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FDA not recognizing efficacy of psychopharmacologic therapies
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
Many years ago, drug development in psychiatry turned to control of specific symptoms across disorders rather than within disorders, but regulatory agencies are still not yet on board, according to an expert psychopharmacologist outlining the ongoing evolution at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists, sponsored by Medscape Live.
If this reorientation is going to lead to the broad indications the newer drugs likely deserve, which is control of specific types of symptoms regardless of the diagnosis, “we have to move the [Food and Drug Administration] along,” said Stephen M. Stahl, MD, PhD, chairman of the Neuroscience Institute and an adjunct professor of psychiatry at the University of California, San Diego.
On the side of drug development and clinical practice, the reorientation has already taken place. Dr. Stahl described numerous brain circuits known to produce symptoms when function is altered that are now treatment targets. This includes the ventral medial prefrontal cortex where deficient information processing leads to depression and the orbital frontal cortex where altered function leads to impulsivity.
“It is not like each part of the brain does a little bit of everything. Rather, each part of the brain has an assignment and duty and function,” Dr. Stahl explained. By addressing the disturbed signaling in brain circuits that lead to depression, impulsivity, agitation, or other symptoms, there is an opportunity for control, regardless of the psychiatric diagnosis with which the symptom is associated.
For example, Dr. Stahl predicted that pimavanserin, a highly selective 5-HT2A inverse agonist that is already approved for psychosis in Parkinson’s disease, is now likely to be approved for psychosis associated with other conditions on the basis of recent positive clinical studies in these other disorders.
Brexpiprazole, a serotonin-dopamine activity modulator already known to be useful for control of the agitation characteristic of schizophrenia, is now showing the same type of activity against agitation when it is associated with Alzheimer’s disease. Again, Dr. Stahl thinks this drug is on course for an indication across diseases once studies are conducted in each disease individually.
Another drug being evaluated for agitation, the N-methyl-D-aspartate receptor antagonist dextromethorphan bupropion, is also being tested for treatment of symptoms across multiple disorders, he reported.
However, the FDA has so far taken the position that each drug must be tested separately for a given symptom in each disorder for which it is being considered despite the underlying premise that it is the symptom, not the disease, that is important.
Unlike physiological diseases where symptoms, like a fever or abdominal cramps, are the product of a disease, psychiatric symptoms are the disease and a fundamental target – regardless of the DSM-based diagnosis.
To some degree, the symptoms of psychiatric disorders have always been the focus of treatment, but a pivot toward developing therapies that will control a symptom regardless of the underlying diagnosis is an important conceptual change. It is being made possible by advances in the detail with which the neuropathology of these symptoms is understood .
“By my count, 79 symptoms are described in DSM-5, but they are spread across hundreds of syndromes because they are grouped together in different ways,” Dr. Stahl observed.
He noted that clinicians make a diagnosis on the basis symptom groupings, but their interventions are selected to address the manifestations of the disease, not the disease itself.
“If you are a real psychopharmacologist treating real patients, you are treating the specific symptoms of the specific patient,” according to Dr. Stahl.
So far, the FDA has not made this leap, insisting on trials in these categorical disorders rather than permitting trial designs that allow benefit to be demonstrated against a symptom regardless of the syndrome with which it is associated.
Of egregious examples, Dr. Stahl recounted a recent trial of a 5-HT2 antagonist that looked so promising against psychosis in Alzheimer’s disease that the trialists enrolled patients with psychosis regardless of type of dementia, such as vascular dementia and Lewy body disease. The efficacy was impressive.
“It worked so well that they stopped the trial, but the FDA declined to approve it,” Dr. Stahl recounted. Despite clear evidence of benefit, the regulators insisted that the investigators needed to show a significant benefit in each condition individually.
While the trial investigators acknowledged that there was not enough power in the trial to show a statistically significant benefit in each category, they argued that the overall benefit and the consistent response across categories required them to stop the trial for ethical reasons.
“That’s your problem, the FDA said to the investigators,” according to Dr. Stahl.
The failure of the FDA to recognize the efficacy of psychopharmacologic therapies across symptoms regardless of the associated disease is a failure to stay current with an important evolution in medicine, Dr. Stahl indicated.
“What we have come to understand is the neurobiology of any given symptom is likely to be the same across disorders,” he said.
Agency’s arbitrary decisions cited
“I completely agree with Dr. Stahl,” said Henry A. Nasrallah, MD, professor of psychiatry, neurology, and neuroscience, University of Cincinnati.
In addition to the fact that symptoms are present across multiple categories, many patients manifest multiple symptoms at one time, Dr. Nasrallah pointed out. For neurodegenerative disorders associated with psychosis, depression, anxiety, aggression, and other symptoms, it is already well known that the heterogeneous symptoms “cannot be treated with a single drug,” he said. Rather different drugs targeting each symptom individually is essential for effective management.
Dr. Nasrallah, who chaired the Psychopharmacology Update meeting, has made this point many times in the past, including in his role as the editor of Current Psychiatry. In one editorial 10 years ago, he wrote that “it makes little sense for the FDA to mandate that a drug must work for a DSM diagnosis instead of specific symptoms.”
“The FDA must update its old policy, which has led to the widespread off-label use of psychiatric drugs, an artificial concept, simply because the FDA arbitrarily decided a long time ago that new drugs must be approved for a specific DSM diagnosis,” Dr. Nasrallah said.
Dr. Stahl reported financial relationships with more than 20 pharmaceutical companies, including those that are involved in the development of drugs included in his talk. Medscape Live and this news organization are owned by the same parent company.
FROM PSYCHOPHARMACOLOGY UPDATE
Catching the runner’s high: Anxiety and the endocannabinoid system
"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.
For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.1 Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.2 Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.
Exploring the endocannabinoid system
Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.2
One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.1 A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.3 These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.
For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.1,3-6
As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.
1. Fuss J, Steinle J, Bindila L, et al. A runner’s high depends on cannabinoid receptors in mice. Proc Natl Acad Sci USA. 2015;112(42):13105-13108.
2. Patel S, Hill MN, Cheer JF, et al. The endocannabinoid system as a target for novel anxiolytic drugs. Neurosci Biobehav Rev. 2017;76(Pt A):56-66.
3. Siebers M, Biedermann SV, Bindila L, et al. Exercise-induced euphoria and anxiolysis do not depend on endogenous opioids in humans. Psychoneuroendocrinology. 2021;126:105173.
4. Dietrich A, McDaniel WF. Endocannabinoids and exercise. Br J Sports Med. 2004;38(5):536-541.
5. Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of Consulting and Clinical Psychology. 2010;78(2):169-183.
6. Watkins BA. Endocannabinoids, exercise, pain, and a path to health with aging. Mol Aspects Med. 2018;64:68-78.
"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.
For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.1 Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.2 Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.
Exploring the endocannabinoid system
Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.2
One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.1 A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.3 These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.
For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.1,3-6
As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.
