this duration,” Dr. Loper said. “This study capitalizes on this unprecedented moment to begin to further understand how compromises in our sociocultural infrastructure of community, like school closures and lockdowns, may manifest as mental health problems in children and adolescents. More importantly, it contributes to the exploration of potential unintended consequences of our current infection control measures so we can adapt to support the overall well-being of our children in this ‘new normal.’ ”

Dr. Loper added that he was not surprised by the new study’s findings.

“We were already seeing a decline in pediatric mental health and overall well-being in the years preceding COVID-19 because of the ‘isolation epidemic’ involving many of the factors that this study explored,” he said. “I think this review further illustrates the vital necessity of community to support the health and well-being of humans, and specifically children and adolescents.”

From a clinical standpoint, “we need to be intentional and consistent in balancing infection control measures with our kids’ fundamental psychosocial needs,” Dr. Loper said.

“We need to recognize that, when children and adolescents are isolated from community, their fundamental psychosocial needs go unmet,” he emphasized. “If children and adolescents cannot access the meaningful interpersonal interactions necessary for resilience, then they cannot overcome or navigate distress. They will exhibit the avoidance and withdrawal behaviors that accumulate to manifest as adverse mental health symptoms like anxiety and depression.

“Additional research is needed to further explore how compromises in the psychosocial infrastructure of community manifest as downstream symptom indicators such as anxiety and depression,” which are often manifestations of unmet needs, Dr. Loper said.
 

Limitations and strengths, according to authors

The findings were limited by several factors, including a lack of examination of school closures’ effects on mental health independent of broader social lockdowns, according to the researchers. Other limitations included the authors potentially having missed studies, inclusion of cross-sectional studies with relatively weak evidence, potential bias from studies using parent reports, and a focus on the first COVID-19 wave, during which many school closures were of limited duration. Also, the researchers said they did not include studies focused on particular groups, such as children with learning difficulties or autism.

The use of large databases from education as well as health care in studies analyzed were strengths of the new research, they said. The investigators received no outside funding for their study. The researchers, Dr. Jay, and Dr. Loper had no financial conflicts to disclose. Dr. Jay serves on the editorial advisory board of Pediatric News.

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.

A social worker called with a plea in April 2020, when the hospital was filled with COVID-19 patients, some so sick they were on ventilators. “I need your help with a family. Mom is in the ICU, intubated; her son died here 2 weeks ago of COVID and her daughters are overwhelmed, unable to visit because of restrictions. The staff anticipates extubating Elvira imminently, but she will be fragile and alone. When is the right time to tell Elvira that Tony died?”

That happened at the beginning of the COVID pandemic. I handled the case remotely with heroic help from overburdened nurses and doctors who were acting as medical staff, social workers, and substitute family to an isolated patient in the hospital. Such was the confusion with the new virus before vaccines and treatments.
 

The impact of pandemics: A historical perspective

Beginning in antiquity, there were pandemics that decimated populations. Before antibiotics, vaccines or awareness of microorganisms, people feared contagion and sought isolation from the sick. People also thought that those who recovered were less likely to fall ill again, and if they did get sick, the illness would be milder.

There is abundant documentation of bubonic plague outbreaks, such as the “Black Death” in the Middle Ages. The Spanish flu of 1918 struck down robust young Americans and spread worldwide. Although the bubonic plague was at the center of major infectious outbreaks, including the pandemic of the Justinian era (500s) and the Great Plague of London (1665-1666), other infectious diseases, untreatable at the time, prevailed simultaneously. Wars, world trade, unsanitary conditions, and urban crowding enhanced the spread. Pandemics shaped history. Some historians attribute the fall of the Roman Empire to unrelenting infectious disease carried in migratory battles.

Even in the earliest outbreaks, the poor populace died more readily than the well off, who had means to escape and seclude themselves from congested areas. Samuel Pepys, a diarist of the London Plague, was a famed businessman and government official; he wrote of seeing the suffering in his city, but he escaped to live with his wife in their country home. What Samuel Pepys wrote of London during the Plague can apply to the early period of the COVID pandemic: “How few people I see, and those looking like people that had taken leave of the world.”

There are lurid descriptions of the chaos of pandemics, especially of the Black Death and the Plague of London. First published in 1722, Daniel Defoe’s “A Journal of the Plague Year” describes the suffering of the sick that included people abandoning the afflicted and others running rampant with delirium in the streets, screaming in pain. City officials took cruel measures that they considered necessary, such as locking away families in their homes, sick and well together, when an individual member showed symptoms. The Middle Ages saw deadly anti-Semitism. During the Black Death, fanatics murdered Jews in the belief that they brought on the pestilence. Ignorance created panic.

As happens in tragedy, there was also bravery. Some stayed to tend to the sick; charities provided food for poor people during the London Plague.
 