"Effortless.” “Weightless.” “Limitless.” “Carefree.” In most cases, these are words one would not commonly associate with running. In fact, many people might experience an uptick in anxiety when fathoming the idea of going out for a run. Believe it or not, these words are direct quotes from runners describing the feeling of a “runner’s high”—a well-documented organic euphoria that cannot be purchased or abused. But how is the innately basic and monotonous act of running able to reliably transform something as complex as human emotion? This answer lies in the endocannabinoid system.
For decades, scientists and the public believed the runner’s high was associated with an exercise-induced increase in levels of opioid peptides called beta-endorphins. The problem with this theory is that beta-endorphin, released into the blood by the pituitary gland in response to exercise and stress, has difficulty passing through the blood-brain barrier, rendering central effects of this peripheral opioid unlikely.1 Only recently have researchers been examining the effects of exercise as it pertains to the endocannabinoid system.2 Interest in the study of this system is peaking as use of cannabis and hemp-based products reaches an all-time high.
Exploring the endocannabinoid system
Within the last 25 years, the endocannabinoid system has emerged as a highly relevant and unique neuromodulatory system. As with other neurotransmitter systems, the endocannabinoid system is comprised of the endogenous cannabinoids, their receptors, and an array of enzymes responsible for both synthesis and degradation. Endocannabinoid receptors are ubiquitous in the brain and take effect primarily in the cortex, amygdala, basal ganglia, hippocampus, hypothalamus, and cerebellum. One fascinating feature of endocannabinoids is that their precursors lie embedded within lipid membranes. Nearly on demand, endocannabinoids can be rapidly synthesized and released. This grants them almost immediate availability to get into the action at the synapse.2
One study of mice found that those who were exercised experienced improvements in anxiety behaviors and better tolerance to pain. Further, when the exercised mice were treated with endocannabinoid receptor antagonists, they remained anxious and were more sensitive to pain. Endorphin antagonists had no effect on the outcome of these tests.1 A similar study conducted in humans found improvement in subjective anxiety scores after 45 minutes of moderate-intensity exercise. This study also showed no change with naltrexone administration vs placebo, again supporting the hypothesis that endorphins play little role in this phenomenon. Interestingly, levels of endogenous cannabinoids were elevated following exercise.3 These findings suggest a possible link between activation of the endogenous endocannabinoid system and the anxiolytic properties of exercise.
For good reason, the endocannabinoid system has attracted substantial interest as a focus for a new class of drugs to treat anxiety and stress-related disorders. It remains unknown how we can best harness its many beneficial effects in a safe and effective manner. With that said, activities such as physical exercise, mindfulness meditation, yoga, and other forms of complementary medicine are immediately available and cost-effective methods that have at least preliminary data revealing their multiple health benefits, including improvement in the symptoms of anxiety and activation of endogenous cannabinoids.1,3-6
As we are all aware, medical training and practice is full of a variety of stresses and demands. Given these demands, finding a balance between mind, body, and spirit can seem like an impossible task. Besides the obvious physical benefits of regular exercise, running can serve to employ the stress-modifying effects of our endogenous cannabinoid system to reduce perceived anxiety and improve wellness. Indeed, at the start of any bout of exercise—especially running—the transition from rest can be startling. Rest assured that there is good news waiting beyond the first few miles. Your reward for patience and perseverance is a beautiful freedom experienced only by those who have earned it. The best part of it all? It is waiting for you right outside your door.
1. Fuss J, Steinle J, Bindila L, et al. A runner’s high depends on cannabinoid receptors in mice. Proc Natl Acad Sci USA. 2015;112(42):13105-13108.
2. Patel S, Hill MN, Cheer JF, et al. The endocannabinoid system as a target for novel anxiolytic drugs. Neurosci Biobehav Rev. 2017;76(Pt A):56-66.
3. Siebers M, Biedermann SV, Bindila L, et al. Exercise-induced euphoria and anxiolysis do not depend on endogenous opioids in humans. Psychoneuroendocrinology. 2021;126:105173.
4. Dietrich A, McDaniel WF. Endocannabinoids and exercise. Br J Sports Med. 2004;38(5):536-541.
5. Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of Consulting and Clinical Psychology. 2010;78(2):169-183.
6. Watkins BA. Endocannabinoids, exercise, pain, and a path to health with aging. Mol Aspects Med. 2018;64:68-78.
1. Fuss J, Steinle J, Bindila L, et al. A runner’s high depends on cannabinoid receptors in mice. Proc Natl Acad Sci USA. 2015;112(42):13105-13108.
2. Patel S, Hill MN, Cheer JF, et al. The endocannabinoid system as a target for novel anxiolytic drugs. Neurosci Biobehav Rev. 2017;76(Pt A):56-66.
3. Siebers M, Biedermann SV, Bindila L, et al. Exercise-induced euphoria and anxiolysis do not depend on endogenous opioids in humans. Psychoneuroendocrinology. 2021;126:105173.
4. Dietrich A, McDaniel WF. Endocannabinoids and exercise. Br J Sports Med. 2004;38(5):536-541.
5. Hofmann SG, Sawyer AT, Witt AA, et al. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. Journal of Consulting and Clinical Psychology. 2010;78(2):169-183.
6. Watkins BA. Endocannabinoids, exercise, pain, and a path to health with aging. Mol Aspects Med. 2018;64:68-78.
Chatbots can improve mental health in vulnerable populations
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
In this modern age of health care where telemedicine rules, conversational agents (CAs) that use text messaging systems are becoming a major mode of communication.
Many people are familiar with voice-enabled agents, such as Apple’s Siri, Google Now, and Microsoft’s Cortana. However, CAs come in different forms of complexity, ranging from a short message service–based texting platform to an embodied conversational agent (ECA).
ECAs allow participants to interact with a physical or graphical figure that simulates a person in appearance, behavior, and dialect. These are essentially virtual humans, or avatars, who talk with participants. By taking greater advantage of these automated agents, some have projected there may be $11 billion in combined cost savings across a variety of business sectors by 2023.1 The health care field is one sector in which CAs can play an important role. Because of their accessibility, CAs have the potential to improve mental health by combating health care inequities and stigma, encouraging disclosure from participants, and serving as companions during the COVID-19 pandemic.
CAs provide accessible health care for rural, low socioeconomic status (SES), and minority communities in a variety of advantageous ways. For example, one study found that long-term use of a text-based agent that combines motivational interviewing and cognitive-behavioral therapy (CBT) can support smoking cessation in adolescents of low SES.2
CAs can help vulnerable participants advocate for themselves and proactively maintain their mental health through access to health care resources. In specific cases, these agents equalize health care treatment for different populations. Even though some participants live in secluded areas or are blocked by barriers, these text-based agents can still provide self-help intervention for them at any time on an individual basis, regardless of their location or socioeconomic status. Furthermore, they serve as highly cost-effective mental health promotion tools for large populations, some of which might not otherwise be reached by mental health care.
In combating mental illnesses such as depression and anxiety, studies have found that CAs are great treatment tools. For example, participants in an experimental group who received a self-help program based on CBT from a text-based CA named Woebot experienced significantly reduced depression symptoms when compared to the control group of participants, who received only information from a self-help electronic book.3 As a result, CAs might prove successful in treating younger populations who find online tools more feasible and accessible. Often, this population self-identifies depressive and anxiety symptoms without consulting a health care professional. Thus, this tool would prove useful to those who are bothered by the stigma of seeing a mental health professional.
Virtual human–based CAs also encourage participants to disclose more information in a nonjudgmental manner, especially among people with diseases with stigma. CAs use neutral languages, which may be helpful when dealing with stigmatized issues such as HIV, family planning, and abortion care because this heightens confidentiality and privacy. When participants believe that the agent does not “judge” or evaluate their capabilities, this elicits more sensitive information from them. For example, one study found that military service members who believed that they were interacting with a computer rather than a human operator reported lower fear of self-disclosure, displayed more sadness, and were rated by observers as more willing to disclose posttraumatic stress disorder symptoms.4 Additional findings show that participants prefer CAs when topics are highly sensitive and more likely to evoke negative self-admissions.
In what we hope will soon be a post–COVID-19 landscape of medicine, CAs are fast being used on the front lines of health care technology. Empathetic CAs can combat adverse effects of social exclusion during these pressing times. Etsuko Ishii, a researcher affiliated with the Hong Kong University of Science and Technology, and associates demonstrated that a virtual CA was as effective as a COVID-19 companion because it uses natural language processing (NLP) and nonverbal facial expressions to give users the feeling that they are being treated with empathy.5 While minimizing the number of in-person interactions that could potentially spread COVID-19, these agents promote virtual companionship that mirrors natural conversations and provide emotional support with psychological safety as participants express their pent-up thoughts. Not only do these agents help recover mood quickly, but they also have the power to overcome geographic barriers, be constantly available, and alleviate the high demand for mental health care. As a result, CAs have the potential to facilitate better communication and sustain social interactions within the isolated environment the pandemic has created.
CAs can predict, detect, and determine treatment solutions for mental health conditions based on behavioral insights. These agents’ natural language processing also allows them to be powerful therapeutic agents that can serve different communities, particularly for populations with limited access to medical resources. As the use of CAs becomes more integrated into telemedicine, their utility will continue to grow as their proven versatility in many situations expands the boundaries of health care technology.
Ms. Wong, a medical student at New York Institute of Technology College of Osteopathic Medicine in Old Westbury, conducts research related to mental health care services. She disclosed writing a telemental health software platform called Orchid. Dr. Vo, a board-certified psychiatrist, is the medical director of telehealth for the department of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia. She is a faculty member of the University of Pennsylvania, also in Philadelphia. Dr. Vo conducts digital health research focused on using automation and artificial intelligence for suicide risk screening and connecting patients to mental health care services. She disclosed serving as cofounder of Orchid.
References
1. Chatbots: Vendor opportunities & market forecasts 2020-2024. Juniper Research, 2020.
2. Simon P et al. On using chatbots to promote smoking cessation among adolescents of low socioeconomic status, Artificial Intelligence and Work: Association for the Advancement of Artificial Intelligence (AAAI) 2019 Fall Symposium, 2019.
3. Fitzpatrick KK et al. JMIR Mental Health. 2017;4(2):e19.
4. Lucas GM et al. Front Robot AI. 2017 Oct 12. doi: 10.3389/frobt.2017.00051.
5. Ishii E et al. ERICA: An empathetic android companion for COVID-19 quarantine. arXiv preprint arXiv:2106.02325.
Spiders, dogs, and PTSD: A virtual treatment for phobias and fear
At Wayne State University’s Stress, Trauma, and Anxiety Research Clinic (STARC) in Michigan, researchers are developing novel interventions for treating some very ancient phobias hardwired into the human brain. By using augmented reality as means of conducting exposure therapy, STARC researchers – including Shantanu Madaboosi, Rakesh Ramaswamy, and Lana Grasser – and STARC director Arash Javanbakht, MD, have produced compelling evidence that they can free patients of their often debilitating fears of spiders, dogs, and snakes. Yet their work doesn’t stop there, and research into treating anxiety and posttraumatic stress disorder among first responders and others with high-stress occupations is ongoing.
This news organization spoke with Dr. Javanbakht, a psychiatrist, about the technological advances that have made this work possible; the future of remote-based psychiatry; and his tarantula colleague, Tony.
Augmenting exposure therapy
How did you begin using artificial intelligence as a way of delivering exposure therapy?
Exposure therapy is a very effective treatment for phobias, obsessive-compulsive disorder, and PTSD. But the problem we had is that, if someone comes to me and says they’re afraid of dogs, snakes, or spiders, I don’t have those in my office. Or, if its social phobia, I can’t create those scenarios. So, despite being such an effective treatment, it’s not utilized as much as it should be.
Several years ago, I saw a TED talk by the CEO of an augmented reality company who happened to be a neuroscientist. I thought the concept was amazing, because it offered a way to overcome those limitations.
Mixed augmented reality allows us to bring all those feared objects to the clinic. I can bring my Labrador to the office for someone who’s afraid of dogs, and they can get the exposure to that one dog. But we know good exposure therapy needs to be generalizable, with as many different breeds of dogs as possible, and is context dependent. If the patient sees a dog in their neighborhood, their fear response may come back. Doing it in a real-life context, and offering as many contexts as possible, makes it more effective.
Augmented reality allows all of these options because you can have as many different types of virtual objects as you want, and the difference between augmented reality and virtual reality is that augmented reality happens in a real-life context. You wear the goggles and you can walk around the environment and track the object, so the context is more realistic.
When did you begin researching augmented reality as a clinical tool?
I became a faculty member here in 2015, right out of my residency training, and I think it was around 2016 or 2017 that we began this work.
I’m very much involved in exposure therapy, utilize it myself, train others, and research how it works and changes the brain. I knew the ins and outs and what would make a better exposure therapy, based on my knowledge of neuroscience.
We spend time thinking about how we can apply these neuroscientific principles in software that can also be easily used by a not very technologically savvy therapist. Because that has been a big barrier when it comes to technology and human use in medicine.
Initially, we had a company create the software for us, but we’ve since brought all the programming inside.
The cool thing about these augmented reality devices is that they have excellent surface mapping. As soon as the person wears the goggles, it automatically maps the surfaces and provides a 3D view of the patient’s environment on the therapist’s computer. Say you’re treating a patient with a fear of spiders. Through drop-down menus, the therapist can choose what type of spider, its color and size, where it should be placed, and the motion. I can choose to move the spider from 6 feet away on the floor to the walls to the ceiling.
Virtual phobias, real fear
A big question for a lot of people was if the spiders are virtual, will they be scary, because it has to be realistic enough to create a fear response for the therapy to work. We use a couple of wires that you can put on a person’s finger and hook them up to a tablet or a cell phone. This provides an online measure of a person’s autonomic sympathetic response.
Like a lie detector test?
Exactly. We put that on their fingers and exposed them to a real-life tarantula and to our virtual tarantulas, and the fear response was no different. That means these do create an objective fear reaction in the body.