Back to the 21st century

After 3 weeks on the ventilator, Elvira got extubated. A team including her doctor, nurse, and Connie, one of her daughters, told Elvira that her 28-year-old son had died of COVID. I began telepsychiatry with Elvira and her two daughters. Treatment continued after Elvira returned home. In telephone sessions, we discussed bereavement and how to cope with the emotional and physical challenges in recovery.

Before he contracted COVID, Tony, Elvira’s son, had compromised health. He was on dialysis awaiting a kidney transplant. His mother prepared his meals and often accompanied Tony to doctor appointments. Still, Elvira said, “I wasn’t there to hold his hand.” At age 71, Elvira was also at high risk. She suffered from diabetes, high blood pressure, hyperlipidemia, and had coronary stents. Elvira was compliant with medications for her conditions.
 

What we know; where we are

“Infectious diseases are not static conditions but depend upon a constantly changing relationship between parasite and invaded species which is bound to result in modifications of both clinical and epidemiological manifestations.”

Hans Zinsser, Rats, Lice and History

We need to be informed by history and grateful to the geniuses who brought us into the modern age of medicine. We can prevent diseases with public health measures, and by understanding and treating crises. Edward Jenner, who recognized the protective effect of cowpox against smallpox, developed inoculations beginning in 1796; he ushered in immunology and saved the lives of millions. Smallpox is now eradicated. A succession of microbe hunters, including Louis Pasteur and Robert Koch, benefited from the development of the microscope by Antonie van Leeuwenhoek. With the advent and use of penicillin in the early 1940s, Alexander Fleming welcomed antibiotics; by the 1960s this modality became widespread. In the mid-20th century, immunologists recognized that bacteria and viruses change and adapt to the environment.

The planet has seen ravaging pandemics that then dissipated and, although untreatable at the time, disappeared into a reservoir, such as rats or lice. People also developed herd immunity from exposure to the offending microorganisms within the population. Less toxic, these agents no longer kill those who get infected but they can be transmissible and endemic to humans.

The mental health consequences of pandemics are reminiscent of other severe illnesses. The seriously ill develop cognitive aberrations and can become delirious. The population at risk and those who get sick can experience depression, PTSD, and anxiety – including panic.
 

Update on Elvira

Elvira continues to improve. She also participates in support groups, including one that addresses bereavement for parents of children who died of COVID and other causes. “I didn’t have a chance to say goodbye,” she said. But what she calls her “brain fog” has dissipated. She walks better, and she is getting evaluation of radiculopathy, probably from nerve root injury during her 3 weeks in bed on the ventilator. She’s still experiencing pain in her feet.

With regard to her symptoms she said: “I cry almost every day.” Her PTSD has abated, but she sometimes has nightmares. Elvira is writing a book about the induced coma and the “hallucinations from hell to heaven” she experienced. She wonders:“Did Tony go through the same thing?” Her empathy is enhanced by her background as a retired social worker with the Administration for Children’s Services in New York.
 

The role of psychiatry

In its early, most virulent form, SARS-CoV-2 devastated thousands of people, especially the elderly medically vulnerable. With scientific tools we developed vaccines and treatments and continue to study the dynamics of this virus.

As Andy Miller, MD, chief of the division of infectious diseases at the Hospital for Special Surgery, said when I spoke with him about the virus, because of the way in which viruses mutate, “we must remain aware” of the trajectory of SARS-CoV-2 and “counter irrational beliefs.”

How should psychiatry deal with COVID? As scientists, we seek the truth without bias and politics. Mental illness is our domain. Other specialties have the expertise to treat and even prevent infectious disease. We can assist our doctor colleagues to understand depression, anxiety, PTSD, and cognitive issues when they occur. Our medical mission should be, as always, to treat those who suffer mental illness. Now that extends to the consequences of COVID.
 

Suggested reading

Camus A. The Plague. New York: Vintage Books,. 1991.

Defoe D. A Journal of the Plague Year. Mineola, N.Y.: Dover Publications, 2001.

Kelly J. The Great Mortality: An Intimate History of the Black Death, The Most Devastating Plague of All Time. New York: Harper Perennial, 2005.

Pepys S. The Diary of Samuel Pepys: The Great Plague of London & The Great Fire of London, 1665-1666. Oxford, England: Benediction Classics, 2020.

Emerg Infect Dis. 2005 Mar 11(3):402-96.

Zinsser H. Rats, Lice and History. Boston/Toronto: Little Brown and Co., 1935.

Dr. Cohen is in private practice of psychotherapy and medication management in New York. She has been a consultant at the Hospital for Special Surgery and at New York–Presbyterian, and a forensic psychiatry expert. She changed key facts about Elvira’s case to protect her anonymity.