We also had people who said, “I know this is not real. I won’t be scared.” And when we started the therapy, it was with a tiny spider 5 meters away from them, and they’d lift their legs off the floor.
With the treatment, we’d come to one room and start with a very little spider, far from them. Then gradually we move them up to bigger, more diverse types of spiders, which are moving around. The patient comes near and tries to touch them.
Then at some point, I’d put a spiderweb on the door, put a few spiders on that, open the door, and have the patient walk through it. They kept walking through this spiderweb.
When they were desensitized to these spiders in this context – and as I said, context is important – we’d go to another room. This was darker, more like a basement, and we’d continue the same thing. That would actually take much less time because they already had desensitized a lot.
In our field, sense of control is very important, especially for when a patient goes home. So at the end, I’d leave the room and talk to the patient via a baby monitor. The patient was surrounded by 20 tarantulas, without the prompt moving around the environment.
Now that they’re desensitized to my virtual spiders, the question is, how would that apply to a real spider? So, we had a real live tarantula, whose name was Tony Stark, because we’re the STARC lab. We’d put Tony at the end of a long hallway before the treatment and see how close the patients could get to him.
It was only one treatment session; nobody’s was longer than 1 hour, and the average treatment time was 38 minutes.
That’s pretty effective.
It’s pretty good, compared with other studies. And I believe this is because of all the components I mentioned: being able to use your real environment; combining it with the real tarantula; the variety of the types of the feared objects; and, of course, giving the patient a sense of autonomy at the end.
Then we had to see how prolonged the effects are. We had them come in 1 week and 1 month after the treatment. I’d remind them of the principles of good exposure therapy and ask them to keep practicing at home between the sessions, looking at pictures and videos. But we never tested who did or did not do it.
After 1 week and 1 month, the effects were either the same or better. A larger number of people at 1 month were able to touch the tarantula than right after treatment.
Treating PTSD in first responders
Did you start with spiders and dogs because those are common fears?
We started with spiders because that worked with the initial goal of creating a prototype. Spiders’ behavior is simple enough for the programming, which takes a lot of time. Another reason for choosing spiders was that we had a lot of other studies of real and virtual reality exposure therapy to compare against.
I think another reason for our success is that, when you do real exposure therapy, you have just one scared tarantula in the corner of their tank, and they don’t listen to you. But my spiders listen to me and do exactly what I tell them.
After our initial success, we obtained more funds to expand it to other phobias. The cool thing is that we don’t need separate software for different phobias. You can choose dogs or snakes, add it to the person’s environment, and decide their behaviors.
We just started a clinical trial using dogs, and another group in Turkey is running a clinical trial with dogs. Eastern Michigan University is working with spiders. And a clinic at the University of Nebraska Medical Center is going to start using them in real-world clinics, not for research.
We have another project whose goal is helping reduce the impact of trauma and also treating PTSD in first responders, who are exposed to a lot of horrible things. Rates of PTSD are around 20%-30% among cops, firefighters, and EMS personnel.
They commonly find it very painful being in crowds because the fight-or-flight instinct in the brain is constantly screening for any sign of threat in their environment. We’re working on them walking into an empty room wearing the goggles, and then their therapist can scale the stimulus up and down.
There’ll be two people in front of you talking to each other, and then another group comes in, and people get louder. People can look at you and talk to you. There’s kids running, Fourth of July fireworks, and other things that might bother someone who’s been involved in gun- or explosion-related traumas. You gradually scale up when the person is next to their therapist.
Another thing we’re doing is related to cardiopulmonary resuscitation. If a young person dies in a CPR situation, that is really painful and traumatic. So, for exposure therapy to that, we’re creating a difficult CPR scenario when that person may die. The responder wears the goggles and basically watches a group of people doing CPR while standing next to a therapist who can help them navigate it and then scale it off.
Another goal is combining this with telemedicine, where the person can do it in their real-life environment. Imagine a person with military trauma. You can put them back in the barracks, connected with their psychiatrists via telemedicine. Then we would put humans in military fatigues near them and have them interact with them to feel comfortable with that situation.
What else is next for you and your group?
The next biggest challenge that we’re tackling is PTSD, because of course creating human-encounter scenarios is much more complicated than spiders and dogs. We’re in the midst of developing this so we can basically bring it to people’s homes.
We’ve been working with some military personnel to see if we can basically give a device to a veteran with PTSD, so they can go home and practice on their own.
There’s another possibility for training. Let’s take the example of a police force, which can have a lot of difficulties and mistakes because of lack of exposure and training. They can wear these goggles, get fully geared up, and be placed in encounters with people of different backgrounds, of different severity, with people who could be severely mentally ill or present different challenges for the officers.
Those situations can teach them a lot. I’m the creator of this thing, but even I’m often surprised by how realistic this technology can be. I find myself interacting with avatars the same way I would if they were real humans. I actually had one of my colleagues, when we started launching the programming with the dogs, immediately jump back. It’s just like the animal brain reacts to them.
Last question: Do you actually interact with Tony, the tarantula?
Oh, Tony is my friend. Unfortunately, he’s not with our lab at this moment. He’s on a sabbatical at Eastern Michigan University for their clinical trials. But yes, I’ve held him. He’s very friendly.
A version of this article first appeared on Medscape.com.
At Wayne State University’s Stress, Trauma, and Anxiety Research Clinic (STARC) in Michigan, researchers are developing novel interventions for treating some very ancient phobias hardwired into the human brain. By using augmented reality as means of conducting exposure therapy, STARC researchers – including Shantanu Madaboosi, Rakesh Ramaswamy, and Lana Grasser – and STARC director Arash Javanbakht, MD, have produced compelling evidence that they can free patients of their often debilitating fears of spiders, dogs, and snakes. Yet their work doesn’t stop there, and research into treating anxiety and posttraumatic stress disorder among first responders and others with high-stress occupations is ongoing.
This news organization spoke with Dr. Javanbakht, a psychiatrist, about the technological advances that have made this work possible; the future of remote-based psychiatry; and his tarantula colleague, Tony.
Augmenting exposure therapy
How did you begin using artificial intelligence as a way of delivering exposure therapy?
Exposure therapy is a very effective treatment for phobias, obsessive-compulsive disorder, and PTSD. But the problem we had is that, if someone comes to me and says they’re afraid of dogs, snakes, or spiders, I don’t have those in my office. Or, if its social phobia, I can’t create those scenarios. So, despite being such an effective treatment, it’s not utilized as much as it should be.
Several years ago, I saw a TED talk by the CEO of an augmented reality company who happened to be a neuroscientist. I thought the concept was amazing, because it offered a way to overcome those limitations.
Mixed augmented reality allows us to bring all those feared objects to the clinic. I can bring my Labrador to the office for someone who’s afraid of dogs, and they can get the exposure to that one dog. But we know good exposure therapy needs to be generalizable, with as many different breeds of dogs as possible, and is context dependent. If the patient sees a dog in their neighborhood, their fear response may come back. Doing it in a real-life context, and offering as many contexts as possible, makes it more effective.
Augmented reality allows all of these options because you can have as many different types of virtual objects as you want, and the difference between augmented reality and virtual reality is that augmented reality happens in a real-life context. You wear the goggles and you can walk around the environment and track the object, so the context is more realistic.
When did you begin researching augmented reality as a clinical tool?
I became a faculty member here in 2015, right out of my residency training, and I think it was around 2016 or 2017 that we began this work.
I’m very much involved in exposure therapy, utilize it myself, train others, and research how it works and changes the brain. I knew the ins and outs and what would make a better exposure therapy, based on my knowledge of neuroscience.
We spend time thinking about how we can apply these neuroscientific principles in software that can also be easily used by a not very technologically savvy therapist. Because that has been a big barrier when it comes to technology and human use in medicine.
Initially, we had a company create the software for us, but we’ve since brought all the programming inside.
The cool thing about these augmented reality devices is that they have excellent surface mapping. As soon as the person wears the goggles, it automatically maps the surfaces and provides a 3D view of the patient’s environment on the therapist’s computer. Say you’re treating a patient with a fear of spiders. Through drop-down menus, the therapist can choose what type of spider, its color and size, where it should be placed, and the motion. I can choose to move the spider from 6 feet away on the floor to the walls to the ceiling.
Virtual phobias, real fear
A big question for a lot of people was if the spiders are virtual, will they be scary, because it has to be realistic enough to create a fear response for the therapy to work. We use a couple of wires that you can put on a person’s finger and hook them up to a tablet or a cell phone. This provides an online measure of a person’s autonomic sympathetic response.
Like a lie detector test?
Exactly. We put that on their fingers and exposed them to a real-life tarantula and to our virtual tarantulas, and the fear response was no different. That means these do create an objective fear reaction in the body.
We also had people who said, “I know this is not real. I won’t be scared.” And when we started the therapy, it was with a tiny spider 5 meters away from them, and they’d lift their legs off the floor.
With the treatment, we’d come to one room and start with a very little spider, far from them. Then gradually we move them up to bigger, more diverse types of spiders, which are moving around. The patient comes near and tries to touch them.
Then at some point, I’d put a spiderweb on the door, put a few spiders on that, open the door, and have the patient walk through it. They kept walking through this spiderweb.
When they were desensitized to these spiders in this context – and as I said, context is important – we’d go to another room. This was darker, more like a basement, and we’d continue the same thing. That would actually take much less time because they already had desensitized a lot.
In our field, sense of control is very important, especially for when a patient goes home. So at the end, I’d leave the room and talk to the patient via a baby monitor. The patient was surrounded by 20 tarantulas, without the prompt moving around the environment.
Now that they’re desensitized to my virtual spiders, the question is, how would that apply to a real spider? So, we had a real live tarantula, whose name was Tony Stark, because we’re the STARC lab. We’d put Tony at the end of a long hallway before the treatment and see how close the patients could get to him.
It was only one treatment session; nobody’s was longer than 1 hour, and the average treatment time was 38 minutes.
That’s pretty effective.
It’s pretty good, compared with other studies. And I believe this is because of all the components I mentioned: being able to use your real environment; combining it with the real tarantula; the variety of the types of the feared objects; and, of course, giving the patient a sense of autonomy at the end.
Then we had to see how prolonged the effects are. We had them come in 1 week and 1 month after the treatment. I’d remind them of the principles of good exposure therapy and ask them to keep practicing at home between the sessions, looking at pictures and videos. But we never tested who did or did not do it.
After 1 week and 1 month, the effects were either the same or better. A larger number of people at 1 month were able to touch the tarantula than right after treatment.
Treating PTSD in first responders
Did you start with spiders and dogs because those are common fears?
We started with spiders because that worked with the initial goal of creating a prototype. Spiders’ behavior is simple enough for the programming, which takes a lot of time. Another reason for choosing spiders was that we had a lot of other studies of real and virtual reality exposure therapy to compare against.
I think another reason for our success is that, when you do real exposure therapy, you have just one scared tarantula in the corner of their tank, and they don’t listen to you. But my spiders listen to me and do exactly what I tell them.
After our initial success, we obtained more funds to expand it to other phobias. The cool thing is that we don’t need separate software for different phobias. You can choose dogs or snakes, add it to the person’s environment, and decide their behaviors.
We just started a clinical trial using dogs, and another group in Turkey is running a clinical trial with dogs. Eastern Michigan University is working with spiders. And a clinic at the University of Nebraska Medical Center is going to start using them in real-world clinics, not for research.
We have another project whose goal is helping reduce the impact of trauma and also treating PTSD in first responders, who are exposed to a lot of horrible things. Rates of PTSD are around 20%-30% among cops, firefighters, and EMS personnel.
They commonly find it very painful being in crowds because the fight-or-flight instinct in the brain is constantly screening for any sign of threat in their environment. We’re working on them walking into an empty room wearing the goggles, and then their therapist can scale the stimulus up and down.
There’ll be two people in front of you talking to each other, and then another group comes in, and people get louder. People can look at you and talk to you. There’s kids running, Fourth of July fireworks, and other things that might bother someone who’s been involved in gun- or explosion-related traumas. You gradually scale up when the person is next to their therapist.
Another thing we’re doing is related to cardiopulmonary resuscitation. If a young person dies in a CPR situation, that is really painful and traumatic. So, for exposure therapy to that, we’re creating a difficult CPR scenario when that person may die. The responder wears the goggles and basically watches a group of people doing CPR while standing next to a therapist who can help them navigate it and then scale it off.
Another goal is combining this with telemedicine, where the person can do it in their real-life environment. Imagine a person with military trauma. You can put them back in the barracks, connected with their psychiatrists via telemedicine. Then we would put humans in military fatigues near them and have them interact with them to feel comfortable with that situation.
What else is next for you and your group?
The next biggest challenge that we’re tackling is PTSD, because of course creating human-encounter scenarios is much more complicated than spiders and dogs. We’re in the midst of developing this so we can basically bring it to people’s homes.
We’ve been working with some military personnel to see if we can basically give a device to a veteran with PTSD, so they can go home and practice on their own.
There’s another possibility for training. Let’s take the example of a police force, which can have a lot of difficulties and mistakes because of lack of exposure and training. They can wear these goggles, get fully geared up, and be placed in encounters with people of different backgrounds, of different severity, with people who could be severely mentally ill or present different challenges for the officers.
Those situations can teach them a lot. I’m the creator of this thing, but even I’m often surprised by how realistic this technology can be. I find myself interacting with avatars the same way I would if they were real humans. I actually had one of my colleagues, when we started launching the programming with the dogs, immediately jump back. It’s just like the animal brain reacts to them.
Last question: Do you actually interact with Tony, the tarantula?
Oh, Tony is my friend. Unfortunately, he’s not with our lab at this moment. He’s on a sabbatical at Eastern Michigan University for their clinical trials. But yes, I’ve held him. He’s very friendly.
A version of this article first appeared on Medscape.com.
At Wayne State University’s Stress, Trauma, and Anxiety Research Clinic (STARC) in Michigan, researchers are developing novel interventions for treating some very ancient phobias hardwired into the human brain. By using augmented reality as means of conducting exposure therapy, STARC researchers – including Shantanu Madaboosi, Rakesh Ramaswamy, and Lana Grasser – and STARC director Arash Javanbakht, MD, have produced compelling evidence that they can free patients of their often debilitating fears of spiders, dogs, and snakes. Yet their work doesn’t stop there, and research into treating anxiety and posttraumatic stress disorder among first responders and others with high-stress occupations is ongoing.
This news organization spoke with Dr. Javanbakht, a psychiatrist, about the technological advances that have made this work possible; the future of remote-based psychiatry; and his tarantula colleague, Tony.
Augmenting exposure therapy
How did you begin using artificial intelligence as a way of delivering exposure therapy?
Exposure therapy is a very effective treatment for phobias, obsessive-compulsive disorder, and PTSD. But the problem we had is that, if someone comes to me and says they’re afraid of dogs, snakes, or spiders, I don’t have those in my office. Or, if its social phobia, I can’t create those scenarios. So, despite being such an effective treatment, it’s not utilized as much as it should be.
Several years ago, I saw a TED talk by the CEO of an augmented reality company who happened to be a neuroscientist. I thought the concept was amazing, because it offered a way to overcome those limitations.
Mixed augmented reality allows us to bring all those feared objects to the clinic. I can bring my Labrador to the office for someone who’s afraid of dogs, and they can get the exposure to that one dog. But we know good exposure therapy needs to be generalizable, with as many different breeds of dogs as possible, and is context dependent. If the patient sees a dog in their neighborhood, their fear response may come back. Doing it in a real-life context, and offering as many contexts as possible, makes it more effective.
Augmented reality allows all of these options because you can have as many different types of virtual objects as you want, and the difference between augmented reality and virtual reality is that augmented reality happens in a real-life context. You wear the goggles and you can walk around the environment and track the object, so the context is more realistic.
When did you begin researching augmented reality as a clinical tool?
I became a faculty member here in 2015, right out of my residency training, and I think it was around 2016 or 2017 that we began this work.
I’m very much involved in exposure therapy, utilize it myself, train others, and research how it works and changes the brain. I knew the ins and outs and what would make a better exposure therapy, based on my knowledge of neuroscience.
We spend time thinking about how we can apply these neuroscientific principles in software that can also be easily used by a not very technologically savvy therapist. Because that has been a big barrier when it comes to technology and human use in medicine.
Initially, we had a company create the software for us, but we’ve since brought all the programming inside.
The cool thing about these augmented reality devices is that they have excellent surface mapping. As soon as the person wears the goggles, it automatically maps the surfaces and provides a 3D view of the patient’s environment on the therapist’s computer. Say you’re treating a patient with a fear of spiders. Through drop-down menus, the therapist can choose what type of spider, its color and size, where it should be placed, and the motion. I can choose to move the spider from 6 feet away on the floor to the walls to the ceiling.
Virtual phobias, real fear
A big question for a lot of people was if the spiders are virtual, will they be scary, because it has to be realistic enough to create a fear response for the therapy to work. We use a couple of wires that you can put on a person’s finger and hook them up to a tablet or a cell phone. This provides an online measure of a person’s autonomic sympathetic response.
Like a lie detector test?
Exactly. We put that on their fingers and exposed them to a real-life tarantula and to our virtual tarantulas, and the fear response was no different. That means these do create an objective fear reaction in the body.
We also had people who said, “I know this is not real. I won’t be scared.” And when we started the therapy, it was with a tiny spider 5 meters away from them, and they’d lift their legs off the floor.
With the treatment, we’d come to one room and start with a very little spider, far from them. Then gradually we move them up to bigger, more diverse types of spiders, which are moving around. The patient comes near and tries to touch them.
Then at some point, I’d put a spiderweb on the door, put a few spiders on that, open the door, and have the patient walk through it. They kept walking through this spiderweb.
When they were desensitized to these spiders in this context – and as I said, context is important – we’d go to another room. This was darker, more like a basement, and we’d continue the same thing. That would actually take much less time because they already had desensitized a lot.
In our field, sense of control is very important, especially for when a patient goes home. So at the end, I’d leave the room and talk to the patient via a baby monitor. The patient was surrounded by 20 tarantulas, without the prompt moving around the environment.
Now that they’re desensitized to my virtual spiders, the question is, how would that apply to a real spider? So, we had a real live tarantula, whose name was Tony Stark, because we’re the STARC lab. We’d put Tony at the end of a long hallway before the treatment and see how close the patients could get to him.
It was only one treatment session; nobody’s was longer than 1 hour, and the average treatment time was 38 minutes.
That’s pretty effective.
It’s pretty good, compared with other studies. And I believe this is because of all the components I mentioned: being able to use your real environment; combining it with the real tarantula; the variety of the types of the feared objects; and, of course, giving the patient a sense of autonomy at the end.
Then we had to see how prolonged the effects are. We had them come in 1 week and 1 month after the treatment. I’d remind them of the principles of good exposure therapy and ask them to keep practicing at home between the sessions, looking at pictures and videos. But we never tested who did or did not do it.
After 1 week and 1 month, the effects were either the same or better. A larger number of people at 1 month were able to touch the tarantula than right after treatment.
Treating PTSD in first responders
Did you start with spiders and dogs because those are common fears?
We started with spiders because that worked with the initial goal of creating a prototype. Spiders’ behavior is simple enough for the programming, which takes a lot of time. Another reason for choosing spiders was that we had a lot of other studies of real and virtual reality exposure therapy to compare against.
I think another reason for our success is that, when you do real exposure therapy, you have just one scared tarantula in the corner of their tank, and they don’t listen to you. But my spiders listen to me and do exactly what I tell them.
After our initial success, we obtained more funds to expand it to other phobias. The cool thing is that we don’t need separate software for different phobias. You can choose dogs or snakes, add it to the person’s environment, and decide their behaviors.
We just started a clinical trial using dogs, and another group in Turkey is running a clinical trial with dogs. Eastern Michigan University is working with spiders. And a clinic at the University of Nebraska Medical Center is going to start using them in real-world clinics, not for research.
We have another project whose goal is helping reduce the impact of trauma and also treating PTSD in first responders, who are exposed to a lot of horrible things. Rates of PTSD are around 20%-30% among cops, firefighters, and EMS personnel.
They commonly find it very painful being in crowds because the fight-or-flight instinct in the brain is constantly screening for any sign of threat in their environment. We’re working on them walking into an empty room wearing the goggles, and then their therapist can scale the stimulus up and down.
There’ll be two people in front of you talking to each other, and then another group comes in, and people get louder. People can look at you and talk to you. There’s kids running, Fourth of July fireworks, and other things that might bother someone who’s been involved in gun- or explosion-related traumas. You gradually scale up when the person is next to their therapist.
Another thing we’re doing is related to cardiopulmonary resuscitation. If a young person dies in a CPR situation, that is really painful and traumatic. So, for exposure therapy to that, we’re creating a difficult CPR scenario when that person may die. The responder wears the goggles and basically watches a group of people doing CPR while standing next to a therapist who can help them navigate it and then scale it off.
Another goal is combining this with telemedicine, where the person can do it in their real-life environment. Imagine a person with military trauma. You can put them back in the barracks, connected with their psychiatrists via telemedicine. Then we would put humans in military fatigues near them and have them interact with them to feel comfortable with that situation.
What else is next for you and your group?
The next biggest challenge that we’re tackling is PTSD, because of course creating human-encounter scenarios is much more complicated than spiders and dogs. We’re in the midst of developing this so we can basically bring it to people’s homes.
We’ve been working with some military personnel to see if we can basically give a device to a veteran with PTSD, so they can go home and practice on their own.
There’s another possibility for training. Let’s take the example of a police force, which can have a lot of difficulties and mistakes because of lack of exposure and training. They can wear these goggles, get fully geared up, and be placed in encounters with people of different backgrounds, of different severity, with people who could be severely mentally ill or present different challenges for the officers.
Those situations can teach them a lot. I’m the creator of this thing, but even I’m often surprised by how realistic this technology can be. I find myself interacting with avatars the same way I would if they were real humans. I actually had one of my colleagues, when we started launching the programming with the dogs, immediately jump back. It’s just like the animal brain reacts to them.
Last question: Do you actually interact with Tony, the tarantula?
Oh, Tony is my friend. Unfortunately, he’s not with our lab at this moment. He’s on a sabbatical at Eastern Michigan University for their clinical trials. But yes, I’ve held him. He’s very friendly.
A version of this article first appeared on Medscape.com.
Cannabis use: Messages remain mixed across diagnoses
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
Marijuana use is now a legal activity in many parts of the United States, but those managing patients with psychiatric disorders are in the difficult position of determining whether this use is helpful, harmful, or irrelevant to the underlying illness on the basis of limited and largely incomplete data, according to an overview of this issue presented at the virtual Psychopharmacology Update presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
While there is clear evidence that cannabis use relative to the general population “is more prevalent among patients with psychiatric disorders,” it is less certain how often this use is risky, said Diana M. Martinez, MD, professor of psychiatry at Columbia University in New York.
Independent of euphoric effects, cannabis can be perceived by individuals with psychiatric diagnosis as self-medication for feelings of stress, social anxiety, and insomnia, among other symptoms. These are the same reasons why many individuals without psychiatric conditions use cannabis-containing products.
The perception that cannabis use is generally benign presumably explains the successful efforts at legalization, but there are risks for those with or without psychiatric illnesses, Dr. Martinez pointed out at the meeting, sponsored by Medscape Live. Not least, about 20% of regular users of cannabis develop cannabis use disorder (CUD), a condition defined in the DSM-5 as the continued use of cannabis despite adverse consequences, such as dependence.
Impact of severe CUD ‘incapacitating’
“Of those who meet criteria for CUD, 23% have severe CUD, which is an incapacitating form,” reported Dr. Martinez, citing work led by Deborah Hasin, PhD, professor of clinical epidemiology at Columbia University.
However, relative to otherwise healthy individuals, those with a psychiatric diagnosis might face greater benefits or greater risks from cannabis use, according to Dr. Martinez, who cited a 2017 report from the National Academies of Science, Engineering, and Medicine (NASEM).
This report evaluated the potential risks and benefits on the basis of published studies.
There is limited evidence that regular cannabis increases rather than modifies symptoms of mania and hypomania in patients with bipolar disorder, according to the report. The report also cited limited evidence that cannabis use increases severity of posttraumatic stress disorder (PTSD). There was limited evidence of adverse effects on symptoms of anxiety, although this appeared to depend on daily or nearly daily use.
The report found no data of acceptable quality to draw conclusions about the effect of cannabis use on symptoms of depression.
In patients with attention-deficit/hyperactivity disorder (ADHD), “a recent study showed that daily but not occasional use of cannabis increased impulsivity but not inattention, working memory, or verbal intelligence,” said Dr. Martinez, citing a study published this year.
Some evidence also suggests that patients with a psychiatric disorder might benefit from cannabis use, but, again, this evidence is limited. For one example, it includes a potential reduction in symptoms of obsessive-compulsive disorder, Dr. Martinez said.
More support for cannabis in medical disease
Relative to the quality of evidence supporting benefit from cannabis in psychiatric disease, the data appear to be stronger for patients with medical illnesses, such as cancer. For example, Dr. Martinez cited evidence that tetrahydrocannabinol (THC), a major active ingredient in cannabis, improves sleep in the context of a medical illnesses. There is also evidence for anxiolytic effects in patients with a medical illness, although that is weaker.
In patients with or without a psychiatric disorder, marijuana does pose a risk of substance abuse disorder, and it shares the risks of intoxicants, such as inattention leading to increased risk of accidents, including motor vehicle accidents. This pertains to those with or without a psychiatric or medical condition, Dr. Martinez said.
While intermittent light use of cannabis appears to pose no risk or a very low risk of long-term adverse effects on cognition, at least in patients without psychiatric disorders, Dr. Martinez indicated that the risk-benefit ratio for any individual is use dependent. The risk of CUD, for example, increases with the frequency of exposure and the potency of the cannabis.
Empirical evidence for therapeutic role
In published studies, other researchers have expressed interest in a potential therapeutic role of cannabis for psychiatric disorders, but there appears to be a general consensus that the supportive data remain weak. One expert who has written on this topic, Jerome Sarris, PhD, professor of integrative mental health, NICM Health Research Institute, Western Sydney University, Westmead, Australia, said that empirical evidence does support a benefit in selected patients.
“Of course, high THC forms are strongly discouraged in people with schizophrenia or high risk of developing psychotic disorder, or in youths,” Dr. Sarris explained. “However, there is a potential role for use in people with sleep and pain issues, and many find it beneficial to also assist with affective disorder symptoms.”
In a systematic review he led that was published last year, the evidence to support cannabis for psychiatric disorders was characterized as “embryonic.” However, small studies and case reports appear to support benefit for such indications as ADHD if precautions are taken.
“I certainly would not discourage use of prescribed standardized medicinal cannabis therapeutics for all people with psychiatric disorders,” Dr. Sarris said. He suggested that attention should be made to the THC potency and terpene composition of the products that patients with psychiatric disorders are taking.
FROM PSYCHOPHARMACOLOGY UPDATE
Pandemic drives uptick in need for mental health services
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
In 2020, amid the COVID-19 pandemic, about 1 in 5 (20.3%) U.S. adults received mental health treatment, up slightly from 19.2% in 2019, new data from the U.S. Centers for Disease Control and Prevention show.
Compared with 2019, the pandemic year of 2020 also saw an uptick in adults receiving prescription medication for a mental health problem (from 15.8% to 16.5%) or counseling or therapy from a mental health professional (from 9.5% to 10.1%), the CDC says.
The percentage of adults who had received mental health treatment in the prior year decreased with age, from 20.9% among people aged 18-44 to 20.5% among those aged 45-64 to 18.7% among those aged 65 and older.
Women were more likely than men to have received any mental health treatment (25.6% vs 14.6%), according to an analysis of 2020 data from the National Health Interview Survey (NHIS).
This is consistent with their higher prevalence of common mental health conditions, including anxiety and depression, and their greater willingness to seek out mental health care, Emily Terlizzi, MPH, and Tina Norris, PhD, with the CDC’s National Center for Health Statistics (NCHS), note in their data brief published online Oct. 20.
Non-Hispanic White adults (24.4%) were more likely than non-Hispanic Black (15.3%), Hispanic (12.65) and non-Hispanic Asian (7.7%) adults to be treated with a mental health issue.
The percentage of adults treated for a mental health problem increased as their place of residence became more rural, from 19.3% for those living in large urban areas to 21.7% among those residing in nonmetropolitan areas.
Social and emotional support
Despite rising mental health care needs, period of July to Dec. 2020, also based on NHIS data.
Social and emotional support is associated with well-being and a reduced risk of early death, NCHS researchers Peter Boersma, MPH, and Anjel Vahratian, PhD, MPH, note in their data brief.
However, social and emotional support varies by age and race/ethnicity.
Groups with lower levels of social and emotional support are Hispanic, non-Hispanic Black, and non-Hispanic Asian adults; adults neither married nor living with a partner; adults without another adult in the home; adults with less than a high school education; and adults with disabilities.
“While most adults always or usually had the emotional support they needed, 1 in 10 adults rarely or never received the social and emotional support they needed,” the authors report.
As reported by this news organization, 2020 data from the National Academies of Sciences, Engineering, and Medicine (NAS) show social isolation in older adults is a major public health concern that contributes to heart disease, depression, and premature death.
The report urged health care systems to take urgent action to address social isolation and loneliness in older adults and proposed a series of recommendations for addressing social isolation.
One recommendation was to improve awareness by including measures of social isolation and loneliness in health surveys, such as the NHIS, which began asking about perceived social and emotional support in July 2020.
A version of this article first appeared on Medscape.com.
But I am the therapist!
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
Dr. Smith’s patient, Anna, was struggling. Her mother, with whom she lived, had died, her boyfriend had broken up with her, her teenagers were being difficult, and her anxiety about catching COVID left her isolated and lonely.
She was working in psychotherapy and a number of medications had been tried, but when Anna suggested that her children might be better off without her, Dr. Smith referred her to an inpatient unit at a local hospital for admission. He faxed over the clinical and demographic information that the hospital wanted, and he never heard a word from the inpatient unit until Anna texted him that she had been discharged. She noted that the hospitalization had been helpful.
“I have an appointment next week with a therapist,” Anna texted.
Dr. Smith was puzzled and he conveyed that in his response to her.
“They told me that you are the psychiatrist and I should see you once a month and that I need a therapist to see weekly.”
Dr. Smith remained puzzled. At times he had seen Anna weekly, and he always saw her for 50-minute (or longer) sessions, but he realized that the person in charge of discharge had decided that psychiatrists are not psychotherapists. As a psychiatrist who sees patients for psychotherapy, Dr. Smith was not in Anna’s health insurance plan, and perhaps the hospital discharged people to see in-network clinicians. Or perhaps they thought that if he were a better psychiatrist, his patient would not need an inpatient admission. All he could do was surmise, but clearly ; they had changed Anna’s treatment without the courtesy of a phone call.
“This happens to me all the time,” said Sally Waddington, MD, a psychiatrist in private practice in Laurel, Md. “Hospitals will tell my patients that psychiatrists are for medications and they need a separate therapist. It really undermines the treatment.”
Ramin Mojtabai, MD, PhD, MPH, is a psychiatrist at Johns Hopkins Hospital in Baltimore. He has done research on trends in psychotherapy among psychiatrists and in 2008 published a study which showed that only 10.8% of psychiatrists see all of their patients for psychotherapy. The same data, however, revealed that 59.4% – or a majority – of psychiatrists see at least some of their patients for psychotherapy.
“Unfortunately, our profession has been defined by the insurance industry for decades,” Dr. Mojtabai said in an interview, “so, I am not surprised that the patient was told to see a ‘proper’ psychotherapist.”
George Dawson, MD, spent 22 years as a psychiatrist on an inpatient unit in Minnesota. On his blog, “Real Psychiatry,” Dr. Dawson has a lengthy post dated Oct. 3, 2021, titled “The problem with inpatient units.” Dr. Dawson writes, “There is a lack of collaboration with outpatient staff: Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. ... The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call – a good faith effort to me means leaving a cell phone number with the message to ‘call me at any time.’ I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.”
In an interview, Dr. Dawson commented on the predicament of Dr. Smith and Anna. “The inpatient staff seem to have a grandiose idea of where the care should be centered and that is with the outpatient doctor making the referral. Any plan not involving the referring doctor is not likely to be successful.”
Dr. Waddington talked about how she handles the situation when an inpatient unit refers her patients to a separate psychotherapist. “Usually, I discuss it with my patient. Sometimes they want a change and so I continue to see them for medications. Most of the time, they keep seeing me for therapy.” She went on to note, “I recently had a patient who was in the hospital and was referred to a trauma specialist for therapy. The referral was probably appropriate in her case; I just wish they had discussed this with me first.”
Dr. Smith calls himself “a dinosaur” – he likes treating patients with a combination of medications and psychotherapy and he does not enjoy seeing patients for brief visits for medication management. He was, however, concerned that Anna had been stretching out the time between sessions because of financial concerns, so he suggested she could meet with the therapist and see if she thought this might be helpful to her. If it was, he recommended she find a psychiatrist in her insurance network to prescribe her medications, with the hope that this would be a reasonable alternative to their current conundrum.
“I believe that many patients are best served by having their care come from a single psychiatrist and not treatment split between clinicians; however, I recognize that this is not always financially the best option. Anna might benefit from not having the financial stress of care from a psychiatrist where she is not reimbursed as well – if at all – by insurance. Still, I am annoyed; it feels like the inpatient team decided to write a new job description for me and to dictate through my patient how it is I should be practicing. And after they implied that I was not the best therapist for her, they hijacked her and sent her to someone who may well have much less experience than I do.”
In the clinical care of any patient, communication between the inpatient team and the outpatient physician is essential, and all too often, this doesn’t happen.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2018). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, both in Baltimore.
To meme or not to meme: The likability and ‘virability’ of memes
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
As the famous saying goes, “laughter is the best medicine.”
So it’s no surprise that humor is a great way to connect with different people and across various groups.
Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene;
I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.
Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”
Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).
The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.
In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).
Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.
Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.
Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.
A version of this article first appeared on Medscape.com.
Why toilet paper is the unofficial symbol of anxiety during COVID
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
An integrated response to Surfside: Lessons learned
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.